Menorrhagia(For undergraduate MBBS)

Menorrhagia(For undergraduate MBBS)

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  Menorrhagia (Heavy menstrual bleeding) DRFahmida Rashid Assistant Professor CMC
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  Definition Cyclical bleeding atnormal interval ; the bleeding is either excessive in amount(>80 ml) or duration(>7 days) or both
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  DEFINITION DEFINITION Menorrhagia is excessivemenstrual blood loss over several consecutive cycles which interferes with the woman's physical, emotional, social, and material quality of life. (Nice 2007) Commonest cause of iron deficiency anaemia in women of reproductive age
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  OTHER IMPORTANT DEFINITION… TERMSDEFINITION 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
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  ClassificationClassification Primary/FunctionalPrimary/Functional Secondary/OrganicSecondary/Organic Idiopathic / DUB Idiopathic/ DUB ovulatoryovulatory Non- ovulatory Non- ovulatory -Uterine and ovarian pathologies -Systemic diseases -Iatrogenic causes -Uterine and ovarian pathologies -Systemic diseases -Iatrogenic causes
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  Symptoms • Soaking through1 or > sanitary pads or tampons every hour for several consecutive hours • Needing to use double sanitary protection to control menstrual flow • Needing to wake up to change sanitary protection during the night • Bleeding for longer than a week • Passing blood clots with menstrual flow for more than one day • Restricting daily activities due to heavy menstrual flow • Symptoms of anemia, such as tiredness, fatigue or shortness of breath
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  When to seea doctor • Vaginal bleeding so heavy it soaks at least one pad or tampon an hour for more than a few hours • Bleeding between periods or irregular vaginal bleeding • Any vaginal bleeding after menopause
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  Risk factors • Adolescentgirls who have recently started menstruating. • Girls are especially prone to anovulatory cycles in the first year after their first menstrual period (menarche). • Older women approaching menopause. • Women ages 40 to 50 are at increased risk of hormonal changes that lead to anovulatory cycles.
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  Complications Iron deficiency anemia: Menorrhagiamay decrease iron levels enough to increase the risk of iron deficiency anemia. Severe pain. with heavy menstrual bleeding, one might have painful menstrual cramps (dysmenorrhea).
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  Common causes ofMenorrhagia • Dysfunctional Uterine Bleeding • Fibroid Uterus • Adenomyosis • Chronic Tubo-Ovarian Mass
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  PRIMARY/FunctionalPRIMARY/Functional
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  • Disturbed Hypothalamo-Pituary- Ovarian-Endometrialaxis
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  DUB •Heavy or irregularmenstrual bleeding , not caused by an underlying anatomical abnormality, such as a fibroid, or tumor (abnormal uterine bleeding without any obvious structural or systemic pathology) •Dx of exclusion •Hormonal imbalance, hypothalamus-pituitary- ovary axis •Women who Just started menstruation/perimenopausal •Heavy or irregular menstrual bleeding , not caused by an underlying anatomical abnormality, such as a fibroid, or tumor (abnormal uterine bleeding without any obvious structural or systemic pathology) •Dx of exclusion •Hormonal imbalance, hypothalamus-pituitary- ovary axis •Women who Just started menstruation/perimenopausal Anovulatory 90% Anovulatory 90% Ovulatory 10% Ovulatory 10% Unopposed estrogen Unopposed estrogen Associated with increased prostaglandin release (hemostatic deficiency) Associated with increased prostaglandin release (hemostatic deficiency) Mx: 1.Medical 2.Surgical Hysterectomy endometrial ablation
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  • Anovulatory cycles  Unpredictable cycle  length •  Unpredictable  bleeding pattern  • Frequent spotting  • Infrequent heavy  bleeding  Monophasic  temperature curve •Ovulatory cycles  Regular cycle length Presence of premenstrual  symptoms  -Dysmenorrhea  -Breast tenderness  -Change in cervical mucus  -Mittleschmertz  Pain  Biphasic temperature  curve  Positive result from use of  luteinizing-hormone  predictor kit
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  SECONDARY CAUSES/OrganicSECONDARY CAUSES/Organic
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  PCOS Uterine and ovarian pathologies/Pelvic Uterine and ovarian pathologies /Pelvic Pelvic endometriosis Fibroid Uterus Adenomyosis Tubercular Endometritis Chronic Tubo-Ovarian Mass IUCD in Utero Retroverted Uterus Granulosa cell tumor of Ovary
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  • Systemic: • LiverDysfunction(Cirrhosis) • Congestive Cardiac Failure • Severe Hypertension • Endocrinal : • Hypothyroidism • Hyperthyroidism
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  • Haematological: • Idiopathicthrombocytopenic Purpura • Leukemia • Von Willebrand,s Disease • Platelet deficiency (thrombocytopenia) • Emotional Upset
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  Endome triosis Age: reproductive age Bleeding pattern: menorrhagia, usuallylasts more than 7 days short interval Ass.symp: dysmenorrhoea/ chronic pelvic pain, dyspareunia, difficulty conceiving Examination: wide spectrum, depends menstruating/n ot abdominal tenderness, mass Speculum: red, hypertrophic lesions , bleeding on contact seen at post.fornix Inv: laparoscop ic, TVUS,
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  Adenomy osis •Age: 40 and50 years old,parous/prior uterine surgery •bleeding pattern: menorrhagia ,postccoital, Intermenstrual •ass, Symp.: dysmenorrhea, dyspareunia •Exam: •The uterus is enlarged and boggy •Tenderness •mass (adenomyo ma) Inv : TAS/TVS (diffuse thickening within wall), MRI, hysterosco pic/laparos copic biopsy
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  • Systemic diseasesand disorders:
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  • Iatrogenic causes: symptomsstart after medication/therapy started
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  Diagnosis • Long durationOf flow • Passage of big clots • Use of incresed number of thick sanitary pads • Pallor • Low level of Hemoglobin
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  History • Full gynaecologicalhistory • Notoriously inaccurate amount of blood loss • Number of pads/tampons used • Clots/ flooding • Frequency of accidents • Menstrual chart can be useful
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  Examination • Weight • Anysigns of endocrine disturbance • Abdominal and pelvic examination • Cervical smear if indicated
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  Tests and diagnosis Blood tests. evaluate for iron deficiency (anemia) and other conditions, such as thyroid disorders or blood-clotting abnormalities.  Pap test. cells from cervix are collected and tested for infection, inflammation or cancerous changes.  Endometrial biopsy.  Ultrasound scan. For uterus, ovaries and pelvis. Based on the results of initial tests, you may recommend further testing, including:
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   Sonohysterogram. During thistest, a fluid is injected through a tube into uterus by way of vagina and cervix. using ultrasound to look for problems in the lining of uterus.  Hysteroscopy. This exam involves inserting a tiny camera through vagina and cervix into uterus, which allows to see the inside of uterus.
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  Management
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  • Drug Usedto treat Menorrhagia: • NSAID- Mefenamic Acid • Ibuprofen • Indomethacin • Antifibrinolytic – Tranexamic Acid • Amino caproic Acid • Hormones-Progesterone • Norethisterone • Combined Estrogen –Progesterone • Other- Danazol • GnRH A
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  Treatment • If anypathology is found it must be treated, rest aim to treat dysfunctional uterine bleeding • Anovulatory- extremes of age. • OCP can help. • Cyclical progestogens used to induce regular withdrawl bleeds. • Acute arrest for heavy bleeding- high dose reducing course of progestogen
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  Treatments and drugs Iron supplements. If have anemia, recommend iron supplements regularly.  Nonsteroidal anti-inflammatory drugs. such as ibuprofen or naproxen - reduce menstrual blood loss. relieving painful menstrual cramps (dysmenorrhea).  Mefanamic acid, given for a few days during menstruation
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  Treatment • Antifibrinolytic drugs- •reduce enhanced fibrinolytic activity within the uterus. • Up to 50% reduction. Tranexamic acid
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  hormone
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   Oral contraceptives- ovulation suppressed . oestrogen levels remain constant. Help regulate menstrual cycles and reduce episodes of excessive or prolonged menstrual bleeding.  Oral progesterone.  help correct hormone imbalance and reduce menorrhagia.
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   The hormonalIUD (Mirena).  Can cause amenorrhoea  releases a type of progestin called levonorgestrel, • makes the uterine lining thin • decreases menstrual blood flow & amenorrhoea • decrease cramping.
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  • Danazol: anti gonadotrophin. Inducesatrophy of endometrium due to low level of circulating sex steroids. Androgenic side effects not tolerated well- virilizing effects
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  Surgical Treatment  Dilation andcurettage (D&C).   Uterine artery embolization.  Fibroids- goal to shrink it in uterus by blocking the uterine arteries and cutting off their blood supply.
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   Myomectomy. surgical removal ofuterine fibroids.  Endometrial ablation. permanently destroying the lining of uterus . hysteroscopically and ablated. Many methods-laser, rollerball, hydrothermal, cryoablation, microwave. amenorrhoeic .
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   Endometrial resection Hysterectomy.  surgery to remove your uterus and cervix . permanent procedure , causes sterility and ends menstrual periods. definative treatment if family complete.