1. By Dr Rukhsana Hussain ST1 17 th November 2009

2. Objectives To increase awareness of menorrhagia, its causes and impact on individuals and society To cover key points in history-taking and examination To increase awareness of medical and surgical treatments available as outlined by the NICE guidelines

3. Menorrhagia - Definition “Excessive menstrual blood loss which interferes with a woman’s physical, emotional, social and material quality of life and which can occur alone or in combination with other symptoms” (NICE guidelines 2007) Objective blood loss >80ml no longer important in defining menorrhagia

4. Impact of menorrhagia 1 in 20 women aged 30-49 years consults GP each year with menorrhagia Many women will have days off work due to menorrhagia 1 in 5 women in UK will have hysterectomy before age of 60 years 50% of all women who have a hysterectomy for menorrhagia will have a normal uterus removed

5. Causes of menorrhagia 4 main subtypes 1) Ovulatory 2) Anovulatory 3) Anatomic 4) Other causes

6. Ovulatory menorrhagia “Primary” or “idiopathic” menorrhagia – treatments guided by probable causes Characterized by heavy bleeding during regular cycles. Usually associated dysmenorrhoea and premenstrual symptoms Probable causes Abnormal prostaglandin synthesis Increased intrauterine fibrinolysis Acquired /congenital clotting disorders eg VWD

7. Anovulatory menorrhagia Usually irregular periods, often heavy and frequently separated by long intervals. Usually minimal pain Menorrhagia in adolescents usually anovulatory Anovulatory cycles less common in 20-40 age group

8. Anovulatory menorrhagia Common in perimenopausal women Intermittent ovulation and ovarian queiscence results in variability in LH/FSH and oestrogen causing erratic cycles During this period follicles remaining in ovary are quite resistant to FSH – sometimes ovulation occurs after long follicular phase, other times it fails.

9. Anovulatory menorrhagia In delayed ovulation/anovulation endometrium is thickened by prolonged stimulation by proliferative levels of oestrogen and is eventually shed in a long and heavy period Long term anovulation increases risk of endometrial hyperplasia

10. Anovulatory menorrhagia Causes include Hyperprolactinaemia Thyroid disease Adrenal disease Anorexia/Bulimia Pituitary adenoma Chronic illness Stress Drugs – eg. tricyclic antidepressants, steroids

11. Anatomic menorrhagia Commonly caused by endometrial polyps or submucosal fibroids Polyp

12. Other causes menorrhagia Cervicitis/endometritis IUD Hyperoestrogenism Endometrial cancer Coagulopathy

13. History – key points Age at menarche Onset and duration of period Cycle – regular or irregular? Length? Amount blood loss – clots? Flooding? Number sanitary towels? Social impact Changes from previous bleeding patterns Intermenstrual bleeding Postcoital bleeding Pelvic pain Dyspareunia

14. History Symptoms related to anaemia - SOB/fatigue/dizziness Symptoms of thyroid disease/systemic illness PMH – Obstetric Hx, Fertility wishes DH- Warfarin? Aspirin? Allergies SH – Stress? Smoking? Alcohol intake? FH – Bleeding disorders? Malignancies?

15. History Cover risk factors for Endometrial Cancer Obesity Age > 45 Nulliparity PCOS Tamoxifen 1 st degree relative with breast, colon or endometrial cancer Personal hx breast/colon cancer Unopposed oestrogen treatment

16. Examination General – pallor? Bruising? Signs of thyroid disease? BMI? Abdominal examination – fibroid uterus? Pelvic examination

17. Investigations FBC – exclude anaemia Cervical smear if due If IMB/PCB vaginal swab for chlamydia screen USS pelvis if indicated Referral for hysteroscopy and endometrial biopsy – Persistent IMB, >45 years, treatment failure, ineffective treatment, risk factors endometrial cancer NO value of TFT unless signs thyroid disease. NO value of hormone levels according to NICE guidelines

18. Medical treatments – First Line Levonorgestrel-releasing intrauterine system (MIRENA) - Slowly releases progestogen, prevents proliferation of endometrium - Reduces menstrual loss by 86% in 3 months, and by 97% at 12 months - Effective contraceptive - Return to fertility after removal

19. Medical treatments – First Line Side effects Mirena coil - progestagenic effects – breast tenderness, acne, headaches - irregular bleeding at start may last for 6 mths - functional ovarian cysts Also, risk of uterine perforation at time of insertion

20. Medical treatments – Second line Tranexamic acid Mefenamic acid/NSAIDs COCP Can be used first line if Mirena not acceptable to patient

21. Tranexamic acid Antifibrinolytic agent Mean reduction blood loss nearly 50% Dose 1-1.5g tds during menstruation only May be combined with mefenamic acid esp if dysmenorrhoea prominent Theoretically increased risk DVT but little evidence in studies Suitable if patient wanting to conceive Use for 3 cycles to determine effectiveness

22. Mefenamic acid Reduces prostaglandin production Indicated for menorrhagia and dysmenorrhoea Mean reduction blood loss around 30% Dose 500mg tds – taken during menstruation Side effects – indigestion, diarrhoea, worsening asthma, peptic ulceration

23. COCP Prevents proliferation of endometrium therefore reducing blood loss Contraceptive Side effects - headache, mood change, fluid retention, risk of DVT, stroke

24. Medical treatments – Third line Oral progestogen – norethisterone Effective when given in high doses between day 5- 26 of cycle Dose 5mg tds Injected progestogen (Depo-provera) Given every 3/12 After 1 year 50% women amenorrhoeic Disadvantage of delayed return to fertility

25. Medical treatments Gn-RH analogue injections Stop production of oestrogen and progesterone inducing amenorrhoea Side effects include menopausal- like symptoms Risk of osteoporosis with longer than 6 month use

26. Surgical/radiological treatments Endometrial ablation Uterine artery embolisation Myomectomy Hysterectomy

27. Endometrial ablation Indication – severe impact on quality of life + no desire to conceive + normal uterus (or small fibroids <3cm diameter) Destroys womb lining Risk of perforation during procedure Possible side effects – vaginal discharge, increased period pain

28. Uterine artery embolisation Indication – fibroids >3cm diameter, pressure symptoms, not wanting surgery, wants to remain fertile Small particles injected into blood vessels supplying uterus, block supply to fibroids causing shrinkage Short hospital stay – usually overnight Side effects – persistent PV discharge, post embolisation syndrome – pain, nausea, vomiting, fever. Risk of haemorrhage

29. Myomectomy Indication – fibroids > 3cm, severe impact on quality of life Risks associated with surgery – adhesions, infection, perforation, haemorrhage Recurrence of fibroids possible

30. Hysterectomy Indication – other treatments failed, no wish to remain fertile, patient request after fully informed, desire for amenorrhoea Vaginal /abdominal as indicated Major surgery – 4-5 days inpatient stay, risks of surgery Longer recovery time- months although permanent solution for menorrhagia!

31. Summary Menorrhagia is a common problem Mirena coil is offered as first line treatment and has reduced need for hysterectomies significantly For women wanting to conceive in short term – tranexamic acid and mefenamic acid appropriate For others COCP, norethisterone, Depo-provera can be effective Surgical and radiological interventions available in secondary care setting

32. References www.nice.org.uk – Heavy menstrual bleeding NICE 2007 www.nice.org.uk www.doctors.net.uk Oxford Handbook of Obstetrics and Gynaecology