Menorrhagia

A quick overview of the most common causes of menorrhagia and how you practically manage this very common problem.

 

Lecture by

Video Duration: 9 minutes

  • Menorrhagia
    Created by Eimear McClenaghan
    General
    Epidemiology

    Subjectively, menorrhagia is a heavy period. This can be defined as bleeding for more than 7 days or blood loss greater than 80ml.

    Pathology

    With a regular cycle and painless:

    • fibroids (leiomyomas) - increase surface area of endometrium, increasing bleeding
    • dysfunctional uterine bleeding (young girls)
    • coagulation disorder
    • endometrial carcinoma
    • endometrial polyp

    With a regular cycle and pain:

    • pelvic inflammatory disease - infection of uterus eg chlamydia, gonorrhea
    • endometriosis - implantation of endometrium outside uterus
    • adenomyometrium - endometrium implants in myometrium

    Short cycle and excessive menses (epimenorrhagia):

    • ovarian dysfunction

    Irregular cycles and excessive menses:

    • thyroid disease (usually hypothyroid in menorrhagia)

    Long cycle and excessive menses:

    • prolonged continuous courses of combined OCP
    Top three causes

    None

    Clinical Features
    Symptoms

    Excessive bleeding with any of following:

    • pain
    • regular cycles
    • irregular cycles
    • short cycles
    • long cycles

    Questions to ask in the History...

    • age of menses starting?
    • (ir)regularity of cycles?
    • last menstrual cycle?
    • days of cycle?
    • flooding? excessive clot formation?
    • how many times do they need to change tampon/pad?
    • dysmenorrhoea?
    • intermenstrual bleeding? - endometrial carcinoma/polyps
    • post-coital bleeding? - pelvic inflammatory disease
    • symptoms of anaemia? - SOB, chest pain, fatigue
    • contraception?
    • PID? - fever, pelvic pain
    • vaginal discharge?
    • pressure on bladder/bowel? - fibroids
    • family history of coagulation disorders?
    Signs
    • clinical signs of anaemia - pale conjunctiva etc
    • abdominal and bimanual examination - masses, fibroids
    • vaginal smear exam
      • smear test (cervical cancer doesn't present with menorrhagia but does present with excessive bleeding!)
      • endocervical and high vaginal swabs (PID)
    Investigations
    Cultures

    Endocervical and high vaginal swabs

    Bloods

    FBC (anaemia)

    Clotting (APTT, INR)

    TFTs (hypo/hyperthyroid)

    Imaging

    Pelvic US - endometrial thickness, polyps, fibroids

    Scopic/Biopsy

    Hysteroscopy - closer look at uterus

    Endometrial sampling

    Functional

    None

    Treatment
    Conservative

    Information and support - comfort that condition is benign

    Medical

    Hormonal

    • combined OCP
    • levonorgesterel releasing intrauterine system
    • progesterone oral or depot injection
    • gonadotrophin releasing hormone analogue: Goserelin
      • decreases negative feedback to hypothalamus, decreasing oestrogen

    Non-Hormonal

    • NSAIDs (mafanamic acid, naproxen, ibuprofen)
      • inhibits COX1&2, decreasing prostaglandin production, decreasing bleeding and dysmenorrhoea
    • anti-fibrinolytics (tranexamic acid)
      • inhibit plasminogen activator, increasing clotting
    Surgical

    In women of child-bearing age:

    • Myomectomy
      • preserves fertility and removes fibroids

    Otherwise:

    • Endometrial ablation
    • Hysterectomy
  • Menorrhagia
    Created by Kate Edmonton
    General
    Epidemiology

    Blood loss >80mL or bleeding for >7 days, or excessive blood loss that interferes with a womens quality of life.

    Very common condition, 1/3 of women complain of heavy bleeding.

    Pathology

    None

    Top three causes

    Painless:

    • Fibroids
    • Dysfunctional uterine bleeding
    • Endometrial polyps

    Painful:

    • Pelvic inflammatory disease
    • Endometriosis
    • Adenomyosis


    Clinical Features
    Symptoms

    Specific:

    • Flooding
    • Large clots
    • Pelvic pain
    • IMB, postcoital bleeding
    • Urinary or faecal frequency

    General:

    • Chest pain
    • Breathlessness


    Signs

    Signs of anaemia: Increased RR, conjunctival pallor

    Abdominal tenderness (fibroids/ masses)


    Investigations
    Cultures

    Endocervical and high vaginal swabs - chlamydia or gonorrhoea

    Bloods

    FBC (Hb - effect of blood loss)

    Clotting (APTT, INR) - clotting disorder?

    TFTs - systemic cause?

    Imaging

    Transvaginal US - assess endometrial thickness, exclude fibroid or ovarian mass and detect larger polyps

    Scopic/Biopsy

    Endometrial biopsy - if endometrial thickness >10mm, polyp suspected, >40 with recent onset menorrhagia, IMB that has not responded to treatment to exclude malignancy

    Hysteroscopy - allows further visualisation of the uterus

    Functional

    None

    Treatment
    Conservative

    Support and information about the condition

    Medical

    Trying to conceive:

    • Transexamic acid (anti-fibrinolytic) and NSAIDs (reduce bleeding and dysmenorrhoea) during the period.

    Not trying to conceive:

    • COCP
    • Progesterone IUS (Mirena coil)
    • Progesterone oral or depot injection
    • GnRH analogue: Goserelin


    Surgical
    • Endometrial ablation
    • Myomectomy (preserve fertility and remove fibroids)
    • Hysterectomy