Menorrhagia – An overview

By Dr Rukhsana Hussain ST117th November 2009

ObjectivesTo increase awareness of menorrhagia, its

causes and impact on individuals and societyTo cover key points in history-taking and

examinationTo increase awareness of medical and

surgical treatments available as outlined by the NICE guidelines

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

Impact of menorrhagia1 in 20 women aged 30-49 years consults GP

each year with menorrhagiaMany women will have days off work due to

menorrhagia1 in 5 women in UK will have hysterectomy

before age of 60 years50% of all women who have a hysterectomy

for menorrhagia will have a normal uterus removed

Causes of menorrhagia4 main subtypes

1) Ovulatory2) Anovulatory3) Anatomic4) Other causes

Ovulatory menorrhagia“Primary” or “idiopathic” menorrhagia –

treatments guided by probable causesCharacterized by heavy bleeding during

regular cycles. Usually associated dysmenorrhoea and premenstrual symptoms

Probable causes Abnormal prostaglandin synthesisIncreased intrauterine fibrinolysisAcquired /congenital clotting disorders eg

VWD

Anovulatory menorrhagiaUsually 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

Anovulatory menorrhagiaCommon 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.

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

Anovulatory menorrhagiaCauses include

HyperprolactinaemiaThyroid diseaseAdrenal diseaseAnorexia/BulimiaPituitary adenomaChronic illnessStressDrugs – eg. tricyclic antidepressants, steroids

Anatomic menorrhagiaCommonly caused by endometrial polyps or

submucosal fibroids

Polyp

Other causes menorrhagiaCervicitis/endometritisIUDHyperoestrogenismEndometrial cancerCoagulopathy

History – key pointsAge at menarcheOnset and duration of periodCycle – regular or irregular? Length?Amount blood loss – clots? Flooding? Number

sanitary towels? Social impactChanges from previous bleeding patternsIntermenstrual bleedingPostcoital bleedingPelvic painDyspareunia

HistorySymptoms related to anaemia

- SOB/fatigue/dizzinessSymptoms of thyroid disease/systemic illnessPMH – Obstetric Hx, Fertility wishesDH- Warfarin? Aspirin? AllergiesSH – Stress? Smoking? Alcohol intake?FH – Bleeding disorders? Malignancies?

HistoryCover risk factors for Endometrial Cancer

ObesityAge > 45NulliparityPCOSTamoxifen1st degree relative with breast, colon or

endometrial cancerPersonal hx breast/colon cancerUnopposed oestrogen treatment

ExaminationGeneral – pallor? Bruising? Signs of thyroid

disease? BMI?Abdominal examination – fibroid uterus? Pelvic examination

InvestigationsFBC – exclude anaemiaCervical smear if dueIf IMB/PCB vaginal swab for chlamydia screenUSS pelvis if indicatedReferral 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

Medical treatments – First LineLevonorgestrel-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

Medical treatments – First LineSide effects Mirena coil

- progestagenic effects – breast tenderness, acne, headaches

- irregular bleeding at start may last for 6 mths- functional ovarian cystsAlso, risk of uterine perforation at time of insertion

Medical treatments – Second line Tranexamic acidMefenamic acid/NSAIDsCOCP

Can be used first line if Mirena not acceptable to patient

Tranexamic acidAntifibrinolytic agentMean reduction blood loss nearly 50%Dose 1-1.5g tds during menstruation onlyMay be combined with mefenamic acid esp if

dysmenorrhoea prominentTheoretically increased risk DVT but little

evidence in studiesSuitable if patient wanting to conceiveUse for 3 cycles to determine effectiveness

Mefenamic acidReduces prostaglandin productionIndicated for menorrhagia and

dysmenorrhoeaMean reduction blood loss around 30%Dose 500mg tds – taken during menstruation

Side effects – indigestion, diarrhoea, worsening asthma, peptic ulceration

COCPPrevents proliferation of endometrium

therefore reducing blood loss Contraceptive Side effects - headache, mood change, fluid

retention, risk of DVT, stroke

Medical treatments – Third lineOral progestogen – norethisterone

Effective when given in high doses between day 5- 26 of cycle

Dose 5mg tdsInjected progestogen (Depo-provera)

Given every 3/12After 1 year 50% women amenorrhoeicDisadvantage of delayed return to fertility

Medical treatmentsGn-RH analogue injections Stop production of oestrogen and

progesterone inducing amenorrhoeaSide effects include menopausal- like

symptomsRisk of osteoporosis with longer than 6

month use

Surgical/radiological treatments Endometrial ablationUterine artery embolisationMyomectomyHysterectomy

Endometrial ablationIndication – severe impact on quality of life +

no desire to conceive + normal uterus (or small fibroids <3cm diameter)

Destroys womb lining Risk of perforation during procedurePossible side effects – vaginal discharge,

increased period pain

Uterine artery embolisationIndication – 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 overnightSide effects – persistent PV discharge, post

embolisation syndrome – pain, nausea, vomiting, fever. Risk of haemorrhage

MyomectomyIndication – fibroids > 3cm, severe impact on

quality of life

Risks associated with surgery – adhesions, infection, perforation, haemorrhage

Recurrence of fibroids possible

HysterectomyIndication – other treatments failed, no wish

to remain fertile, patient request after fully informed, desire for amenorrhoea

Vaginal /abdominal as indicatedMajor surgery – 4-5 days inpatient stay, risks

of surgeryLonger recovery time- months although

permanent solution for menorrhagia!

SummaryMenorrhagia is a common problemMirena 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

Referenceswww.nice.org.uk – Heavy menstrual bleeding

NICE 2007www.doctors.net.ukOxford Handbook of Obstetrics and

Gynaecology