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Menorrhagia

From Mediwikis

Menorrhagia

Defined as a monthly blood loss of >80mls, however as blood loss is exceptionally difficult to measure the diagnosis is subjective (the patient feels they are bleeding heavily and it is affecting their life).
‘Normal’ menstruation is considered as:

  • Blood loss for around 7 days
  • Cycle of 21–35 days, 28 being the average
  • Blood loss is heaviest for the first few days

40-60% who complain of excessive bleeding have no pathological cause; this is called ‘dysfunctional uterine bleeding’. 20% of cases are associated with anovulatory cycles, which commonly occur in the extremes of reproductive age.

Causes

History and examinations

As well as performing a normal gynae history, make sure you ask about:

  • Use of towels and tampons – do they have to use both? Do they ever flood through to their clothing?
  • Any passage of clots - large clots can be signs of miscarriage, or just sever menorrhagia
  • Plans to have further children, as this will influence management
  • Easy bruising or bleeding gums, this indicates a clotting disorder
  • Any prolapse or a sense of heaviness around menstruation, this indicates a fibroid as it becomes engorged with blood and heavy.

You don’t necessarily have to examine all patients, but look out for fat patients (excess oestrogen production), signs of hypothyroidism, signs of anaemia or clotting disorders and palpate the abdomen feeling for any masses. Don’t forget to do a pregnancy test!

Investigations

  • Pelvic USS (first line)
  • Pipelle biopsy
  • FBC
  • Thyroid function
  • Clotting profile

Management

Flow chart for menorrhagia treatment

Medical Treatment

First line

Second line

  • Tranexamic acid – non hormonal, improves clotting
  • NSAIDS (mefenamic acid) – if have dysmenorrhea as well
  • Combined oral contraception – prevents proliferation of endometrium

Third line

Other

  • Gonadotropin releasing hormone analogue – prevents production or oestrogen and progesterone simulating the menopause, therefore the patient may require HRT if on for >6 months. Usually used short term to shrink fibroids before surgery.

Surgical Treatment

  • Endometrial ablation – if there is a severe impact on QOL and the patient has no desire for further children with a normal uterus
  • Hysterectomy – if other treatments have failed and the patient does not want periods or more children. Vaginal removal results in quicker return to normal function than abdominal removal, and should be preferred where possible[1].
  • Myomectomy (removal of fibroid) – if there is a severe impact on QOL and there is an abnormal uterus with fibroids >3 cm
  • Uterine artery embolization (cut off blood supply to fibroid) – if there is a severe impact on QOL and an abnormal uterus.
  • Laser ablation of endometriosis

References

  1. Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677