Menorrhagia

Menorrhagia


DEFINITION:

  • A complaint of heavy cyclical menstrual blood loss over several consecutive menstrual cycles in a woman of reproductive years, or more objectively, a total menstrual blood loss of more than 80 ml per menstruation.

CLASSIFICATION:

Primary 

  •  Idiopathic / DUB 
  • Ovulatory
  •  Non-ovulatory

Secondary 

  • Uterine and ovarian pathologies
  • Systemic diseases 
  • Iatrogenic causes

ETIOLOGY:

TYPES CAUSES
General Causes
  • Blood dyscrasia:
  • Leukaemia
  • Severe anaemia
  • Coagulopathy:Thyroid dysfunction
  • Thrombocytopenic purpura
  • Coagulation disorders are seen in 20% adolescents
  •  Von Willebrand’s disease.
  • Genital TB
  • Intersitial myoma(Inhibit uterine contraction)
Pelvic Causes
  • PID, pelvic adhesions
  • Uterine fibroids, endometrial hyperplasia
  • Adenomyosis
  • Feminizing tumour or the ovary
  • Endometriosis,Pelvic congestion, varicose veins in the pelvis
  • Retroverted uterus
Contraceptive Use
  • IUCD
  • Post-tubal sterilization
  • Progestogen-only pills
Hormonal/AUB
  • Ovulatory—irregular ripening or irregular shedding
  • Anovulatory—Resting endometrium – 80%
  • Metropathia haemorrhagica

INVESTIGATIONS:

  • Complete haemogram.
  • Bleeding time and clotting time.
  • Thyroid profile as indicated.
  • Pelvic sonography—sonosalpingography.
  • Diagnostic hysteroscopy.
  • Diagnostic laparoscopy.
  • Endometrial study by ultrasound and curettage.
  • Sonosalpingography can delineate a submucous fibroid clearly.
  • Pelvic angiography is required when the cause of menorrhagiais not detected by other means. This shows varicosity and arteriovenous fistula.

MANAGEMENT:

                                          YOUNG WOMEN       OLDER WOMEN
 Contraception not desirable

Contraception desired

  • Combined OCPs
  • Progestogens and other hormones
  • Mirena
  

Rule out cancer &uterine pathology

Progestogens

Ethamsylate, NSAIDs

Estrogen

Tranexamic for 3–4 months

GnRH 3–4 months

 Effective  Fails  Normal uterus (DUB) Uterine pathology 
 

Continue for 6–9 months

Minimal invasive surgery

Hysterectomy with conservation of ovaries

 Progestogens and others

 ↓No response 

Hysterectomy  with removal of ovaries after 50 years

 Surgery
  • Removal of an intrauterine contraceptive device if medical therapy fails.
  • Myomectomy/hysterectomy for uterine fibroids.
  • Wedge resection/hysterectomy for adenomyosis of the uterus.
  • Dilatation and curettage with blood transfusion  is the primary treatment of puberty menorrhagia with low Hb%
  • Laparoscopic lysis of adhesions for chronic PID.
  • Multipara, hypertensive woman with menorrhagia should be treated with MIRENA
  • Electrocautery or laser vaporization of endometriosis and drainage of chocolate cysts in pelvic endometriosis.
  • Hysterectomy with or without removal of the adnexa according to the age and the individual needs of the patient.
  • In patients suffering from bleeding disorders, a haematologist’s opinion should be sought.
  • Uterine artery embolization in varicose vessels.
  •  Von Willebrand’s disease; intravenous desmopressin
Exam Question
 
  • Myomectomy is specifically indicated in an infertiie woman or woman desirous of bearing child and wishing to retain her uterus in severe menorrhagia
  • Fundal myomas commonly present as Menorrhagia
  • Intersitial myomas predispose to menorrhagia by Inhibiting uterine contractility
  • Puberty menorrhagia is treated by Progesterone, estrogen & GnRH analogues
  • Female presenting with dysmenorrhoea & menorrhagia most probably has Endometriosis & Fibroid
  • A woman is said to be have menorrhagia if the menstrual blood loss is more than 80 ml
  • Hysterectomy is the definitive treatment of adenomyosis
  • NSAID’s, Norethesterone & Tranexamic acid are indicated in menorrhagia
  • Dilatation and curettage with blood transfusion  is the primary treatment of puberty menorrhagia with low Hb%
  • Commonest condition associated with menorrhagia is Fibroid
  • Retroverted uterus causes menorrhagia
  • Puberty menorrhagia associated with anovulatory bleeding
  • Puberty menorrhagia Routine screening for bleeding disorder is done
  • Hematinics & Hormone therapy is the treatment of choice for Puberty menorrhagia 
  • A patient comes to you with history of frequent cycles with heavy bleeding. This condition is called Polymenorrhagia
  • Multipara, hypertensive woman with menorrhagia should be treated with MIRENA
  • Adenomyosis  presents with menorrhagia, dysmenorrhia, and an enlarged uterus
  • lUCD of choice in women with menorrhagia Progesterone containing IUCD
Don’t Forget to Solve all the previous Year Question asked on Menorrhagia

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