Menorrhagia

1
Menorrhagia

• Samadhi Reid
• NPT VTS
• September 2008

2
Definition

• Excessive menstrual blood loss, which
  interferes with a womans physical, social,
  emotional and/or material quality of life.
  Whether menstrual blood loss is a problem should
  be determined not by measuring blood loss but by
  the woman herself
• NICE 2007

3

• Age if gt 45 need to think of endometrial
  carcinoma or atypical hyperplasia
• Menstrual Hx
• Establish impact on QOL
• Duration of symptom if since menarche, consider
  bleeding disorder
• Is the cycle regular and heavy or
• Is there IMB, polymenorrhoea or post coital
  bleeding

4

• If there is abnormal bleeding
• Need to explore smear Hx
• PV Discharge, Sexual Hx
• Is there pelvic pain/ dyspareunia
• Contraception - COCP, Implant, Cu coil
• Contraception
• Is this needed?
• Obstetric Hx
• Relevant if a coil is being considered,
• Is the family complete?
• Check for symptoms of hypothyroidism, PMH and DH

5
Examination and Investigations

• If the Hx suggest no structural or histological
  abnormality Rx can be started without physical
  examination or other Ix, in the primary care
  setting (NICE 07)
• Swabs may be indicated
• ? FBC
• ? Routine TFT, clotting
• USS - If structural or histological abnormality
  is suspected

6
Management

• If no structural or histological
  abnormality is present, or for fibroids less than
  3 cm in diameter which are causing no distortion
  of the uterine cavity (NICE 07)
• LNG-IUS provided long-term use is anticipated
• 2) Tranexamic acid (1g TDS) or NSAIDs
• (Mefenamic acid 500mg QDS)
• or COCP
• 3) Norethisterone (15 mg) daily from days 5 to 26
  of the menstrual cycle
• or injected long-acting progestogens

7
Oxford General Practice Library- Womens Health,
Salder C at el, 2008, Oxford University press
8

• Consider Referral
• Endometrial biopsy - treatment failure, if gt45
  yrs, persistent IMB
• Further Ix - Hysteroscopy (when USS results are
  inconclusive)
• Palpable fibroids, or uterine length gt 12 cm on
  USS

9

• Surgical Treatment
• If fertility is to be preserved
• Uterine artery embolisation as first line Rx
• Myomectomy
• If fertility is not an issue
• Endometrial ablation is the first choice
• Hysterectomy, Vaginal preferred to Abdominal

10

• Case 1
• 42 yr, presented in Dec 07 with HMB
• Regular cycle 28-32/7, prolonged bleeding,
  lasting 2/52
• O/E NAD, Refused coil, Rx with Tranexamic Mef
  acid
• Bleeding slightly better continued to c/o
  tiredness
• Hb 6, USS Referral
• USS - ? Endometrial thickening
• Hysteroscopy - Polyp, was Rx, benign