Abnormal Menstrual Cycle Menorrhagia

Terminology
Menorrhagia

Prolonged and increased menstrual

flow

Metrorrhagia
Polymenorrhoea

Regular intermenstrual bleeding

Menses occurring at < 21day
interval
Increased bleeding and frequent
cycle
Prolonged menses and
intermenstrual bleeding
Absence of menstruation > 6
months
Menses at intervals of > 35 days

Polymenorrhagia
Menometrorrhagia
Amenorrhoea
Oligomenorrhoea

Menorrhagia/ Heavy Menstrual Bleeding (HMB)

Defined clinically as bleeding that has adverse impact on the life of
a woman.
May occur with other symptoms.
Commonest cause of iron-deficiency anaemia in women (affluent
world)
Normal range of blood loss is 80ml/month
Common indication for hysterectomy
Causes of Menorrhagia/ Heavy Menstrual Bleeding

Organic
- Presence of pathology
Non-organic
- Absence of pathology
- 50% of cases
- Also known as Dysfunctional Uterine Bleeding

Causes of Organic Menorrhagia

Local Disorders:
1. Fibroids (excessively heavy loss of >200ml)
2. Adenomyosis
3. Endocervical or Endometrial polyp
4. Cervical eversion
5. Endometrial hyperplasia
6. Intrauterine contraceptive device (IUCD)
7. Pelvic inflammatory disease (PID)

8. Endometriosis
9. Malignancy of the cervix or uterus
10.
Hormone producing tumors
11.
Trauma
12.
Others e.g. arteriovenous malformations
Systemic Disorders:
Endocrine Disorders

Disorders of Hemostasis

Hyper/ hypothyroidism
Diabetes mellitus
Adrenal disease
Prolactin disorders
Von Willebrands disease
ITP
Factor II, V, VII and XI
deficiency

Liver disorders
Renal disease
Drugs

Anticoagulants

Pregnancy:
1. Miscarriage
2. Ectopic pregnancy
3. Gestational trophoblastic disease
4. Postpartum hemorrhage

Assessment of Menorrhagia
History:
Number of sanitary towels used/duration of bleeding
Symptoms of flooding
Degree of inconvenience caused
Irregular bleeding
Dyspareunia
Pelvic pain
Intermenstrual/post-coital bleeding
Symptoms of anaemia
Thyroid disorders
Clotting screening
Risk factors for cancer
Family history
History of thromboembolism treatments are hormonal and could be
contraindicated

Examination:
Signs of anaemia
Abdominal examination
Speculum examination
Signs
Bulky, enlarged
uterus
Tenderness

Fibroids
Endometriosis, Pelvic
Inflammatory Disease,
Adenomyosis

Investigations:
Laboratory tests FBC (anaemia), Thyroid function test,
Coagulation tests, Liver function test
Ultrasound Pelvic ultrasound, Transvaginal ultrasound
Endometrial assessment (Biopsy/Hysteroscopy) Women aged
>45years, Red light symptoms, Younger women who are
unresponsive to treatment
Cervical cytology
Treatment of Menorrhagia
Focal uterine pathology benign intrauterine polyps removed using
hysteroscopic techniques
Malignant pathology treated appropriately
Fibroids
a) Medical: GnRH analogues used to cause fibroid shrinkage (fibroid
growth is hormone dependant)
b) Surgical: Hysteroscopic resection of small submucous fibroids,
endometrial ablation, hysterectomy
Non-organic cause of Menorrhagia
Dysfunctional Uterine Bleeding (DUB)

50% of women with abnormal uterine bleeding

Diagnosis made by exclusion
Subdivided into
Anovulatory
85% of all DUB
Occurs at extremes of reproductive life
Irregular cycle
More common in obese women

Ovulatory

More common in women aged 35-45 years

Regular heavy periods
Due to inadequate progesterone production
by corpus luteum

Investigating DUB
Full blood count
Cervical smear
TSH
Coagulation screen
Renal/Liver function tests
Transvaginal ultrasound scan
Endometrial thickness
Presence of fibroids and other pelvic masses
Endometrial sampling
Pipelle biopsies
Hysteroscopic directed
Dilatation & curettage (D & C)

Treatment of DUB Medical

Medical Therapy
Progestogens
Combined oral contraceptive pill
Danazol
GnRH analogues
Non-steroidal anti-inflammatory drugs (NSAIDs)
Anti-fibrinolytic
Capillary wall stabilisers
Progestogen-releasing IUCD
Mirena IUS

Treatment of DUB Surgical

Endometrial resection/ablation
Transcervical endometrial resection (TCRE)
Rollerball endometrial ablation (REA)
Bipolar mesh endometrial ablation (Novasure)
Thermal balloon ablation (Thermachoice)
Thermal hydroablation (Hydroblate)
Hysterectomy
Sub-total hysterectomy

Comparison

Total abdominal hysterectomy

Vaginal hysterectomy
LASH/LAVH/TLH
between Medical & Surgery Treatments of DUB

Medical Treatments
Cheaper
No waiting list

No anesthetic risks

Adverse effects nonpermanent

May not be effective

Fertility can be retained

Surgical Treatment
More expensive
On waiting list
Anesthetic risks present
Complications possible
Very effective (amenorrhoea
with hysterectomy)
Fertility is lost

Comparison between Hysteroscopic Surgery and Hysterectomy

Endometrial ablation
Day case procedure
Shorter operating time
Shorter recovery
Fewer complications
Requires cervical smears
Combined HRT required

Hysterectomy
Major operation
Longer operating time
Longer recovery
More complications
No cervical smears required (for
total hysterectomies)
Oestrogen-only HRT (unless cervix
is retained)