Heavy menstrual bleed

Menorrhagia or heavy menstrual bleed – this chart on A4Medicine discusses the cause, assessment and treatment options of menorrhagia. The five options of treatment are discussed briefly and referral criteria are mentioned to assist in management. Use of Norethisterone is discussed with particular focus on situations when it should not be used. Use of Tranexamic acid is also explored with practical prescribing tips

Excessive menstrual blood loss which interferes with the woman’s physical , emotional , social and material quality of life , and which can occur alone or in combination with other symptoms ( NICE )
 Clinically defined as greater than or equal to 80 mL blood loss per menstrual cycle ( Cole 1971 ).Common and debilitating problem Annual community incidence of 25 % among women aged 18-54 yrs 12 % of all gynecological referral – second most common reason for referral 1 million seek help each yr in UK- mostly in Primary care Recent audit has revealed
○ almost 1/3rd had received no previous medical treatment before referral to secondary care
○ over 40 % having surgical intervention in the yr following first attendance at hospital

Causes- local uterine pathology –Uterine fibroids Uterine polyps Pelvic inflammatory disease and pelvic infections Uterine cancer or endometrial hyperplasia Endometriosis and adenomyosis AV malformation PCOS systemic causes-Coagulopathy – eg von Willebrand’s disease Hypothyroidism Liver or renal disease   Iatrogenic-Anticoagulation Chemotherapy IUD Tubal sterilization

History-Exclude pregnancy Enquire- flooding , clots , frequency of pad change , overnight wear Menstrual history – if regular ( non-hormonal Rx may be effective )
 irregular anovulatory cycles ( Hormonal Rx likely to work )
○ age of menarche any previous problems
○ length of cycle
○ number of days of menstruation Recent change in pattern of menstruation and pain ( may indicate structural pelvic pathology ) Ask about – intermenstrual bleeding , post coital bleeding , dyspareunia , pelvic pain or premenstrual pain Pressure symptoms ( including bowel and urinary ) may suggest a large fibroid Impact on quality of life Family history – endometriosis or coagulation disorders Contraception history/ use Smear status

Assessment-Anaemia Systemic coagulopathy ( bruise , petechiae ) Endocrine disease
○ hirsuitism
○ hypothyroidism
○ skin pigmentation Examination-Exclude pelvic mass ( eg fibroid ) Speculum to assess
○ vulva
○ vagina
○ cervix
Obtain swabs if infection suspected Bimanual ( uterine/ adnexal enlargement )
tenderness Investigations-FBC ( commonest cause of anemia in western world ) TFTs – usually ordered as part of normal initial screen but CKS advice is to order only if other signs and symptoms thyroid disease present Test for bleeding disorder ( if coagulopathy suspected ) Ultrasound ( Transvaginal and transabdominal ) if
○ palpable uterus
○ pelvic mass of uncertain origin ( also consider urgent referral )
○ treatment has not worked Opportunistic cervical screening if appropriate

Hormonal-Combined contraceptive pill- cycle control and contraception
 Progesterone ( oral , injected ) -works as antiestrogen by minimizing the effects of estrogen on target cells –> minimizing the effects of estrogen on target cells thereby maintaining the endometrium in a state of down-regulation
 Growth hormone analogue – Danazol , ethamsylate and gestrinone
 Hormone coil ( first choice ) – atleast 12 months. Non-hormonal-Tranexemic acid ( anti-fibronolytic )
 Mefenemic acid
NSAIDs – better than placebo but less effective than tranexemic acid , danazol or LNG -IUS ( Cochrane review ).Endometrial ablation Endometrial resection.Hysterectomy-Surgery particularly hysterectomy reduces menstrual bleeding more than medical Rx at one year No conclusive evidence of a difference in satisfaction rates between surgery and LNG-IUS ( bleeding spotting↑ likely with LNG-IUS ) Hysterectomy although definitive treatment can cause serious complications for a minority of women Both conservative surgery and LNG-IUS appear to be safe , acceptable and effective.Risk of serious complication 4 women in every 100 Damage to bladder and or ureter and long term disturbance to bladder function Bowel damage Haemorrhage Return to theater – bleeding , wound dehiscence Pelvic abscess infection VT , PE Risk of death within 6 weeks
( 32 women in every 100,000 )

LNG-IUS-LNG-IUS is the preferred first choice provided that long term 
contraception with an IUD is acceptable 
( reduces menstrual blood loss by as much as 97 % )

Progesterone- Oral norethisterone or long acting progestogens should be considered 3 rd choice Norethisterone-not a contraceptive but do not prescribe if wishing to conceive Should be taken during follicular and luteal phases ( days 5-26 ) No information on ideal duration of the course ( probably lasting several months ) Depo-provera is considered as long acting progestogen ( IM every 12 weeks ) Tranxexmic acid-If hormonal treatment not desired No sig dysmenorrhoea Awaiting investigations or definitive Rx Tranexemic acid is a synthetic lysine amino acid derivative – diminishes the dissolution of haemostatic fibrin by plasmin Common SEs
○ headache ○ sinus and nasal symptoms ○ back pain ○ abdominal pain ○ MSK- joint pain ○ muscle cramp Two 500 mg tablets tds for upto 4 days

 


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