Menorrhoagia - Lecture Notes

Menorrhagia Average blood loss is 40mls with 70% is 1st 48hrs Menorrhagia = heavy cyclical bleeding over several consecutive cycles (>80mls) Assessment Flooding, leaking, double protection, Impact on life Irregular bleeds, dyspareunia, pelvic pain, IMB, PCB may à underlying pathology Symptoms of anaemia, thyroid disorders, clotting disorders Break through on pill IUCD Last smear Medication (inc warfarin, cocp (compliance good?), tamoxifen/clomiphene (sister drugs, partial oestrogen agonists) Examination Systemic – pulse, BP, height, weight, thyroid/anaemia signs Abdomen – masses (inc pregnancy), tenderness V+V – vulva & vagina Cx – cervix should be “pink & happy”, check coil threads Ut – uterus (85% anteverted, 15% retroverted) Ad – Adenexa for tenderness, masses Investigations – FBC (anaemia), TFTs & clotting only if in history, USS for physical pathology, Pipelle biopsy > 40 yrs ? endometrial Ca, Smear if one due or cervix looks suspicious DUB (>80% cases) Menorrhagia in absence of recognisable pelvic pathology, complications or systemic disease = diagnosis of exclusion. Can be ovulatory (regular with cramping pain) or anovulatory (painless & irregular). Anovulatory = no progesterone à continual proliferation, eventually bleed will occur Due to abnormal Prostaglandin levels in endometrium so give NSAIDS (mefonamic acid) Non hormonal treatment FeSO4 – to treat anaemia prostaglandin synthesis inhibitors (NSAIDs = mefenamic acid) – also analgesic actions antifibrinolytics (tranexamic acid) inhibits plasminogen activator à increases clot formation contraindicated if predisposition to thromboembolism Hormonal Treatment COCP/HRT – suppresses endometrium & regulates cycle Systemic progestogens (mini pill, depot, implanon) – suppresses endometrium Mirena – suppresses endometrium, = alternative to hysterectomy peri/post menopausal GnRH analogues – short term use only, suppresses pituitary & ovarian activity Danazol – synthetic androgen, suppresses endometrium but à androgenic side effects (hirsuitism, increased muscle bulk, voice change (irreversible) Surgical treatment Hysterectomy (abdominal, vaginal or laparoscopic) – only definite treatment Endometrial resection – remove down to transition layer so wont grow back Endometrial ablation – electrocautery, laser, thermal, microwave (80% have relief) Polyps – benign localized growths of endometrium – fibrous core covered by columnar epithelium Can cause irregular / IM bleeding, <1% malignant Management: remove under GA by polypectomy or laser/resection Fibroids Leiomyomas, benign tumours of myometrium, well circumscribed whorls of smooth muscle cells with collagen. Can be subserosal, submucous, intramural, cervical. Growth mediated by sex steroids (esp oestrogen) so grow in pregnancy & shrink in menopause) 20% of reproductive age women, more common in afro-carribean, nullips, intertile, obese less common in OCP users (oestrogen sensitive) & smokers Symptoms Can cause menorrhagia, infertility, miscarriage, dyspareunia or pelvic discomfort. Affect uterine contraction & can have own blood supply. Can cause pressure effects on bladder à frequency & hydronephrosis. Medical treatment – GnRH analogues à low oestrogen (causes menopausal symptoms + osteoporosis) à shrinkage, regrowth occurs on cessation of treatment. Limited to 6 months. Surgical treatment – resection of small fibroids may be possible, can à improved fertility and relief of menstrual problems. Myomectomy if wish to retain fertility (has same risks as hysterectomy. Uterine artery embolisation – allows to maintain fertility. Hysterectomy if family complete. Endometrial Hyperplasia & Carcinoma Can cause PMB, irregular bleeding & menorrhagia. See page on uterine cancers Adenomyosis Causes heavy & painful periods Endometrial tissue within the myometrium Bulky tender uterus Treatments as for endometriosis (often unsuccessful) – hysterectomy = only cure Medical disorders (inc clotting defects) Thyroid disease, hepatic or renal disease Coagulation abnormalities (von Willebrands disease), platelet defects (thrombocytopenia), heparin & warfarin Dysmenorrhoea Excessive pain (cramping, lower abdominal pain) Primary – within 2 yrs of menarche – most severe on 1st day. Thought to be due to higher PG. Managed mainly by discussion and reassurance. Management - Can use NSAIDs, COCP or Progestogens. Hyoscine is muscle relaxant Secondary – associated with pelvic pathology. Most commonly endometriosis, adenomyosis, pelvic infection, fibroids or presence of IUCD. Management is by treatment of pathology