Menorrhagia – An overview

1. Menorrhagia – An overview By Dr Rukhsana Hussain ST1 17th November 2009

2. Objectives • To increase awareness of menorrhagia, its causes and impact on individuals and society • To cover key points in history-taking and examination • To increase awareness of medical and surgical treatments available as outlined by the NICE guidelines

3. Menorrhagia - Definition “Excessive menstrual blood loss which interferes with a woman’s physical, emotional, social and material quality of life and which can occur alone or in combination with other symptoms”(NICE guidelines 2007) Objective blood loss >80ml no longer important in defining menorrhagia

4. Impact of menorrhagia • 1 in 20 women aged 30-49 years consults GP each year with menorrhagia • Many women will have days off work due to menorrhagia • 1 in 5 women in UK will have hysterectomy before age of 60 years • 50% of all women who have a hysterectomy for menorrhagia will have a normal uterus removed

5. Causes of menorrhagia • 4 main subtypes 1) Ovulatory 2) Anovulatory 3) Anatomic 4) Other causes

6. Ovulatory menorrhagia • “Primary” or “idiopathic” menorrhagia – treatments guided by probable causes • Characterized by heavy bleeding during regular cycles. Usually associated dysmenorrhoea and premenstrual symptoms • Probable causes • Abnormal prostaglandin synthesis • Increased intrauterine fibrinolysis • Acquired /congenital clotting disorders eg VWD

7. Anovulatory menorrhagia • Usually irregular periods, often heavy and frequently separated by long intervals. Usually minimal pain • Menorrhagia in adolescents usually anovulatory • Anovulatory cycles less common in 20-40 age group

8. Anovulatory menorrhagia • Common in perimenopausal women • Intermittent ovulation and ovarian queiscence results in variability in LH/FSH and oestrogen causing erratic cycles • During this period follicles remaining in ovary are quite resistant to FSH – sometimes ovulation occurs after long follicular phase, other times it fails.

9. Anovulatory menorrhagia • In delayed ovulation/anovulation endometrium is thickened by prolonged stimulation by proliferative levels of oestrogen and is eventually shed in a long and heavy period • Long term anovulation increases risk of endometrial hyperplasia

10. Anovulatory menorrhagia • Causes include • Hyperprolactinaemia • Thyroid disease • Adrenal disease • Anorexia/Bulimia • Pituitary adenoma • Chronic illness • Stress • Drugs – eg. tricyclic antidepressants, steroids

11. Anatomic menorrhagia • Commonly caused by endometrial polyps or submucosal fibroids Polyp

12. Other causes menorrhagia • Cervicitis/endometritis • IUD • Hyperoestrogenism • Endometrial cancer • Coagulopathy

13. History – key points • Age at menarche • Onset and duration of period • Cycle – regular or irregular? Length? • Amount blood loss – clots? Flooding? Number sanitary towels? Social impact • Changes from previous bleeding patterns • Intermenstrual bleeding • Postcoital bleeding • Pelvic pain • Dyspareunia

14. History • Symptoms related to anaemia - SOB/fatigue/dizziness • Symptoms of thyroid disease/systemic illness • PMH – Obstetric Hx, Fertility wishes • DH- Warfarin? Aspirin? Allergies • SH – Stress? Smoking? Alcohol intake? • FH – Bleeding disorders? Malignancies?

15. History • Cover risk factors for Endometrial Cancer • Obesity • Age > 45 • Nulliparity • PCOS • Tamoxifen • 1st degree relative with breast, colon or endometrial cancer • Personal hx breast/colon cancer • Unopposed oestrogen treatment

16. Examination • General – pallor? Bruising? Signs of thyroid disease? BMI? • Abdominal examination – fibroid uterus? • Pelvic examination

17. Investigations • FBC – exclude anaemia • Cervical smear if due • If IMB/PCB vaginal swab for chlamydia screen • USS pelvis if indicated • Referral for hysteroscopy and endometrial biopsy – Persistent IMB, >45 years, treatment failure, ineffective treatment , risk factors endometrial cancer • NO value of TFT unless signs thyroid disease. NO value of hormone levels according to NICE guidelines

18. Medical treatments – First Line • Levonorgestrel-releasing intrauterine system (MIRENA) - Slowly releases progestogen, prevents proliferation of endometrium • Reduces menstrual loss by 86% in 3 months, and by 97% at 12 months • Effective contraceptive • Return to fertility after removal

19. Medical treatments – First Line • Side effects Mirena coil - progestagenic effects – breast tenderness, acne, headaches - irregular bleeding at start may last for 6 mths - functional ovarian cysts Also, risk of uterine perforation at time of insertion

20. Medical treatments – Second line • Tranexamic acid • Mefenamic acid/NSAIDs • COCP • Can be used first line if Mirena not acceptable to patient

21. Tranexamic acid • Antifibrinolytic agent • Mean reduction blood loss nearly 50% • Dose 1-1.5g tds during menstruation only • May be combined with mefenamic acid esp if dysmenorrhoea prominent • Theoretically increased risk DVT but little evidence in studies • Suitable if patient wanting to conceive • Use for 3 cycles to determine effectiveness

22. Mefenamic acid • Reduces prostaglandin production • Indicated for menorrhagia and dysmenorrhoea • Mean reduction blood loss around 30% • Dose 500mg tds – taken during menstruation • Side effects – indigestion, diarrhoea, worsening asthma, peptic ulceration

23. COCP • Prevents proliferation of endometrium therefore reducing blood loss • Contraceptive • Side effects - headache, mood change, fluid retention, risk of DVT, stroke

24. Medical treatments – Third line • Oral progestogen – norethisterone • Effective when given in high doses between day 5- 26 of cycle • Dose 5mg tds • Injected progestogen (Depo-provera) • Given every 3/12 • After 1 year 50% women amenorrhoeic • Disadvantage of delayed return to fertility

25. Medical treatments • Gn-RH analogue injections • Stop production of oestrogen and progesterone inducing amenorrhoea • Side effects include menopausal- like symptoms • Risk of osteoporosis with longer than 6 month use

26. Surgical/radiological treatments • Endometrial ablation • Uterine artery embolisation • Myomectomy • Hysterectomy

27. Endometrial ablation • Indication – severe impact on quality of life + no desire to conceive + normal uterus (or small fibroids <3cm diameter) • Destroys womb lining • Risk of perforation during procedure • Possible side effects – vaginal discharge, increased period pain

28. Uterine artery embolisation • Indication – fibroids >3cm diameter, pressure symptoms, not wanting surgery, wants to remain fertile • Small particles injected into blood vessels supplying uterus , block supply to fibroids causing shrinkage • Short hospital stay – usually overnight • Side effects – persistent PV discharge, post embolisation syndrome – pain, nausea, vomiting, fever. Risk of haemorrhage

29. Myomectomy • Indication – fibroids > 3cm, severe impact on quality of life • Risks associated with surgery – adhesions, infection, perforation, haemorrhage • Recurrence of fibroids possible

30. Hysterectomy • Indication – other treatments failed, no wish to remain fertile, patient request after fully informed, desire for amenorrhoea • Vaginal /abdominal as indicated • Major surgery – 4-5 days inpatient stay, risks of surgery • Longer recovery time- months although permanent solution for menorrhagia!

31. Summary • Menorrhagia is a common problem • Mirena coil is offered as first line treatment and has reduced need for hysterectomies significantly • For women wanting to conceive in short term – tranexamic acid and mefenamic acid appropriate • For others COCP, norethisterone, Depo-provera can be effective • Surgical and radiological interventions available in secondary care setting

32. References • www.nice.org.uk – Heavy menstrual bleeding NICE 2007 • www.doctors.net.uk • Oxford Handbook of Obstetrics and Gynaecology