Menorrhagia (heavy menstrual bleeding)

DAHVINIA B.DEVAN

DEFINITIONTERMS DEFINITION

Menorrhagia a complaint of heavy cyclical menstrual blood loss over several consecutive menstrual cycles in a woman of reproductive years, or more objectively, a total menstrual blood loss of more than 80 ml per menstruation. (MOH,2004)

Clinically, menorrhagia is defined as total blood loss exceeding 80 ml per cycle or menses lasting longer than 7 days

Menorrhagia is excessive menstrual blood loss over several consecutive cycles which interferes with the woman's physical, emotional, social, and material quality of life. (Nice 2007)

OTHER IMPORTANT DEFINITION…

TERMS DEFINITION

metrorrhagia Menstrual flow at irregular intervals

Menometrorrhagia irregular and excessive flow

Polymenorrhoea bleeding at intervals of less than 21 days

Postcoital bleeding is non-menstrual bleeding that occurs immediately after sexual intercourse

Classification

Primary Secondary

Idiopathic / DUB

ovulatory Non-ovulatory

-Uterine and ovarian pathologies

-Systemic diseases

-Iatrogenic causes

PRIMARY

DUB

•heavy or irregular menstrual bleeding that is not caused by an underlying anatomical abnormality, such as a fibroid, or tumor (abnormal uterine bleeding without any obvious structural or systemic pathology

•Usually is a diagnosis of exclusion

•Hormonal imbalance, hypothalamus-pituitary-ovary axis

• normally in women just started menstruation/perimenopausal

Anovulatory 90%

Ovulatory 10%

•Ovulatory cycles Regular cycle length

Presence of premenstrual symptoms -Dysmenorrhea -Breast tenderness -Change in cervical mucus -Mittleschmertz

Biphasic temperature curve

Positive result from use of

luteinizing-hormone predictor kit

•Anovulatory cycles Unpredictable cycle length Unpredictable bleeding pattern Frequent spotting Infrequent heavy bleeding Monophasic temperature curve

Unopposed estrogen

Associated with increased prostaglandin release (hemostatic deficiency)

Mx:

1. Medical

2. Surgical-hysterectomy-endometrialablation

SECONDARY CAUSES

PCOS

Uterine and ovarian pathologies

endometriosis

CONDITION HISTORY PHYSICAL EXAMINATION (General, abdominal, pelvic)

inv

Uterine fibroids •Age: reproductive age

•Bleeding pattern: menorrhagia, metrorrhagia

•Ass. Symp. dysmenorrhoea, dyspareunia, urinary/defecation problem

•enlarged uterus(>8 weeks) •tenderness/palpable on vaginal exam

•Inv: TAS/TVUS Transvaginal sono hysterography/dx hysteroscopy/dx laparoscopy, +/- endometrial biopsy, MRI

Endometriosis Age: reproductive age

Bleeding pattern: menorrhagia, usually lasts more than 7 days short interval

Ass.symp: dysmenorrhoea/ chronic pelvic pain, dyspareunia, difficulty conceiving

wide spectrum, depends menstruating/notabdominal tenderness,mass

Speculum:red, hypertrophic lesions , bleeding on contact seen at post.fornix

Inv: laparoscopic, TVUS,

adenomyosis •Age: 40 and 50 years old,parous/prior uterine surgery

•bleeding pattern: menorrhagia ,postccoital, Intermenstrual

•ass, Symp.: dysmenorrhea, dyspareunia

•The uterus is enlarged and boggy

•Tenderness

•mass(adenomyoma)

Inv : TAS/TVS(diffuse thickening within wall), MRI, hysteroscopic/laparoscopic biopsy

Pelvic inflammatory disease (endometritis)

•Age: any age

•BleedIng pattern: excessive, Intermenstrual and postcoital bleeding

•Ass. Symp: foul smelling vaginal discharge, pelvic pain and fever,

• febrile, rigor

• abd tenderness

Inv: FBC,ESR gram stain, cultures from cervix, endometrial biopsyCt scan if do not respond to AB therapy for 48-72 hours

Endometrial polyps

•Age: rare <20, peaks at 5th decade, decrease post menopausal

•Bleeding patern: excessive, metrorrhagia,post coital,post-menopausal

• endometrial polyps that protrude through the cervix on VE

• enlarged uterus

• Inv: TVUS /Transvaginal sono hysterography/ hysteroscopy•Biopsy+/- D&C

Endometrial carcinoma

•Age: >40/post menopausal

10% of women with postmenopausal bleeding will be diagnosed with endometrial cancer and an equal number with hyperplasia

•Bleeding pattern: excessive, postcoital,Intermenstrual bleed

•Ass. Symp :pelvic pain

•uterus will be enlarged or softened and masses may be detected•Pelvic examination: cervix may be involved with cancer (Stage II), and the vagina (Stage III)• rectal examination•Enlarged lymph nodes in the neck and groin.•Enlarged liver, abdominal mass or excessive abdominal fluid (ascites).•Vaginal discharge (thin/clear)

•stigmata of chronic anovulation(hirsutism,acne, acanthosis,obesity,wt>90kg)

ONLY IF GOT RISK FACTORS!!!•TVS/TAS•If ET >12Endometrial biopsy/ D&C

Endometrial hyperplasia

Age: post/perimenopausal>Rf:unopposed estrogen

Bleeding pattern: menometrorrhagia, Ass.symptoms:-symptomatic anemia-Infertilitymood swings, Hot flushes,dyspareunia

stigmata of chronic anovulation (hirsutism,acne,acanthosis,obesity,wt>90kg)

ONLY IF GOT RISK FACTORS!!!•TVS/TAS•If ET >12Endometrial biopsy/ D&C

RF:•Age >40•Obese•Nulliparous•Hormone therapy (HRT)•Diabetes•Family history

• Systemic diseases and disorders:CONDITION ASSESTMENT TESTS

Coagulation disorders

Hx: Menorrhagia since menarche Family history of bleeding disorders

Personal history of 1 or more of the following:

-Notable bruising without known injury-Bleeding of oral cavity or gastrointestinal tract without obvious lesion-Epistaxis greater than 10 minutes duration (possibly necessitating packing or cautery)

In a 9 year review of 59 cases of acute menorrhagia in adolescents it was discovered that 20% had a primary coagulation disorder

•Routine screening for coagulation defects should be reserved for young patient who has heavy flow with the onset of menstruation

•Coagulation screen

•rule out von Willebrand disease; ITP; and factor II, V, VII, or IX deficiency.

Hypothyroidism Ass. Symp: Hypothyroid symptoms fatigue, constipation, intolerance of cold, and hair and skin changes

TFT

Liver or renal disease

Ass. Symp: liver/renal failure symptoms(Dysfunction of either organ can alter coagulation factors and/or the metabolism of hormones)

RP/LFT/COAG screen

• Iatrogenic causes: symptoms start after medication/therapy started

CONDITION

Anticoagulant treatment

Chemotherapydisrupt the normal menstrual cycle, which is restored easily upon cessation of the products

Intrauterine contraceptive device (Conventional types can cause excessive bleeding)OCP’s (inadequate dose/compliance)

Management

Acute bleeding

Acute bleeding

Orthostatic hypotension/ hb<10 gm/dl

NOoutpatient mx

Yes hosp admission

•Premarin 2.5 mg PO qid plus promethazine 25 mg PO or IM or PR q4-6h as needed (nausea)

•No improvement in 2-4 doses of premarin/bleeding soaking 1 pad/hour or more after treatment D&C

•Bleeding stopsswitch to OCP/cycle provera

•Oral iron

•Premarin 25 mg IV q4h x 24h + promethazine 25mg PO or IM or PR q4-6h as needed for nausea

•Transfuse 2 pint packed rbc if Hb< 7.5mg/dl

•1-2 doses no response D &C

•Simultnoeus with premarin start OCP/cycle provera

•Oral ion

MEDICAL

Surgical

PRIMARY DYSMENORRHEA

Indications•Failed medical treatment (minimum 3-6 months)•Intolerable side effects of medical treatment• Organic causes warranting surgery (e.g. fibroid, cancer)•Patient's preference•Co-existing conditions (e.g. adenomyosis withdysmenorrhoea)

Secondary menorrhagia

CONDITION TREATMENT

Uterine fibroidsTx:Asymptomatic(- tx)•medical hormonal/non-hormonal-non-hormonal: transnemic acid/NSAID (during menstruation)-hormonal : OCP, progestogens, androgens, levonogestral releasing IUD, GnRH,GnRH and hormonal add-back•Surgical: myomectomy (hysteroscopic ,laparoscopic, tans abd resection,)hysterectomy, uterine artery embolization, MRI-guided focused US

endometriosis Tx:Medical: hormonalSurgical: Excision, endometrial ablation ,TAHBSO

adenomyosis •tx:-medical-surgicalhysterectomy(without oophorectomy),UAE ,endometrial ablation,

Pelvic inflammatory disease

tx: -medical: broad spectrum AB, clindamycin and gentamicin administered intravenously every 8 hours

Uterine polyps •tx: hysteroscopy + polypectomy

Endometrial carcinoma

•Total abdominal hysterectomy with bilateral salpingo-oophorectomy is required both as a primary treatment and for the purpose of staging

Endometrial hyperplasia

MedicalSimple endometrial hyperplasia without atypia responds to high-dose progestogens, with repeat histology after three months (IUD)SurgicalEndometrial ablation or transcervical resection of the endometriumHysterectomy - usually advised for atypical endometrial hyperplasia

Coagulation disorders

Vitamin k/FFP/coagulation factors/desmopressin

Hypothyroid Thyroid hormone replacement therapy

Anticoagulant’s levonorgestrel releasing intrauterine device (Mirena coil)hysterectomy

IUCD (mx chart)

OCP’s (mx chart)

MANAGEMENT FLOW

Hx and pe

Pregnancy

Non uterine source (cervical ca, lacerations, anus, rectal, urethral)

exclude

FBC

Correct anemia +/- acute

bleeding mx

pap smear (esp if + postcoital bleed)FOBTUFEME

B-HCG

Menarche onset screen for coagulation disorders

Mx accordingly

Mx accordingly

MiscarriageEctopic preg.Antepartum haemorrhage(pp, Abruptio placenta, vasa previa)Etc.

MENORRHAGIA

Symptoms/signs of hypothyroid

Low risk group (most likely DUB)

treat hypothyroidism

Normal

hormonal therapy

iatrogenic

Mx accordingly

Normal/bulky uterus 8-10

weeks

Uterus>10 weeks in size, pelvic mass, tenderness

Further inv:

•TVS

•Hysteroscopy/transvaginal sonohysterography/

•Biopsy

•d & c

•Endometrial hyperplasia/carcinoma•SubmucosalFibroid•endometrial polyps

Symptoms suggests underlying pathology

-

+

HIGH RISK GROUP

Symptoms suggests underlying pathologyAge > 40Irregular/intermenstrual/postcoital bleedingSudden change in bleeding patternDyspareunia

Pelvic painSecondary dysmenorrhea

Risk factorsTamoxifenUnopped estrogenPCOS ( Hirsutism)obesity

Mx accordingly

1st line Abd USS

-

TFT

Need contraceptionyes

no

hormonal therapy-Levonogestrel intrauterine device

-Norethisterone

ovulatory

Yes/does not want hormone therapyno

Tranexamic acid NSAID (ist 5 days of menstruation)

Cyclic oral progestin(luteal phase)

Treatment Successful

Continue medical therapy

treatment failure

Further assestment hysteroscopy and

biopsy

Oral contraceptive pill

Evaluate in 6

months

Evaluate in 3

months

No improvement add mefenemic

acid(NSAIDS) and evaluate in 3 months

No improvement

improve Continue management

CASE STUDY• A 14-year-old girl was referred for assessment

of heavy menses. Menses commenced at the age of 12 years and were unremarkable until the past six months when she noticed an increased amount and duration of bleeding. The menses were regular but had increased from four to seven days of bleeding and she was now using up to 10 pads/day for the first three days. She denied any sexual activity.

• Review of systems was positive for fatigue but negative for change in weight, cold intolerance, shortness of breath, easy bruising or prolonged bleeding

• Past medical history was unremarkable other than for asthma, and a family history could not be obtained because the patient was adopted..

• On physical examination the patient was pale but in no distress. Vital signs were normal. General physical and external genital examination was normal, with no evidence of bruising.

• Laboratory investigation showed hemoglobin concentration of 74 g/L (normal 120 to 153 g/L), mean corpuscular volume and mean corpuscular hemoglobin were both slightly below normal, UPT (-)

• Bleeding time was slightly prolonged at 10 min (normal 2 to 9 min).

• Factor VIII was normal, von Willebrand factor (vWf) antigen was 0.28 IU/mL (normal 0.50 to 1.50 IU/mL).

• The ristocetin cofactor (a measure of vWf activity) was 0.36 IU/mL (0.50 to 1.50 IU/mL).

• Based on these results a diagnosis of von Willebrand’s disease (vWD) type I (vWf is quantitatively reduced but not absent) was made.

Amenorrhea

Definition

• Amenorrhea– Absence of menstruation

• Oligomenorrhea– Menstrual cycles of 35 days - 6 months (and cycle

length typically irregular)

Types of amenorrhea

• Primary• Secondary

Primary amenorrhea

• absence of menstrual bleeding and secondary sexual characteristics (breast development and pubic hair) in a girl by age 14 years

• absence of menstrual bleeding with normal development of secondary sexual characteristics in a girl by age 16 years

Secondary amenorrhea

• cessation of menses after menstruation established– 3 months in woman with previously normal

menstruation– 9 months in woman with previous oligomenorrhea

Incidence

• Secondary more common than primary• 20% vigorously exercising women, up to 50%

elite female athletes• Most affecting– Competitive athletes– Ballet dancers– Gymnasts

Causes for primary amenorrheaBreast + Uterus Breast + Uterus Breast + Uterus Breast + UterusGonadal failure 50% 45 X, 25% 46 X abnormal X (deletion), 25% mosaicism, pure XY gonadal dysgenesis, XY gonadal dysgenesis (Sawyer's Syndrome - XY karyotype, palpable Mullerian system, normal female testosterone levels, lack of sexual development), 17-hydroxylase deficiency (with 46 XX)

Androgen insensitivity (testicular feminization - normal female phenotype, 46 XY, normal or slightly increased male testosterone levels, X-linked recessive)

17,20-desmolase deficiency

Hypothalamic causes

Pituitary causes

Ovarian causes

Uterine causes

CNS-hypothalamic-pituitary disorder - CNS lesion, inadequate GnRH release, isolated gonadotropin deficiency

Congenital absence of uterus (utero-vaginal atresia)

Agonadism 1. Physiological delay2. Weight loss/ anorexia3. Imperforate hymen

Causes of secondary amenorrhea• Hypothalamic-pituitary - destructive lesions, Sheehan syndrome,

hyperprolactinemia, hypothalamic-pituitary dysfunction, weight loss

• Virilizing disorder - PCOS, hyperthecosis, ovarian tumor, congenital adrenal hyperplasia, adrenal tumor, Cushing syndrome

• Psychogenic - anorexia nervosa, change in environment (stress), adolescence

• End organ cause - uterine adhesions, cervical stenosis, vesicovaginal fistula, hormone-resistant endometrium

• Ovarian - gonadal dysgenesis with limited menstrual function, premature ovarian failure, resistant ovaries syndrome

• Thyroid disease

Management

Treatment

• Initial mx– Exclude pregnancy– Perimenopausal symptoms (flushings, vaginal dryness)– History of weight changes, drugs, medical disorders

and thyroids symptoms– Examination assessing the height, weight, visual fields,

presence of virilisation or hirsutism, pelvic examination

– Serum for LH, FSH, prolactin, testosterone, TFT– TVS – polycystic ovaries

Investigations Results TreatmentUltrasound scan PCOS – small, peripheral

placed follicular ovarian cysts surrounded by thickened echodense stroma(supported by LH:FSH ratio >3 and testosterone >3)

If pregnancy desired – clomiphineIf not desired – COCP

Elevated PL level PL> 800 mU/L on 2 occasion – hyperprolactinemia

MRI pituitary and treat with dopamine agonist – bromocriptine

Elevated FSH level FSH > 30 U/L, for patient above 40 is menopause and patient less than 40 is premature ovarian failure

HRT

Abnormal TFT Treat according to the pathology

• If all the test is normal– Weight loss– Depression, emotional disturbances, extreme

exercise– Asherman’s syndrome– Idiopathic amenorrhea

Reference

• Cpg menorrhagia kkm malaysia• Acess medicine• Ten teachers• Dutta gynecology• Shaw’s gynaecology