Definition and causes of various menstrual dysfunctions. Menorrhagia / HMB - causes and management

1. Menstrual Irregularities
And Menorrhagia
Antima Rathore
MTI Trainee

2. Topics
1. Introduction
2. Menstrual irregularities
a. Definitions
b. Causes
3. History taking
4. Physical Examination
5. Investigations
6. Management
7. Case based discussion
(Including special cases)

3. Menstrual Cycle
• Interval = 28 days (±7 days)
• Average duration = 4 to 7 days
• Mean menstrual blood loss = 35 ml
(range 31-80 ml)

4. Menstrual Cycle
• 28 days cycle – 15 %
• Irregular cycles – 20%

5. Abnormal Uterine Bleeding (AUB)
Any change in -
frequency of menstruation
duration of flow
amount of blood loss

6. Menstrual irregularities
Amenorrhea Absent menses
Oligomenorrhea Menses less frequent than every 35
days
Polymenorrhea Menses more frequent than every 21
days
Metrorrhagia Menses at irregular intervals
Menorrhagia
or
Hypermenorrhea
Abnormally long or heavy menses,
lasting > 7 days
or
involving blood loss >80 ml
Hypomenorrhea Blood flow < 2 days

7. Menorrhagia
Menorrhagia is cyclical bleeding at regular intervals which is excessive in
amount (> 80 mL) or duration (longer than 7 days) or both.

8. Normal range
5th and 95th percentiles

9. HMB
Heavy menstrual bleeding (HMB) is defined as excessive menstrual blood loss which
interferes with a woman's physical, social, emotional and/or material quality of life.
It can occur alone or in combination with other symptoms

10. Causes of
HMB
Anatomical a. Submucous fibroid
b. Adenomyosis
c. Endometriosis
d. Pelvic inflammatory disease
e. Tubercular endometritis (early)
f. Intrauterine contraceptive device
g. Functioning ovarian tumors
h. Uterine A-V malformation.
Hormonal a. Hypothyroidism
b. Dysfunctional uterine bleeding
Systemic Thrombocytopenia, Leukemia
Drug related Anticoagulant like warfarin, heparin, antiplatelet like
aspirin, some herbal remedies rich in estrogen.

11. PALM-COEIN
(FIGO)
PALM
(Structural)
Polyp
Adenomyosis
Leiomyoma
Malignancy or
Hyperplasia
COEIN
(Functional)
Coagulopathy
Ovulatory
Dysfunction
Endometrial Causes
Iatrogenic
Not yet classified

12. Menstrual
irregularities
Acyclic bleeding
a. Normal - childbirth and abortion and preceding menopause
b. Submucous fibroid
c. Uterine polyp
d. Carcinoma cervix and endometrial carcinoma
Postcoital bleeding
a. Carcinoma cervix
b. Mucous polyp of cervix
c. Vascular ectopy of the cervix especially during pregnancy, pill use
d. Infections—chlamydial or tubercular cervicitis
e. Cervical endometriosis

13. Menstrual
irregularities
Intermenstrual bleeding
Apart from the causes of contact bleeding, other causes are:
a. Urethral caruncle
b. Ovular bleeding
c. Breakthrough bleeding in pill use
d. IUCD in utero
e. Decubitus ulcer
Hypomenorrhea
a. local - uterine synechiae or endometrial tuberculosis
b. endocrinal – oral contraceptives, thyroid dysfunction, and
premenopausal period
c. systemic - malnutrition

14. Menstrual
irregularities
Oligomenorrhea
a. Age-related—during adolescence and preceeding
menopause
b. Weight-related—obesity
c. Stress and exercise related
d. Endocrine disorders—PCOS (commonest),
hyperprolactinemia, hyperthyroidism
e. Androgen producing tumors—ovarian, adrenal
f. Tubercular endometritis—late cases
g. Drugs: Phenothiazines, Cimetidine, Methyldopa

15. History
Presenting complaints
1) Onset
2) Nature of the bleeding
a) Duration
b) Interval (regular –
ovulatory; irregular –
anovulatory)
c) Amount
d) Presence of clots

16. History
Presenting complaints
3) Related symptoms –
a) Persistent intermenstrual bleeding
b) Postcoital bleeding
c) Pelvic pain
d) Discharge per vaginum
e) Pressure symptoms (uterine cavity abnormality, histological abnormality, adenomyosis
or fibroids)
f) Dysmenorrhea/dyspareunia/dyschezia/ dysuria/infertility - endometriosis

17. History
• Dysmenorrhea – pain during menstruation
- Spasmodic dysmenorrhea
- Congestive dysmenorrhea (premenstrual pain relieved by flow) due to
endometriosis or PID
• Anovulatory cycles are painless

18. History
Presenting complaints
4. PCOS – Weight gain, Acne, Excessive hair growth or unwanted hair
5. Hypothyroidism - Weight gain, Cold intolerance, Fatigue, Lethargy,
Constipation
6. Impact on her quality of life
Drug history/contraception
Usage of intrauterine contraceptive device
Hormonal drug intake or herbal remedies which may contain estrogen

19. History
Past/Family history
1. Coagulation disorder
• History of easy bruisability/prolonged bleeding from wounds
• heavy bleeding after any surgery/ dental procedure
• h/o of nosebleed which lasted for more than 10 min or required medical
attention
• Family history
2. Comorbidities or previous treatment for HMB

20. Pictorial
blood
assessment
chart (PBAC)

21. Physical examination
HMB with other related symptoms
Before all investigations or LNG-IUS
fittings

22. Physical examination
HMB without other related symptoms consider pharmacological
treatment without carrying out a physical examination

23. Physical examination
Examination
General physical examination –
• Pallor to know severity of bleeding.
• Lymphadenopathy is suggestive of tuberculosis or hematological causes like
leukemia or lymphomas.
• Thyromegaly–as hypothyroidism could be a cause of menorrhagia.
• Petechiae/ecchymosis/gum bleeding are suggestive of a coagulation disorder

24. Physical examination
Examination
Per abdominal examination:
• Splenomegaly is present in a patient of ITP, hepatosplenomegaly in a patient
of leukemia.
• Abdomino-pelvic mass – could be due to fibroid, Adenomyosis, estrogen
secreting ovarian tumor

25. Laboratory
tests
Urine Pregnancy Test

26. Laboratory tests
Full Blood Count (FBC) - All
Coagulation Profile
 HMB since menarche
 personal or family history suggesting a coagulation disorder
Thyroid hormone – only if other signs and symptoms of thyroid disease are present
Serum Ferritin Test / Female Hormone Testing – not offered routinely

27. INVESTIGATIONS

28. Investigations
Before starting investigations
• Consider pharmacological treatment without investigating the cause
if history and/or examination suggests a low risk of fibroids, uterine cavity abnormality,
histological abnormality or adenomyosis
• If cancer is suspected - recognition and referral

29. Investigations
• Pelvic Ultrasound
a) Persistent intermenstrual bleeding
b) Risk factors for endometrial pathology
c) Uterus is palpable abdominally
d) History or examination suggests a pelvic mass
e) Examination is inconclusive or difficult, for example in women who are
obese

30. Investigations
Pelvic ultrasound

31. Investigations
• Outpatient Hysteroscopy
a) Suspected submucosal fibroids, polyps or endometrial pathology

32. Investigations
Outpatient Hysteroscopy

33. Investigations
Outpatient Hysteroscopy

34. Investigations
• Endometrial Sampling
1. Age > 45 years
2. No response to medical therapy
3. Persistent intermenstrual bleeding
4. Other risk factors for endometrial cancer
5. Obese adolescents after 2 to 3 years of anovulatory bleeding
6. ET > 12mm in premenopausal woman

35. Investigations
Different Methods Of Endometrial Sampling
• Endometrial aspiration
• DnC
• Hysteroscopic guided Endometrial Biopsy
NICE - Do not offer 'blind' endometrial biopsy to women with HMB

36. Office Endometrial Aspiration Biopsy
• Blind sampling technique
• Less painful - does not
require dilatation
• Chances of perforation - less
• Sensitivity - 89.6%,
Specificity - 100%

37. Office Endometrial
Aspiration Biopsy
• Karman cannula
• Pipelle device
• Vabra aspirator

38. Other diagnostic tools
• Dilatation and Curettage
- do not use alone

39. Other diagnostic tools
• Saline Infusion
Sonography (SIS) -
do not use as a first-
line

40. Other diagnostic tools
• MRI - do not use as a first-
line

41. NICE

43. Management of HMB
• Woman's preferences
• Any comorbidities
• Presence or absence of fibroids (including size, number and location), polyps,
endometrial pathology or adenomyosis
• Other symptoms such as pressure and pain

44. Management of HMB
LNG-IUS
The first treatment for HMB in women with:
1. No identified pathology
2. Fibroids less than 3 cm in diameter, which are not causing distortion of the uterine cavity or
3. Suspected or diagnosed adenomyosis

45. Management of HMB
LNG-IUS
Wait for at least 6 cycles to see the benefits

46. Management of HMB
If declines an LNG-IUS or it is not suitable
Pharmacological treatments
1) Non-hormonal:
a) Tranexamic acid
b) NSAIDS (non-steroidal anti-inflammatory drugs)
2) Hormonal:
a) Combined hormonal contraception
b) Cyclical oral progestogens

47. Management of HMB
If treatment is unsuccessful
or
Woman declines pharmacological
treatment
or
symptoms are severe
1) Investigate the cause
2) Alternative treatment choices
a) Pharmacological options not
already tried
b) Surgical options

48. Surgical
Management
Fertility sparing
• Myomectomy
• Uterine Artery Embolisation
• Polypectomy
Non-fertility sparing
• Endometrial ablation
• Hysterectomy

49. Endometrial ablation
1. Failed medical management
2. Fertility – not desired
3. Wish to avoid a hysterectomy
4. Not candidates for major surgery
First generation
Hysteroscopic laser
ablation (HLA)
• Transcervical resec-
tion of endometrium
(TCRE)
• Rollerball endometrial
ablation
Second generation
• Fluid balloon: cavaterm, thermachoice, menotreat
• Microwave: MEA
• Cryotherapy: Cryogen, Her choice
• Electrode-Mesh: Vesta Balloon: Novasure
• Interstitial laser: ELITT
• Photodynamic therapy
• Hydrothermal ablation

50. Endometrial ablation
Exclusion criteria
• Uterine size >12 weeks
• Premalignant or malignant lesion of the
cervix and endometrium
• Acute pelvic inflammatory lesion
• Bleeding disorder
• Submucous and intramural fibroids
• Septate uterus
• Previous failed endometrial ablation
procedure
• Incidental pregnancy
• Desire for future fertility
• History of gynecological malignancy
within the last 5 years

51. Endometrial ablation
Destruction of the entire endometrial thickness with superficial myometrium
while leaving the rest of uterus intact
Pretreatment with GnRHa, medroxyprogesterone acetate, or danazol - to
make the endometrium thin for better results
Advise women to avoid subsequent pregnancy and use effective
contraception, if needed, after endometrial ablation

52. Hysterectomy
Not first line
When other treatment options - failed/contraindicated/declined
Fertility – not desired
Routes
• Vaginal Hysterectomy (VH)
• Total Abdominal Hysterectomy (TAH)
• Total Laproscopic Hysterectomy (TLH)
• Laproscopy Assisted Vaginal Hysterectomy (LAVH)

53. NICE

54. Case based discussion

55. Case 1
• A 14-year-old girl gives history of irregular cycles with HMB since
menarche (at 13 years) with weakness and fatigue.
• Examination findings
• Pallor ++
• Tachycardia + BP 100/60,
• No lymph nodes
• Per abdomen – soft, liver and spleen not palpable

56. Case 1
Differential diagnosis
• DUB – Anovulatory
• Ovulatory
• Thyroid disorder
• Coagulation disorders

57. Case 1
Investigations
1. Urine pregnancy test - negative
2. FBC – Hb = 95
3. Coagulation screen - normal

58. Case 1
Puberty menorrhagia
• Physiological – up to 1-2 years after onset of menarche
• Cause – immaturity of HPO axis

59. Case 1
Puberty menorrhagia
• Main treatment –
a. Reassurance
b. Menstrual charting
c. Perimenstrual nonsteroidal anti-inflammatory drugs
Mefenamic acid & Tranexamic acid
d. Iron and vitamin supplementation
e. Cyclic OCP – 6-12 months

60. Case 1
Puberty menorrhagia
Severe anemia or/and acute bleeding
Hospitalization.
Hypovolemic shock – resuscitate with IV fuids (crystalloid), Blood transfusion
Deranged Coagulation profile - involve hematologist
 First line - 1) High dose progesterone
(Medroxyprogesterone acetate – 10-20 mg, 4 hourly
for 24 hrs; f/b 20 mg OD for 10 days)
2) Tranexemic acid (PO/IV)

61. Case 1
Puberty menorrhagia
Severe anemia or/and acute bleeding
Second line – 1) High dose unconjugated oestrogen
(0.625 – 1.25 mg PO 4-6 hourly or 15-25 mg IV, 6-12 hourly)
Non-responder - USS rule out oestrogen secreting tumour
Rarely – UAE, Factor VIIa

62. CASE - 2

63. Case 2
A 30-year woman presented with complaints of heavy bleeding during
periods (regular) for the last six months.
No pallor, Abdomen soft
Tranexamic acid for 3 months – no response
Speculum exam – cervix and vagina healthy
Vaginal examination – uterus normal sized,
firm, smooth, nontender, no adnexal mass

64. Case 2
Differential diagnosis
1. Dysfunctional uterine bleeding
2. Pelvic inflammatory disease
3. Adenomyosis
4. Hypothyroidism

65. d/d

66. DUB
Dysfunctional Uterine Bleeding
Abnormal uterine bleeding that occurs in the absence of systemic or organic
pathology of the genital tract
Ovulatory Anovulatory

67. Ovulatory DUB
Irregular shedding of endometrium
(Halban’s disease)
Due to persistent corpus luteum
Cycles - regular
prolonged
not heavy
Histopathology - mixed picture of secretory
and proliferative endometrium (even on day
5-6 of menstruation)
A self-limiting process
Treatment - NSAIDs up to 6 months
Irregular ripening
Inadequate progesterone support - due to
deficient corpus luteal function
Breakthrough bleeding (spotting or
brownish discharge) before the actual
menstruation
Histopathology –incomplete secretory
changes in endometrium
Treatment - progesterone in the
premenstrual phase

68. Anovulatory DUB
Irregular bleeding
Histopathology
a. Proliferative endometrium
b. Endometrial hyperplasia without atypia
c. Endometrial hyperplasia with atypia

69. Anovulatory DUB
Irregular bleeding
Histopathology
a. Proliferative endometrium
b. Endometrial hyperplasia without atypia
c. Endometrial hyperplasia with atypia

70. Anovulatory DUB
Irregular bleeding
Histopathology
a. Proliferative endometrium
b. Endometrial hyperplasia without atypia
c. Endometrial hyperplasia with atypia

71. Management of Endometrial Hyperplasia without atypia
Progression to endometrial cancer - < 5% over 20 years
Many cases spontaneously regress
Progestogen treatment is the preferred option – high regression rate
a. Levonorgestrel-releasing intrauterine system (MIRENA) as first line or
b. Continuous oral progestogens such as medroxyprogesterone 10 - 20mg
per day or Norethisterone 10 - 15mg per day if an intrauterine system is
declined

72. Management of Endometrial Hyperplasia without atypia
Reduce risk factors (eg weight loss, optimize PCOS, stop source of estrogen)
All patients should have a pelvic ultrasound scan to exclude ovarian
tumours

73. Management of Endometrial Hyperplasia without atypia
• Follow up – biopsy alone
• Repeat biopsy at 6 months
• Regressed
• continue LNG-IUS; stop oral progesterone
• Repeat biopsy after 6 months
• 2 biopsy sample should be negative
• annual biopsy for 5 years – high risk patient
• Not regressed
• continue LNG-IUS & progesterone for further 6 months
• Regressed – as above
• Not regressed (after 1 year) – consider surgery

74. Management of Endometrial Hyperplasia without atypia
Surgical management - Hysterectomy (if fertility not desired)
1. Progression to atypia occurs during follow up
2. There is no histological regression of hyperplasia despite 12 months of treatment
3. There is relapse of endometrial hyperplasia after completing progestogen
treatment
4. There is persistence of bleeding symptoms
5. Endometrial surveillance and medical treatment is declined
Endometrial ablation is not recommended

75. Management
of
endometrial
hyperplasia
with atypia

76. Case 3
A 42 years-old P3L3 presented to the gyne OPD with complaints of the
menorrhagia with severe dysmenorrhea, dyspareunia with increased
frequency of urine for 2 years. There is no family or personal history of
any cancer.
Obesity +
Pallor +
Per abdomen – uterus is just palpable
Per speculum examination – cervix and vagina healthy
Per vaginum examination – uterus is 12 weeks, midposition, firm, restricted
mobility, both fornices free and nontender

77. Case 3
d/d
• Uterine fibroid
• Adenomyosis
• Uterine malignancy (endometrial cancer, sarcomas)

78. Case 4
A 48-year-old multiparous lady with history of irregular and heavy
bleeding: 12 months.
Examination
Per speculum – cervix and vagina healthy
Per vaginum – uterus 8 weeks, firm, smooth, mobile, nontender.
The possible differential diagnosis are:
1. Perimenopausal DUB
2. Polyp
3. Endometrial carcinoma

79. Thank you
for
your attention