1. OVERVIEW OF MENORRHAGIA
JEHAD AL-HARMI
BM, BCh, FRCS(C), FACOG
ASSISTANT PROFESSOR
DEPARTMENT OF OBSTETRICS & GYNECOLOGY
FACULTY OF MEDICINE/KUWAIT UNIVERSITY
CONSULTANT/AL-ADAN HOSPITAL

2. DISCLAIMER I HAVE NO CONFLICT OF INTEREST REGARDING THIS TOPIC
KMA CONFERENCE: UPDATES IN MEDICINE
Saturday, November 24, 2018

3. HEAVY MENSTRUAL BLEEDING (HMB)
INTERNATIONAL CONSENSUS, FIGO 2011
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Saturday, November 24, 2018

4. OBJECTIVES Who? Why? How? KMA CONFERENCE: UPDATES IN MEDICINE
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5. OUTLINE What is HMB? How important is HMB? What causes HMB?
What is the management of HMB?
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Saturday, November 24, 2018

6. What is HMB? KMA CONFERENCE: UPDATES IN MEDICINE
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7. DEFINITION Type of abnormal uterine bleeding (AUB)
Reproductive age group
Exclude pregnancy
Not all vaginal bleeding is uterine
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8. NORMAL MENSTRUATION Age Menarche Menopause Change in pattern Duration
Frequency
Regularity
Volume
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9. SOURCES OF VAGINAL BLEEDING
Uterus
Volume
Color
Circumstances
The rest of the genital tract
Other sources
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10. OTHERS History Examination Urethral caruncle
Hemorrhoids or rectal mass
Investigations
Fecal occult blood
Urine microscopy
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11. How important is HMB? KMA CONFERENCE: UPDATES IN MEDICINE
Saturday, November 24, 2018

12. EPIDEMIOLOGY Common problem Increases with age Peak: 30-49 years
UK: 5% of women consult GP for HMB annually
US: 20-25% of healthy pre-menopausal women C/O HMB
Prevalence in Kuwait???
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Saturday, November 24, 2018

13. EPIDEMIOLOGY
Major impact on QoL, productivity & utilization of healthcare services
Concerns regarding malignancy
IDA develops in 21-67%
Most are managed in an outpatient setting
Occasionally emergency medical care is required
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14. EPIDEMIOLOGY UK: HMB accounts for 25% of gynecological surgeries
20% of women have a hysterectomy by the age of 60 years, mainly for HMB
40% of them have a normal uterus on histological examination
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Saturday, November 24, 2018

15. What causes HMB? KMA CONFERENCE: UPDATES IN MEDICINE
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16. PALM (STRUCTURAL) Uterine Leiomyomas Endometrial Polyps Adenomyosis
Miscellaneous (CS scar, AV malformation)
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17. COEIN (FUNCTIONAL) Ovulatory dysfunction
Coagulation/bleeding disorders
Iatrogenic (anticoagulants, hormonal contraceptives, IUCD)
Neoplastic (endometrial hyperplasia or carcinoma, uterine sarcoma)
Infection and inflammation (endometritis, PID)
Disorders of local Endometrial hemostasis
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18. CAUSES OF ANOVULATION Eating disorders Acute liver failure
Chronic renal failure
Ovarian lesions
Psychiatric disorders
Hypogonadotrophic hypogonadism
Hyperprolactinemia
Hypothyroidism
Pituitary adenomas
PCOS
POF
Adrenal disorders
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19. What is the management of HMB?
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20. CONFIRM THE DIAGNOSIS History Physical examination Rule out pregnancy
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21. INITIAL ASSESSSMENT HEMODYNAMICALLY UNSTABLE Resuscitation
IV fluids, blood products
CBC, PT/aPTT
X-match
Rule out pregnancy
Stop the bleeding (hormonal, mechanical, surgical, interventional radiology)
Referral
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Saturday, November 24, 2018

22. INITIAL ASSESSSMENT HEMODYNAMICALLY STABLE Rule out pregnancy CBC
Rule out a primary medical condition
Referral
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23. DETERMINANTS OF MANAGEMNET
Etiology
Severity of bleeding
Associated symptoms & issues
Contraceptive needs
Medical co-morbidities
Patient preferences
Medical vs. surgical
Short-term vs. long-term therapy
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Saturday, November 24, 2018

24. EMPIRICAL MANAGEMENT
Treatment should not be initiated until the etiology has been evaluated & premalignant or malignant conditions excluded
Empiric treatment without evaluation may miss a primary etiology that may be corrected or mask symptoms of malignant conditions
Treat/prevent IDA
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Saturday, November 24, 2018

25. INITIAL OFFICE WORK-UP
CBC, PT/aPTT
Cervical smear
High vaginal & endocervical swabs
Endometrial biopsy
Ultrasound scan/± saline infusion (SIS)
Hysteroscopy & proceed
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Saturday, November 24, 2018

26. WORK-UP FOR ANOVULATION
COMMON
UNCOMMON
FSH/LH
Estradiol
Progesterone
TSH
Prolactin
OGTT
Cortisol/± ACTH stimulation test
Total/free testosterone
DHEAS
17-OH-progesterone
Pregnenolone
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27. UNDERLYING CAUSE The primary etiology should be treated
Endocrine disorders that are treated medically (PCOS or chronic endometritis)
Structural lesions that are resectable via hysteroscopy (endometrial polyp, single submucosal fibroid)
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28. MEDICAL MANAGEMENT The initial approach is pharmacologic treatment
Levonogestrel IUD
COP’s (cyclic, extended, continuous)
Ultra-low estrogen pills
Depot MPA
High dose oral progestins (norethindrone acetate, MPA)
NSAID’s & tranxemic acid
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29. AVOID ESTROGEN Age ≥ 35 years & smoking ≥ 15 cigarettes/day
Risk factors for CVD (older, smoker, DM & HTN)
Uncontrolled hypertension (≥ 160/100 mmHg)
VTE
Known thrombogenic mutations
Known IHD
History of stroke
Valvular heart disease complicated with pulmonary HTN, AF, SBE
SLE or unknown antiphospholipid antibodies
Migraine with aura
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30. SURGICAL MANGEMENT Women who fail or cannot tolerate medical therapy
Prefer treatment options that do not require frequent dosing
Whether the patient is planning future childbearing
The level of invasiveness & risk associated with the procedure
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Saturday, November 24, 2018

31. SURGICAL MANAGEMENT Fibroids Myomectomy (route) UAE
MRI-guided high-frequency US ablation
Endometrial ablation
Hysterectomy
Vaginal
Abdominal
Laparoscopic
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32. CONCLUSIONS Ascertain hemodynamic stability
Ensure that the bleeding is uterine
Rule out pregnancy
Rule out anemia
Remember the PALM & COIEN
Treat medical underlying conditions if any
Refer to the gynecologist to treat structural causes & chronic anovulation
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Saturday, November 24, 2018

33. THANK YOU KMA CONFERENCE: UPDATES IN MEDICINE
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