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  1. 1. Dr J Romain Menorrhagia
  2. 2. Definition <ul><li>Heavy, regular bleeding over several cycles with menstrual blood loss greater than 80mls </li></ul>
  3. 3. In the UK… <ul><li>Each year causes 1 in 20 women between 30-49yrs to visit their GP </li></ul><ul><li>Commonest cause of iron deficiency anaemia in women of reproductive age </li></ul>
  4. 4. Interesting Facts <ul><li>Tenfold increase in number of periods women experience (reducing family size, less lactation, early menarche, late menopause) </li></ul><ul><li>If loss >60mls, neg iron balance can occur </li></ul><ul><li>Clinicians rely on woman’s assessment of menstrual blood loss, which may be inaccurate in 50% cases </li></ul>
  5. 5. History <ul><li>Full gynaecological history </li></ul><ul><li>Notoriously inaccurate amount of blood loss </li></ul><ul><li>Number of pads/tampons used </li></ul><ul><li>Clots/ flooding </li></ul><ul><li>Frequency of accidents </li></ul><ul><li>Menstrual chart can be useful </li></ul>
  6. 6. Examination <ul><li>Weight </li></ul><ul><li>Any signs of endocrine disturbance </li></ul><ul><li>Abdominal and pelvic examination </li></ul><ul><li>Cervical smear if indicated </li></ul>
  7. 7. NICE Referral Guidelines <ul><li>If there is suspicion of underlying cancer </li></ul><ul><li>They also have persistant intermenstrual or postcoital bleeding </li></ul><ul><li>Despite 3 months of drug treatment the bleeding is still heavy and interfering with quality of life </li></ul><ul><li>Wish to explore the possibility of surgical intervention rather than persist with drugs </li></ul><ul><li>They have severe anaemia failing to respond to drugs </li></ul>
  8. 8. Pathophysiology <ul><li>Menstrual bleeding either ovulatory or anovulatory </li></ul><ul><li>Regular and painful- ovulatory </li></ul><ul><li>Irregular and painless- anovulatory </li></ul><ul><li>With menorrhagia there is evidence of elevated levels of prostaglandins in endometrium and altered responsiveness to vasodilator PGE2. </li></ul>
  9. 9. Pathophysiology <ul><li>Ovulatory bleeding is associated with normal levels of circulating progesterone and oestradiol, therefore altered prostaglandin synthesis is thought to be responsible for increased menstrual loss </li></ul><ul><li>Ratio of PGE2 and prostacyclin (causing vasodilatation and inhibition of platelet aggregation) and PGF2a (promoting vasoconstriction and platelet aggregation) is significant </li></ul>
  10. 10. Aetiology <ul><li>Physiological- normal loss but interpreted as excessive. Commonly occuring in those who stop the OCP </li></ul><ul><li>Dysfunctional Uterine Bleeding- diagnosis made after pelvic pathology excluded </li></ul><ul><li>Congenital- increased endometrial surface area, eg bicornuate uterus </li></ul><ul><li>Traumatic, eg. IUD </li></ul>
  11. 11. Aetiology <ul><li>Infective, eg. Chronic PID </li></ul><ul><li>Neoplastic, eg. Fibroids, endometrial polyps </li></ul><ul><li>Metabolic, eg. Hyperthyroid </li></ul><ul><li>Psychological factors </li></ul><ul><li>Adenomyosis </li></ul><ul><li>Blood dyscrasias </li></ul><ul><li>Iatrogenic, eg. Warfarin </li></ul><ul><li>NOTE- physiological and DUB account for 50% </li></ul>
  12. 12. Investigations <ul><li>Full blood count </li></ul><ul><li>Thyroid function tests, clotting profiles </li></ul><ul><li>If suspect infection- endocervical swabs </li></ul><ul><li>Vaginal Ultrasonography- measure thickness of endometrium (<5mm normal). Detects abnormalities of the cavity eg.polyps. Can assess ovaries and uterus </li></ul>
  13. 13. Investigations <ul><li>Endometrial biopsy should be performed if- menorrhagia is a recent phenomenon </li></ul><ul><li>woman over 40 yrs </li></ul><ul><li>if there is any intermenstrual bleeding </li></ul><ul><li>Even if procedure is performed via D&C it is diagnostic and NOT therapeutic </li></ul>
  14. 14. Treatment <ul><li>If any pathology is found it must be treated, rest aim to treat dysfunctional uterine bleeding </li></ul><ul><li>Anovulatory- extremes of age. OCP can help. Cyclical progestogens used to induce regular withdrawl bleeds. If these stop, woman has reached menopause </li></ul><ul><li>Acute arrest for heavy bleeding- high dose reducing course of progestogen </li></ul>
  15. 15. Treatment <ul><li>NSAIDS- inhibit synthesis of prostaglandins, decrease blood loss by up to 30%. Mefanamic acid, given for a few days during menstruation </li></ul><ul><li>Antifibrinolytic drugs- reduce enhanced fibrinolytic activity within the uterus. Up to 50% reduction. Tranexamic acid </li></ul><ul><li>Oral Contraceptive Pill- ovulation suppressed and oestrogen levels remain constant. </li></ul>
  16. 16. Treatment <ul><li>Hormone releasing IUD’s- progestogen released causes atrophy of endometrium. Can cause amenorrhoea </li></ul><ul><li>Danazol- anti gonadotrophin. Induces atrophy of endometrium due to low level of circulating sex steroids. Androgenic side effects not tolerated well- virilizing effects </li></ul>
  17. 17. Treatment <ul><li>Endometrial ablation or resection- visualised hysteroscopically and ablated. Many methods-laser, rollerball, hydrothermal, cryoablation, microwave. Can become amenorrhoeic but not always successful </li></ul><ul><li>Hysterectomy- definative treatment if family complete. </li></ul>
  18. 18. <ul><li>THANKS! </li></ul>