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Menorrhagia (Aetiology (Neoplastic Fibroids Polyps Cancer (cervical,…
Menorrhagia
Aetiology
Neoplastic
Fibroids
Polyps
Cancer (cervical, endometrial)
Idiopathic
Dysfunctional uterine bleeding (DUB)
heavy menstrual bleeding (HMB)
Inflammatory/infection
Endometriosis
Adenomyositis
PID
Endocrine
Hypothyroidism
Hyperprolactinaemia
PCOS
Haematological
Coagulation disorder e.g. vWD
Metabolic
CLD
CKD
Drugs
Anticoagulation
Copper IUD
Chemotherapy
Epidemiology
Commonest gynae symptom
Commonest cause is DUB/HMB
Commonest gynae referral
Increases with age, peak 30-50y
Diagnosis
Examination
Bimanual examination
Tender, enlarged uterus (adenomyositis, fibroids)
Tender adnexae (endometriosis)
Cervical excitation (cancer, STI)
NOT if young girl not sexually active
Speculum examination
Masses (polyps, cervical Ca)
NOT if young girl not sexually active
Investigations
Bedside
Obs (temp)
Bloods
B-hCG (pregnancy), FBC, haematinics (anaemia, infection)
CRP, cultures (infection), TFTs (thyroid), U+Es, LFTs (baseline)
clotting (APPT, INR), BBV screen (HIV, HCV, HBV, syphilis)
Clotting disorders screen (vWD etc.)
Swabs
Endocervical/vulvovaginal swabs (STIs)
Cervical smear (cytology)
Imaging
Pelvic/transvaginal USS (fibroids, polyps, Ca, adenomyositis)
Hysteroscopy and biopsy (Ca, fibroids, polyps)
Urine
Pregnancy test
History
Obstetric history
Gravidy and parity
Gestation, births, complications
PMH/PSH
Medical - hypothyroidism, clotting disorder
Surgical - previous abdo/pelvic surgery
Past gynae history
LMP, cycle length/regularity
Known gynae issues
Smear history
Sexual history
Contraception
DH
Contraception, anticoagulants
Allergies
HPC
Onset, character (floods, clots), associated (dysmenorrhoea, bloating/pressure, discharge, bowel/urinary symptoms, acne, hirsuitism, systemic symptoms e.g. red flags),
changing menstrual products every 1-2h
FH
Gynae disorders
Cancers
Clotting/thyroid disorders
SH
Occupation, smoking/alcohol
social support
Management
Medical
Hormone therapy
IUD progestrone
Indication: 1L if not needing fertility
E.g. Mirena
MOA: levornogestrel causes endometrial atropy,
inhibits normal cycle, reducing blood loss and pain
SEs: initial irregular bleeding
LHRH-releasing hormones
Indication: acute tx if severely anaemic
COCP
Indication: 2L, not requiring fertility
MOA: inhbits menstrual cycle, reducing blood loss and pain
E.g. microgynon, yasmin
Progesterone only
Indication: 3L, not needing fertility, short term
E.g. norethisterone IM/PO
SE: can completely suppress menses
Anti-fibronolyics
Indication: patients trying to concieve
E.g. tranexamic acid
MOA: increases coagulation, reducing bleeding
CI: thromboembolic disease
NB. take during bleeding only
NSAIDs
Indication: patients trying to concieve
E.g. mefenamic acid
MOA: inhibit PGs, reducing bleeding
CI: peptic ulceration
Surgical
Endometrial ablation
Indication: endometriosis, not needing fertility
MOA: destruction of endometrium by microwave,
thermal balloon, electrical impedence
SEs: reduced fertility
Uterine artery embolisation
Indcation: fibroids, want to retain fertility
MOA: ablation of arteries supplying fibroid
Myomectomy
Indication: fibroids, want to retain fertility
MOA: removal of fibroids
Hysterectomy
Indication: large fibroids, not needing fertility
MOA: vaginal or abdominal hysterectomy
SEs: infertility
Conservative
Identify cause
Information and advice
Referral to gynae for hysteroscopy, USS
Referral (abdominal mass, unclear diagnosis,
refractory to treatment etc)
Clinical
presentation
Heavy vaginal bleeding
Prolonged (>7d)
Floods (>80mL, normally 40mL)
Clots (>2.5cm)
Anaemia
Pallor
Fatigue
Complications
Anaemia
Reduced QoL
Definition
Excessive menstrual blood loss
occurring on a regular basis
that interferes with QoL
(>80mL and/or >7d)