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HEAVY MENSTRUAL BLEEDING [MENORRHAGIA] (CAUSES (MED DISORDER - clotting…
HEAVY MENSTRUAL BLEEDING [MENORRHAGIA]
most common cause of iron deficiency anaemia in women in affluent world
abnorm = >80ml/month
this is a common indication for hysterectomy
CAUSES
UTERINE PATHOLOGY
BENIGN
adenomyosis
pelvic infection
endometrial polyps
fibrous tissue core covered by columnar epithelium
arise as a result of disordered cycle of apoptosis and regrowth of endometrium
Fibroids
over half usually have excessively heavy loss >200ml
{leiomyomas) well circumscribed whorls of smooth muscle cells with collagen
more commin in afro-caribbean
submucous project into uterine cavity, intramural are contained within uterine wall, subserosal project from surface of uterus.
presentation depends on size of fibroid
menstrual dysfunction
infertility - due to impeding implantation
miscarriage
dyspareunia
pelvic discomfort
may affect surrounding organs - frequency micturition (press on bladder) or even hydronephrosis due to ureteric compression
growth mediated by sex steroids = grow during preg and shrink in menopause
MALIG
Endometrial cancer
NO APPARENT CAUSE
diagnosis of exclusion
MED DISORDER - clotting defect
hypo and hyper thyroid
hepatic disease
renal disease (but end stage renal failure is amenorrhoeic)
coag abnorm: vWd and platelt defectse.g. thrombocytopenia assoc with inc incidence of HMB
ASSESSMENT
HISTORY
number of sanitary towels used
duration of bleeding
complaints of flooding - leak heavy blood loss onto clothing
having to use double sanitary protection
Hx of irreg bleeding, dyspareunia, pelvic pain or intermenstrual or post-coital bleeding - RAISES SUSPICION OF PATHOLOGY [RED LIGHT SYMPTOMS]
SYMPTOMS SUGGESTIVE OF ANAEMIA: fatigue, light-headed
HX SUGGESTIVE OF SYSTEMIC DISEASE
Thyroid disorder
clotting abnormality
RF for endometrial cancer
unopposed oest
tamoxifen use
PCOS
fam hx of endo or colon cancer
hx of thromboembolism as many HMB treatments are hormonal = contraindicated
EXAMINATION
Signs of anaemia
abdo exam
bimanual and speculum exam
enlarged bulky uterus suggests uterine fibroids
tenderness suggests endometriosis, pelvic inflam disease or adneomyosis
IX
US (pelvic)
if exam suggest structural uterine pathology or if not possible to assess uterus clinically due to obesity
site and size of fibroids can be determined as well as assess ovaries
ENDO ASSESSMENT
performed in all women >45 and in young with persistent HMB spite treatment, red light symptoms and those with rf of endo cancer
can be biopsy or hysteroscopy
LAB TESTS
FBC - diag anaemia; TFT - (hx dependent); COAG - (hx dependent); no other endocrine test usualy indicated
CERVICAL CYTOLOGY
performed if it is due or cervix looks suspicious
TREATMENT
FOCAL UTERINE PATHOLOGY
MEDICAL
GnRH analogue (result in hypooestrogenism) cause fibroid shrinkage but response is poor
shrink by 50% over 3 mths - but regrow on cessation
hypo-oestrogenim may cause: hot flush, bone loss
limited to short term use <6mths
add back therapy of HRT to minimise risk of osteoporosis and side effects
NEW DRUGS: PROGESTERONE MODULATORS [ulipristal acetate] - good for fibroid related HMB- no effectto oest level- restricted use 3mths due to changes in endo
SURGICAL
hysteroscopic resection of small submucous fibroids = imrpoved fertility and relieve mens prob
ENDO ablation in presence of small fibroid is possible
myomectomy conserves facility but at risk of haemorrhage due to vasculature of fibroids, adhesions may form, other fibroids may grow. CS at labour due to fear of uterine rupture in labour
UTERINE ARTERY EMBOLISATION - stop blood supply to fibroid= shrink to 50%. severe pain after occlusion = need opiate analgesia. COMPLICATIONS = infection, fibroid expulsion and effects to exposure of ionizing radiation
HYSTERECTOMY if completed family
HMB WITH NO PATHOLOGY
MEDICAL
Intrauterine progestogens [levonorgetrel intrauterine system] FIRST LINE TREATMENT FOR HMB
Can stay in place up to 5 yrs
after 12mths menstrual blood loss reduced by up 95%
main issues are irreg bleeding within first 3-6mth after insertion and an expulsion rate 5%
PROSTAGLANDIN SYNTHESIS INHIBITORS
nsaids taken during mens dec blood loss by 25%
use MEFENAMIC ACID (nsaid)
SE: GI complaints, dizzy, headache
also good in treating dysmenorrhoea
ANTIFIBRINOLYTICS
TRANEXAMIC ACID
inhibit plasminogen activator = dec fibrinolytic activity in endo
this inc clot formation in spiral arteriole and reduces menstrual loss by 50%
SE: GI, N+V, tinnitus
dont take if predisposed to thromboembolism
NSAIDs and antifibrinolytics are best options for those wanting to coneive as only taken during menstruation and dont suppress ovulation
COCP
DEC blood loss by 50%
no age restriction on use
SYSTEMIC PROGESTOGENS
taken in a cyclical fashion
useful in regulating otherwise irreg cycles
DEPOT INJECTABLE = MEDROXYPROGESTERONE ACETATE ----> AMENORRHOEA
initally bleeding can be unpredicatable and heavt
SE: nausea, bloating, headache, breast tenderness, weight gain,acne
GnRH ANALOGUES
Amenn results due to pituitary downreg = inhib ovarian activity
may exp hot flush and vag dryness
used short term (6mths) and add back HRT
DANAZOL
SYNTHETIC ANDROGEN WITH ANTI-OEST AND ANTI-PROGESTOGEN ACTIVITY = reduces menstrual blood loss but no longer recommended - poor SE profile (virilization)
SURGICAL
ENDO ABLATION
blate to the endomyometrial border as is able to regenerate from the basal layer
shorter hosp stay and recovery than hysterectomy
70-80% overall satisfaction
possible complications (rare): uterine perforation, hyponatraemia, infection
preg is contraindicated after an ablation procedure = use contraception
HYSTERECTOMY
only procedure that guarantees amenorrhoea as a consequence
TOTAL ABDO HYSTERECTOMY
PROS
cervix is removed, therefore no further smears or risk of cervical malignancy
good access to ovaries
CONS
increased surgical morbidity
SUBTOTAL ABDO HYSTERECTOMY
PROS
fewer complications than TAH (bleed/infec/bladder injury/ureteric damage)
good access to ovaries
CONS
risk of cervical cancer remains as before
VAGINAL HYSTERECTOMY
PROS
may be lower incidence of bladder and bowel injury in straightforward cases (compared with abdo hysterectomy)
no painful abdo wound
CONS
limited ovarian access
contraindicated in those with:
large uterus
restricted uterine mobility
limited vaginal space
adnexal pathology
cervix flush with vagina
risk of bowel trauma/damage urinary tract/postop thromboembolism/risk of vag prolapse yrs later
