Menorrhagia

1. Dr Amy Faulkes ST4 O&G April 28th 2011 Menorrhagia

2. Objectives • Definition • Incidence • Clinical history and examination • Causes • Investigations • Treatments • Questions

3. MCQs! • With regard to menorrhagia: a) 1/3 women report periods to be heavy T/F b) Hyperthyroidism causes menorrhagia T/F c) All women should have TFTs checked T/F d) All women should have an FBC T/F

4. MCQs! • With regard to menorrhagia: e) Ibuprofen reduces blood loss T/F f) Subserosal fibroids are the most common fibroid type to cause the problem T/F g) A Cu coil is a method of treatment T/F h) A Mirena coil is a method of treatment T/F

5. MCQs! • With regard to menorrhagia: i) Underlying pathology is identified in dysfunctional uterine bleeding? T/F j) Fibroids are most common in Caucasian women? T/F

6. Menorrhagia definition • 3-7/7 → 35-40mls • Menorrhagia >80mls/period • Blood loss @ which fall Hb usually occurs • NICE: • 'excessive menstrual blood loss which interferes with woman's physical, emotional, social and material quality of life...can occur alone or in combination with other symptoms.'

7. Dysfunctional Uterine Bleeding (DUB) • Irregular/ excessive bleeding in absence of pregnancy, infection, trauma, hormone Rx • No pathology or organic cause • Dx of exclusion • Aetiology; • ? disordered prostaglandin production • ? abnormalities of endometrial vascular development

8. Incidence menorrhagia • Commonly referred problem to secondary care • 9-15% population studies in Western Europe • 1/3 women regard their menstrual loss as heavy • In UK 5% women aged 30-49 yrs consult GP with menorrhagia

9. History • Subjective • Pattern of bleeding • Irregular → ? anovulatory • Volume; • Clots, flooding, no. tampons/ pads • Internal & external protection • Menstrual calendar • Impact on pts lifestyle and QoL • Interference with work and social events

10. History • Symptoms which many suggest dx other than DUB: • Irregular, IMB, PCB, sudden change; smear hx • Dyspareunia, pelvic pain • Pre-menstrual pain • Excessive bleeding from other sites/ situations • e.g. after tooth extraction

11. History • Symptoms of anaemia • Symptoms of thyroid disease • Clotting disorder • Teenage years • Factors which may determine Rx options: • Co-morbidity • Family complete? • Trying for conception?

12. Other Hx • O&G: routine inc... • Previous surgery/ LSCS • Contraceptive use; e.g. IUCD • PMHx: e.g. • VTE • Asthma • Peptic ulcers etc • Drug Hx inc. Allergies → warfarin ? • FHx • SHx

13. Examination • Signs Fe deficiency, thyroid disorder • Abdominal palpation • Mass from pelvis? Tenderness? • Speculum: • Cx pathology? Polyp? • Bimanual: • Uterine size, any adnexal masses?

14. Investigations • FBC → all women (NICE guidance) • TFTs, clotting studies • Symptoms • Menorrhagia since menarche • PMHx/ FHx suggesting clotting dysfunction • TVUSS/ TAUSS • Endometrial bx • Hysteroscopy

15. USS • First line Ix for identifying structural abnormalities (TV vs TA) • Uterus palpable abdominally • Pelvic mass of uncertain origin on bimanual • Pharmaceutical treatment fails • Identifies: • Abnormal appearing endometrium • Fibroids (position), polyps, (ovaries)

16. Endometrial biopsy • Exclude endometrial carcinoma/ atypical hyperplasia • Indicated with; • Persistent IMB • 45 yrs or > Rx failure or ineffective Rx • Suspicious findings on USS • Good practice if >45yrs and 'treating endometrium'

17. Hysteroscopy • When USS inconclusive • Direct visualisation of endometrium • Treatment if endometrial polyp identified on USS • I/P vs O/P

18. Causes of menorrhagia • Idiopathic: • No organic pathology • DUB (majority) • Secondary to organic causes: • Fibroids • Endometrial polyps • IUCD • Oral anticoagulants • (Endometrial Ca/ hyperplasia) • Systemic disorders (thyroid/ Von Willebrand's etc)

19. Fibroids (uterine leiomyoma) • Benign tumour originating in smooth muscle layer (myometrium) of uterus • 20-40% women; most do not cause sx • Twice as common in Afro-Caribbean population than Caucasian • Dependent on oestrogen and progesterone • Expected to shrink after the menopause

21. Fibroid type • Intramural: • Within wall of uterus • Subserosal: • Beneath mucosal (peritoneal) surface of uterus • Submucosal: • Beneath endometrium • Distort uterine cavity • Most likely to cause menorrhagia

22. Fibroids causing menorrhagia • Distort and enlarge uterine cavity • Increase surface area from which menstruation occurs • Can produce prostaglandins • implicated in aetiology of menorrhagia

23. Endometrial polyps • Increase surface area of endometrium • Hormonally active

24. Intra Uterine Contraceptive Device (IUCD) • Inert or copper containing devices • Contraceptive • Inhibit fertilisation due to direct toxicity • ? anti-implantation effect from inflammatory reaction • Commonly plastic frame • Pure copper wire wound around • e.g. Copper T, Multi-load

25. IUCD • Spotting, light-bleeding, heavier or longer periods • Common in first 3-6/12 after insertion • Usually decrease with time • Copper T IUCD

26. Treatment • Correct iron deficiency • Treat systemic disorders where relevant • Medical treatments • Surgical treatments

27. Medical treatments • Non-hormonal: • NSAIDs e.g. Mefanamic Acid • Antifibrinolytics e.g. Tranexamic acid • Hormonal: • Progestogens • Oral e.g. Norethisterone (NET) vs Levonorgestrel releasing intra-uterine system (LNG-IUS or 'Mirena') • Combined oral contraceptives (COCP) • Gonadotrophin releasing hormone agonists (GnRH anologues)

28. Surgical Treatments • Endometrial ablation • Myomectomy • for fibroids • Uterine Artery Embolisation (UAE) • for fibroids • Hysterectomy • Abdominal, vaginal, laparoscopically assisted

29. NSAIDs • Restore imbalanced endometrial prostaglandin synthesis • Reduce blood loss 20-49% • e.g. Mefanamic, naproxen, ibuprofen • Common S/Es (1:100); • Indigestion, diarrhoea • Rare (1:10 000); • Worsening asthma, peptic ulcers

30. Antifibrinolytics • Inhibit fibrinolysis in endometrium • Reduce blood loss 29-58% • Tranexamic acid • Taken at onset of menses; up to five days • Less common (1: 100) • Indigestion, diarrhoea, headaches

31. Systemic Progestogens • Keeps endometrium thin • Norethisterone 15mg daily D5-26 menstrual cycle • Common S/Es (1:100) • Wt gain, acne, bloating, breast tenderness, headaches • Rare S/Es (1:10 000) • Depression

32. Systemic Progestogens • Injected long-active progesterogens e.g. Depo provera • Common S/Es; • Wt gain, irregular bleeding, amenorrhoea • Premenstrual syndrome; • Bloating, fluid retention, breast tenderness • Less Common (1: 1000); • Small loss bone mineral density • Largely recover when treatment stopped

33. Mirena • Levonorgestrel 20mcg/ 24 hrs • Endometrial atrophy • Minimal systemic absorption • Changed every 5 yrs • Also; contraceptive → equal to sterilisation • Fertility return almost immediately removed • ~ 30% amenorrhoeic by 1 year

34. Mirena • Mean reduction in blood loss ~95% by 1 yr • NICE; considered as first line Rx • Provided at least 12/12 use anticipated

35. Mirena • Common S/Es (1:100) • Irregular bleed 6-12/12 • Breast tenderness • Acne • Headaches • All usually minor and transient • Rare (1: 10 000) • Uterine perforation at time insertion

36. COCP • Inhibits ovulation • Regular shedding of thin endometrium • Mean reduction blood loss ~50% • Common (1: 100) S/Es: • Mood changes, headaches, nausea, breast tenderness, fluid retention • Rare (1: 10 000) S/Es: • DVT, CVA, MI

37. GnRH agonists • Suppress pituarity-ovarian axis • Temporary reversible menopausal state • Pre-operative adjunct • Other Rx options for fibroids C/I • If Rx >6/12 or adverse S/Es experienced • HRT 'add-back' recommended

38. GnRH agonists • Common S/Es (1:100); • Menopausal Sx • Hot flushes • increased sweating • vaginal dryness • Less common (1:1000); • Osteoporosis • Particularly trabecular bone >6/12 use

39. Endometrial ablation • Consider where bleeding having severe impact on quality of life • Does not wish future conception • Normal menstruation; upper functional layer endometrium shed • Basal 3mm retained • Ablation of endometrium lining of uterus • Basal endometrium destroyed • Endometrium cannot regenerate

40. Endometrial ablation • Mean reduction in blood loss up to 90% • No guarantee of amenorrhoea • Speed of surgery vs major surgery • Quicker recovery • Rapid return to work • Local vs general anaesthesia

41. Endometrial ablation • Common S/Es; • Vaginal discharge • Increased period pain even in absence of further bleeding • Need for additional surgery • Less common (1:1000); • Infection • Rare (1:10 000); • Uterine perforation

42. Myomectomy • Surgical removal of fibroid; • Abdominal incision, major surgery • Hysteroscopic resection • Risk of intraoperative Haemorrhage • Retain uterus • Often fibroids grow back

43. Myomectomy • Less common S/Es • Adhesions → pain, impaired fertility • Additional surgery/ recurrence • Uterine perforation → hysteroscopic route • Rare S/Es: • Haemorrhage

44. Uterine artery embolisation • Minimally invasive; interventional radiology • Catheter inserted through femoral artery • Occlusion of vessel to fibroid causing degeneration of fibroids • Suitable in large fibroids >3cm diameter • Plus symptoms • Potential retention of fertility

45. UAE

46. UAE • Common S/Es: • Vaginal discharge, Post-embolisation syn. • Pain, N+V, fever • Less common: • Additional surgery required • Premature ovarian failure, haematoma • Rare: • Haemorrhage • Non-target embolisation → tissue necrosis • Infection causing septicaemia

47. Hysterectomy • Operation and recovery time longer than for other surgical techniques • Removal of uterus +/- cervix (subtotal) • ?Conserve ovaries • Oestrogen loss, bone density loss • HRT • TAH vs VH vs LAVH

48. Hysterectomy • Common (1:100) S/Es • Infection • Less common (1:1000) • Intra-operative haemorrhage • Damage to viscera → urinary tract, bowel • Urinary dysfunction → frequency/ incontinence • Rare (1:10 000): • VTE • Very rare (1:100 000): Death

49. MCQs! • With regard to menorrhagia: a) 1/3 women report periods to be heavy T b) Hyperthyroidism causes menorrhagia F c) All women should have TFTs checked F d) All women should have an FBC T

50. MCQs! • With regard to menorrhagia: e) Ibuprofen reduces blood loss T f) Subserosal fibroids are the most common fibroid type to cause the problem F g) A Cu coil is a method of treatment F h) A Mirena coil is a method of treatment T