2. Menorrhagia
• NICE Definition:
“excessive menstrual blood loss which interferes
with the woman’s physical, emotional, social
and material quality of life, and which can
occur alone or in combination with other
symptoms. Any interventions should aim to
improve quality of life measures.”
>80ml per cycle
5. • RCT, n=638 with undertaken in the UK on
women with menorrhagia (Critchley et al,
2001)
• <40 yr group: 11.5% endometrial/uterine
polyps, 36% uterine fibroids, 1% endometrial
cancer and 1% had hyperplasia
• >40 group: 6% endometrial/uterine polyps,
19% uterine fibroids
6. Dysfunctional Uterine Bleeding
• 80% of women treated for heavy menstrual
bleeding have no anatomical pathology
(Lethaby et al, 2008)
• Absence of pelvic pathology
• menarche and perimenopause
• Ovulatory(10%) or unovulatory(90%)
7. Fibroids
• Benign smooth muscle tumour (leiomyomas)
• Common, 20% of women
• Oestrogen-dependent
• Presentation:
– menorrhagia,
– fertility problems,
– pain,
– mass
8.
9. Endometrial Polyps
• growth of the lining of the
uterus
• Presentation:
• asymptomatic, irregular
bleeding, IMB, PMB,
menorrhagia
10. History
• Nature of bleeding
• Symptoms suggesting possible significant
pathology
• Other features that may determine treatment
or other action
12. Investigations
• FBC, ferritinin: anemia
• TFT, coagulation: to exclude systemic cause
• TVS: To exclude local organic causes
• Endometrial biopsy (at hysteroscopy or with
a pipelle)
• Hysteroscopy: visualize uterine cavity
13. Measurement of blood loss
• Direct measurement of MBL – alkaline
haematin
• Indirect measurement of MBL – pictorial
blood loss assessment charts (PBAC)
• Surrogate and self-assessment measures of
MBL
36. Hysterectomy
• 60% of GP referrals for HMB – Hysterectomy
• 24,355 in 1993
• 10,559 in 2002
• Over 95% satisfaction rate after 3 years
• Up to 67% experience complication
– Haemorrhage, damage to abdo. organs
19
37. Hysterectomy - NICE
• Not 1st
line treatment
• Pros/cons/risks
1.Vaginal (fewer complications)
2.Abdominal
Total or Subtotal – shared choice
20
39. Pharmacological intervention - Oral
contraceptive pill
•Farquhar, C. and Brown, J., 2009, Oral contraceptive
pill for heavy menstrual bleeding
•Only one trial of 45 fit criteria
•No significant difference between OCP, mefenamic
acid, low dose danzol or naproxen
•Review unable to achieve objectives
40. • Lethaby, A et al, 2009, Antifibrinolytics for heavy menstrual bleeding.
• Four of fifteen trials that met criteria were used in meta-analysis
• Significant reduction compared to placebo -94.0 (95% CI: -146.5 to -73.8)
• Comparisons with mefenamic acid, norethisterone in luteal phase and
etamsylate all produced a significant reduction in blood loss.
• -73 (95% CI: -123.4 to -22.6), -111.0 (95% CI: -178.5 to – 43.5) and -100
(95% CI: -143.9 to -56.1)
Pharmacological intervention -
Antifibrinolytics
41. • Lethaby, A. et al, 2009, Nonsteroidal anti-inflammatory drugs for heavy
menstrual bleeding
• Nine of seventeen selected trials were included
• NSAIDS were more effective than placebo at reducing bleeding
• Less effective than tranexamic acid, danazol and the levonorgestrel
intrauterine system
• No significant differences between NSAIDS and other medical treatments
Pharmacological intervention -
NSAIDS
42. • Lethaby, A. Et al, 2009, Cyclical progestogens for heavy
menstrual bleeding
• Seven randomised trials that were selected included
• No comparison with placebo
• Significantly less effective than tranexamic acid, danazol and
levonorgestrel IUS
Pharmacological intervention – Oral
progestogens
43. • Lethaby et al, 2009, Progesterone or progestogen-releasing intrauterine
systems for heavy menstrual bleeding
• Nine trials were selected and incorporated
• LNG IUS significantly reduced blood loss compared with luteal
progestogens
• Endometrial ablation compared favourably with LNG IUS
• -45.2 units (95% CI: -56.9 to -33.5), but similar patient satisfaction
Pharmacological intervention –
Levonoregestrel IUS (LNG IUS)
44. • Lethaby, A. et al, 2009, Endometrial resection / ablation
techniques for heavy menstrual bleeding
• No significant difference between hysteroscopic and blind
ablation
• Significant advantage of hysterectomy when compared with
ablation
• Ablation cheaper in short term but narrows over longer term
• Hysterectomy stops all bleeding
Surgical intervention
45. • Majoribanks J, et al, 2010, Surgery versus
medical therapy for heavy menstrual bleeding
• Twelve trials met criteria and were included
• 58% of those randomised to medical
treatment had received surgery by 2 years
Medical vs. surgical
46. • Compared to oral medication endometrial resection
significantly more effective NNT = 2, one study
• Conservative surgery significantly more effective than LNG-
IUS at one year
• Two small studies favoured LNG IUS or found no difference –
skewed data, loss to follow up
• No difference in satisfaction rates between LNG IUS and
surgery
Pharmacological intervention –
Medical vs. surgical
47. Summary
Treatment Reduction in
blood loss (%)
Notes
Combined oral
contraceptive pill
43 Contraceptive, little evidence base,
weight change etc.
Tranexamic acid 29–58 Well tolerated. Do not improve
dysmenorrhea
NSAIDs 20–49 Only taken during menstruation. GI side
effects
oral progestogen* 83 Weight change, nausea, headache,
bloating
Levonorgestrel IUS
(Mirena)
71–94 Contraceptive, irregular bleeding,
ectopics
Endometrial ablation 10% amenorrhea
90% sig.
reduction
Infertility? All methods similar, go for
cheapest.
Hysterectomy 100 Infertility
48. References
• Farquhar, C. & Brown, J. (2009) Cochrane Review – Oral contraceptive pill for heavy
menstrual bleeding.
• Lethaby, A., Irvine, G. & Farquhar, C. (2010) Cochrane Review – Cyclical progestogens for
heavy menstrual bleeding.
• Majoribanks, J., Lethaby, A. & Farquhar. (2010) Surgery versus medical therapy for heavy
menstrual bleeding.
• Lethaby, A., Hickey, M., Garry, R. & Penninx, J. (2009) Cochrane Review – Endometrial
resection/ablation techniques for heavy menstrual bleeding
• Lethaby, A., Shepperd, S., Farquhar, C & Cooke, I. (2009) Ecochrane Review – Endometrial
resev=ction versus hysterectomy for heavy menstrual bleeding
• Lethaby, A., Farquhar, C. & Cooke, I. (2009) Cochrane Review – Antifibrinolytics for heavy
menstrual bleeding.
• Lethaby, A., Augood, C., Duckitt, K. & Farquhar, C. (2009) Cochrane Review – Nonsteroidal
anti-inflammatory drugs for heavy menstrual bleeding
• Lethaby, A., Ivanova, V. & Johnson, N. (2009) Total versus subtotal hysterectomy for benign
gynaecological conditions
• NICE – Heavy menstrual bleeding
Editor's Notes
1. Normal loss is about 35-40 ml monthly
Menorrhagia is very subjective; a more practical definition may be that it is menstrual loss that is greater than the woman feels she can reasonably manage.
Menorrhagia is menstrual blood loss which interferes with the woman&apos;s physical, emotional, social, and material quality of life, and which can occur alone or in combination with other symptoms
n one study, over half the women referred for endometrial ablation complaining of heavy periods had menstrual blood losses of less than 80 mL. 3 Social embarrassment, inconven ience, costs of sanitary protection, the safety of using tampons, and interference with sexual activity all make coping with menstruation difficult.
Heavy menstrual bleeding (HMB) should be recognised as having a major impact on a woman&apos;s quality of life, and any intervention should aim to improve this rather than focusing on menstrual blood loss.
33% of women describe their periods as heavy, most do not seek help. 1 in 20 women aged 30 to 49 years consult their GP each year for heavy periods and menstrual disorders. It is the second commonest gynaecological condition to be referred to hospital, accounting for 12% of all gynaecological referrals. Heavy menstrual bleeding accounts for 12% of all gynaecology referrals in the UK.
Pitkin J; Dysfunctional uterine bleeding. BMJ. 2007 May 26;334(7603):1110-1.
Harlow SD, Campbell OMR. Epidemiology of menstrual disorders in developing countries: A systematic review. BJOG: an
International Journal of Obstetrics and Gynaecology 2004;111(1):6–16.
Blood dyscrasias: von willebrand:von Willebrand disease (vWD) is the most common hereditary coagulation abnormality described in humans, although it can also be acquired as a result of other medical conditions. It arises from a qualitative or quantitative deficiency of von Willebrand factor (vWF), a multimeric protein that is required for platelet adhesion.
40 to 60% of those who complain of excessive bleeding have no pathology and this is called dysfunctional uterine bleeding.20% of cases are associated with anovulatory cycles and these are most common at the extremes of reproductive life.Local causes include:Fibroids.Pelvic inflammatory disease.Carcinoma, especially endometrial carcinoma in women over 40; this usually presents with postmenopausal bleeding, but 20 to 25% of cases present with abnormalities of the menstrual cycle.Systemic disease can include hypothyroidism and bleeding disorders.An intra-uterine contraceptive device (IUCD) will increase menstrual flow and it has been claimed that sterilisation operations also increase loss. Prior to the operation women may have been taking oral contraceptives and, in comparison, they make periods artificially light. Further studies have found that sterilisation does not increase menstrual loss.2
Systemic disease: hypothyroidism, liver disease, obesity, polycystic ovarian syndrome (PCOS), haematological disorders
Critchley HO, Warner P, Lee AJ, et al. Evaluation of abnormal uterine bleeding: comparison of three outpatient procedures within
cohorts defined by age and menopausal status. Health Technology Assessment 2001;8:(34)iii–iv,1–139.
Diagnosis must be made by exclusion, since organic pathology must first be ruled out
Periods soon after the onset of menstruation in girls (the menarche) and just before menopause may in some women be particularly heavy. Hormonal disorders involving the ovaries-pituitary-hypothalamus (the &apos;ovarian endocrine axis&apos;) account for many cases, and hormonal-based treatments may regulate effectively.
10% of cases occur in women who are ovulating, but progesterone secretion is prolonged because estrogen levels are low. This causes irregular shedding of the uterine lining and break-through bleeding. Some evidence has associated Ovulatory DUB with more fragile blood vessels in the uterus.
The lining of the uterus builds up naturally under the hormonal effects of pregnancy, and an early spontaneous miscarriage may be mistaken for a heavier than normal period.
As women age and move towards menopause, ovulation is delayed and the remaining follicles in the ovaries become resistant to GnRH ( Gonadotropin releasing hormone )secreted by the hypothalamus gland in the brain. Either that or they don&apos;t develop an egg, and thus no progesterone is produced. Without progesterone, the estrogen is &quot;unopposed&quot; and keeps building up the lining of the uterus.
During a woman&apos;s period, the endometrial lining which is normally shed never gets the signal to stop thickening. It keeps growing and sheds irregularly. Due to the extra thickness, the bleeding is unusually heavy. Less frequently in this age group, too little estrogen causes the irregular bleeding. Most cases of hemorrhagic are due to normal hormonal changes preceding menopause.
Lethaby A, Irvine G, Cameron I; Cyclical progestogens for heavy menstrual bleeding. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD001016. [abstract]
The GDG identified three main areas of questioning.
Nature of bleeding
Initially the clinician should establish that the woman has menstrual bleeding that is, in her and
the clinician’s opinion, heavy.
32
Heavy menstrual bleeding
While non-menstrual bleeding is outside the scope of this guideline, epidemiological evidence
suggests that an alteration in the menstrual cycle, intermenstrual bleeding or post-coital bleeding
may be the first symptoms of gynaecological cancer and indicate the need for a pelvic examination.
95 Persistent intermenstrual bleeding requires investigation to exclude malignancy.95
Symptoms suggesting possible significant pathology
The GDG felt that pelvic pain and pressure effects should be investigated, as these may indicate
the presence of uterine pathology or disorders.
Other features that may determine treatment or other action
It is important for the clinician to explore the woman’s perspective. By exploring the woman’s
ideas, concerns and expectations regarding HMB and its treatment, the requirements of therapy,
education and reassurance may be determined. In addition, the clinician should elicit details of
what treatment the woman has already undergone, if any.
In addition, the GDG felt that issues such as age, an up-to-date smear test, family history of pathology,
and future fertility and contraception plans should be ascertained.
General obs: Note general appearance and BMI. Body fat is very important in relation to metabolism of steroid hormones.
Note any signs suggestive of endocrine abnormality or bruising.
Look at the tongue for pallor and the nails for koilonychia.
Anaemia is common; pallor (pale skin, mucosal linings and nail beds) but this is not a reliable sign.
Irregular enlargement of uterus suggests fibroids; tenderness with or without enlargement suggest adenomyosis.
Ovarian mass might be felt. Tenderness and immobile pelvic organs are common with infection and endometriosis.
Ferritin is a ubiquitous intracellular protein that stores iron and releases it in a controlled fashion. The protein is produced by almost all living organisms, including bacteria, algae and higher plants, and animals. In humans, it acts as a buffer against iron deficiency and iron overload.[3] If the ferritin level is low, there is a risk for lack of iron, which could lead to anemia
Tvs: will assess endometrial thickness, detect fibroids, ovarian mass, detect larger intrauterine polyps
Endo biopsy: if woman is &gt;40 with recent onset of menorrhea, ass w/ imb or has not responded to tx. To exclude endometrial malignanacy
Hysteroscopy: polyps or fibroids that could be resected
Pipelle:To make a diagnosis of, or exclude malignancy and premalignancy, it is necessary to obtain an endometrial biopsy for histological examination
Evidence from six diagnostic studies shows that the estimation of MBL from sanitary material
using the alkaline haematin test is an accurate and precise method
Given that sanitary product recovery methods may have limited use in clinical practice, other
methods have been developed. These methods focus on indirect measures or self-assessment.
Measuring menstrual blood loss either directly (alkaline haematin) or indirectly (‘pictorial
blood loss assessment chart’) is not routinely recommended for HMB. Whether menstrual
blood loss is a problem should be determined not by measuring blood loss but by the woman
herself. [D(GPP)]
Endometrial polyps
Indications for useEndometrial biopsy should be considered in the following women:All women aged &gt;40 years with abnormal bleeding.Younger women with risk factors for endometrial cancer:Nulliparity (pregnancy protects against endometrial carcinoma by interrupting the continued stimulation of the endometrium by oestrogen)Family history of endometrial or colonic cancerA history of abnormal smearsObesityPolycystic ovary syndromeTamoxifen therapyUnopposed oestrogen therapyYounger women in whom abnormal bleeding does not resolve with medical treatment.
Procedure:
Bimanual examination to assess the size and position of the uterus.The cervix is visualised using a vaginal speculum and cleaned.Recent research has looked at transcervical instillation of 5 mls 2% lignocaine. This was shown significantly to reduce pain during endometrial sampling.2A tenaculum applied to the anterior lip of the cervix is used to provide gentle traction whilst a sound is inserted though the cervical os. This reduces the risk of uterine perforation. The tenaculum should be used to straighten the uterocervical canal, thereby preventing the pipelle from passing through the thin walled posterior vaginal wall.Dilators may be required if there is difficulty in passing the sound.When the position and size of the uterine cavity have been assessed, the pipelle is inserted through the cervical os and advanced until gentle resistance is felt.The inner piston of the device is then withdrawn to create suction and the endometrial sample is obtained by moving the pipelle up and down within the uterine cavity by approximately 2-3 cm but not beyond the cervical os. As the cannula is rotated during removal, a strip of endometrium is peeled off and sucked into the syringe.This procedure should be repeated at least four times and the device rotated 360 degrees to ensure adequate coverage of the area.The pipelle is then withdrawn from the cervical os and the endometrial sample expelled into a solution of formalin for transport to the laboratory.
Antifibrinolytics - Inhibits plasminogen activation. Stops fibrinolysis. Contraindication – thromboembolic disease
Oral progestogens - Imbalance between oestrogen and progesterone. Too much oestrogen, lots of endometrium. Possibly anovulatory cycles
Weight change, nausea, headache, dizziness, insomnia, loss of libido, bloating…
Cost in 1995
Progesterone or progestogen-releas- ing intrauterine systems (PPRIUS) were initially introduced in an effort to reduce IUCD expulsion, by the addition of ’uterine- relaxing hormones’
Found that it caused a significant reduction in menstrual blood loss.
Mirena is only currently available
Endometrial hyperplasia – estrogen replacement therapy
Half of pregnancies that occur with mirena are ectopic
Mirena cant be used in people with PID & also itself is associated with higher risk of PID
Use hormonal based if acceptable. If not, then use tranexamic acid/NSAIDs
Progestogen throughout cycle, NOT just luteal
Direct – can see what ur doing, can see polyps etc
Non hyst – doesn’t require theatre/anaesthesia
(a large uterus and/or uterine fibroids make it more difficult to use the less invasive techniques
Vaginal route – shorter recovery, fewer complications
Total is bigger operation
Subtotal has slightly higher chance of ongoing menstrual bleeding
Hysterectomy also anaesthetic, DVTs etc
Other options have failed
Wish for amenorrhea
Woman who has been fully informed requests it
Nwoman no longer wishes to retain her uterus and fertility
