Modern Management

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Modern Management

• of Menorrhagia

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To study the indications for hysterectomy is
to study the interface between medicine and
society
Coulter et al, 1986
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Perspectives

• In California, only 50 of women have their
  uterus at death.
• A gynaecologist in Saudi Arabia will perform only
  one hysterectomy a year.
• In the UK, 20 will have had a hysterectomy

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Local Variations

• Perceived excessive menstruation accounts for 70
  of hysterectomies whilst 25 will have pathology
• 70 of hysterectomy specimens at City Hospital
  have Pathology.
• 40 of hysterectomy specimens at Solihull
  Hospital have Pathology.
• Balachandra et al, 1994 (unpublished data)

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A Structured Approach

• Definition(s)
• Assessment
• Diagnosis
• Management Options

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Definitions

• Objective
• Menstrual Blood Loss gt 80ml
• Clinical Blood Flow Resulting In
• Flooding
• Clots
• Time off work
• Anaemia
• Practical
• Any menstrual blood loss deemed to be excessive
  by the woman

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Assessment

• History
• Regular Cycle suggests Ovulatory
• Irregular Cycle suggests anovulation
• Associated Pain Dyspareunia Intermenstrual
  Bleeding.
• Thyroid Dysfunction (Hypothyroidism)RARE
• Blood Dyscrasias VERY RARE

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Examination

• Anaemia
• Thyroid (Goitre Signs of Hypothyroidism)
• Abdominal Examination
• Cervical Inspection
• Uterus
• Adnexal Masses

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Investigations

• Haematological FBC, (Clotting, Profile, TFTs)
• Pipelle Biopsy (30 Endometrium Sampled)
• Ultrasound PA and TV
• Hysteroscopy (10 will require this)

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Management in Primary Care

• Prostaglandin Synthetase Inhibitors
• Blood Loss by 20-50 (in 75 of women)
• Pain
• Rx Mefenamic Acid 500mg tds during the period
• Antifibrinolytics
• Blood Loss by 50 in women with
• Dysfunctional Uterine Bleeding
• Uterine Fibroids
• Coagulation Defects
• Rx Tranexamic Acid, 3-6g Daily (N.B. side effects)

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Management in Primary Care (Continued)

• Synthetic Progestagens
• Of no benefit in ovulatory menorrhagia
• Must be used from day 5-26 of the cycle
• Variable efficacy
• Rx Norethisterone, 5mg tds or Medroxyprogesterone
  Acetate 10mg tds
• Intrauterine Progestagens
• Blood loss (85 in 3 months 97 at 12 months)
• But Large bore, difficult insertion and cost

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Management in Primary Care (more)

• Combined OCP 50 reduction in blood loss
• Danazol Useful but has adrogenic side effects
• GnRH Analogues (? Livial)
• Synarel
• Zoladex
• Prostap

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Conservative Surgical Options
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Non-Conservative Hysterectomy
Laparoscopic
Subtotal
Abdominal
Total
Vaginal
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When to Refer?

• Age (gt 40yrs)
• Persistent IMB
• Failed Medical management
• Other or Associated Factors
• Abnormal Smear
• Post-coital bleeding
• Severe Pain
• Palpable Mass

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Learning Points

• Regular Cycle ?Ovulation
• Best Option Tranexamic Acid
• Consider MIRENA
• Irregular Cycle?Anovulation
• Still Best Option, Tranexamic Acid
• Consider NET D5-D26
• Refer if Medical Rx Fails, PCB, IMB