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  1. 1. Menorrhagia (heavy menstrual bleeding) DAHVINIA B.DEVAN
  2. 2. DEFINITIONTERMS DEFINITIONMenorrhagia 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. (MOH,2004) Clinically, menorrhagia is defined as total blood loss exceeding 80 ml per cycle or menses lasting longer than 7 days Menorrhagia is excessive menstrual blood loss over several consecutive cycles which interferes with the womans physical, emotional, social, and material quality of life. (Nice 2007)
  3. 3. OTHER IMPORTANT DEFINITION…TERMS DEFINITIONmetrorrhagia Menstrual flow at irregular intervalsMenometrorrhagia irregular and excessive flowPolymenorrhoea bleeding at intervals of less than 21 daysPostcoital bleeding is non-menstrual bleeding that occurs immediately after sexual intercourse
  4. 4. Classification Primary Secondary Idiopathic / DUB -Uterine and ovarian pathologies -Systemic diseasesovulatory Non-ovulatory -Iatrogenic causes
  5. 5. PRIMARY
  6. 6. Anovulatory Unopposed 90% estrogen Mx: DUB 1. Medical Associated with Ovulatory increased 10% prostaglandin 2. Surgical release -hysterectomy•heavy or irregular menstrualbleeding that is not caused by (hemostatic -endometrialan underlying anatomical deficiency) ablationabnormality, such as a fibroid,or tumor (abnormal uterinebleeding without any obviousstructural or systemic •Ovulatory cycles luteinizing-hormone predictor kitpathology Regular cycle length •Anovulatory cycles•Usually is a diagnosis of Presence of premenstrual Unpredictable cycle lengthexclusion symptoms Unpredictable bleeding pattern•Hormonal imbalance, -Dysmenorrhea Frequent spottinghypothalamus-pituitary-ovary -Breast tenderness Infrequent heavy bleedingaxis -Change in cervical mucus Monophasic temperature curve -Mittleschmertz• normally in women juststarted Biphasic temperature curvemenstruation/perimenopausal Positive result from use of
  8. 8. Uterine and ovarian endometriosispathologies PCOS
  9. 9. CONDITION HISTORY PHYSICAL inv EXAMINATION (General, abdominal, pelvic)Uterine fibroids •Age: reproductive age •enlarged uterus •Inv: TAS/TVUS (>8 weeks) Transvaginal sono •Bleeding pattern: •tenderness/palpabl hysterography/dx menorrhagia, metrorrhagia e on vaginal exam hysteroscopy/dx laparoscopy, +/- •Ass. Symp. dysmenorrhoea, endometrial biopsy, dyspareunia, MRI urinary/defecation problem
  10. 10. Endometriosis Age: reproductive age wide spectrum, Inv: laparoscopic, depends TVUS, Bleeding pattern: menstruating/not menorrhagia, usually abdominal tenderness, lasts more than 7 days mass short interval Speculum: Ass.symp: red, hypertrophic dysmenorrhoea/ lesions , bleeding on chronic pelvic pain, contact seen at dyspareunia, difficulty post.fornix conceiving
  11. 11. adenomyosis •Age: 40 and 50 years •The uterus is Inv : old,parous/prior uterine surgery enlarged and boggy TAS/TVS(diffuse thickening within •bleeding pattern: menorrhagia •Tenderness wall), MRI, ,postccoital, Intermenstrual hysteroscopic/lapar •mass oscopic biopsy •ass, Symp.: dysmenorrhea, (adenomyoma) dyspareuniaPelvic •Age: any age • febrile, rigor Inv: FBC,ESR graminflammatory stain, cultures fromdisease •BleedIng pattern: excessive, • abd tenderness cervix, endometrial(endometritis) Intermenstrual and postcoital biopsy bleeding Ct scan if do not respond to AB •Ass. Symp: foul smelling vaginal therapy for 48-72 discharge, pelvic pain and fever, hoursEndometrial •Age: rare <20, peaks at 5th decade, • endometrial • Inv: TVUSpolyps decrease post menopausal polyps that /Transvaginal sono protrude through hysterography/ •Bleeding patern: excessive, the cervix on VE hysteroscopy metrorrhagia,post coital,post- •Biopsy+/- D&C menopausal • enlarged uterus
  12. 12. Endometrial •Age: >40/post •uterus will be enlarged or softened and ONLY IF GOT RISKcarcinoma menopausal masses may be detected FACTORS!!! •Pelvic examination: cervix may be •TVS/TAS •If ET >12 10% of women with involved with cancer (Stage II), and the Endometrial biopsy/ postmenopausal vagina (Stage III) D&C bleeding will be • rectal examination diagnosed with •Enlarged lymph nodes in the neck and RF: •Age >40 endometrial cancer and groin. •Obese an equal number with •Enlarged liver, abdominal mass or •Nulliparous hyperplasia excessive abdominal fluid (ascites). •Hormone •Vaginal discharge (thin/clear) therapy (HRT) •Bleeding pattern: •Diabetes excessive, postcoital, •stigmata of chronic •Family history Intermenstrual bleed anovulation(hirsutism,acne, acanthosis,obesity,wt>90kg) •Ass. Symp :pelvic painEndometrial Age: stigmata of chronic anovulation ONLY IF GOT RISKhyperplasia post/perimenopausal> (hirsutism,acne,acanthosis,obesity,wt>90 FACTORS!!! Rf:unopposed estrogen kg) •TVS/TAS •If ET >12 Endometrial biopsy/ Bleeding pattern: D&C menometrorrhagia, Ass.symptoms: -symptomatic anemia -Infertilitymood swings, Hot flushes,dyspareunia
  13. 13. • Systemic diseases and disorders:CONDITION ASSESTMENT TESTS Hx: Menorrhagia since menarche •Routine screening for coagulationCoagulation Family history of bleeding disorders defects should be reserved for youngdisorders patient who has heavy flow with the onset of menstruation Personal history of 1 or more of the following: •Coagulation screen -Notable bruising without known injury -Bleeding of oral cavity or gastrointestinal tract •rule out von Willebrand disease; ITP; without obvious lesion and factor II, V, VII, or IX deficiency. -Epistaxis greater than 10 minutes duration (possibly necessitating packing or cautery) In a 9 year review of 59 cases of acute menorrhagia in adolescents it was discovered that 20% had a primary coagulation disorderHypothyroidism Ass. Symp: Hypothyroid symptoms fatigue, TFT constipation, intolerance of cold, and hair and skin changesLiver or renal Ass. Symp: liver/renal failure symptoms RP/LFT/COAG screendisease (Dysfunction of either organ can alter coagulation factors and/or the metabolism of hormones)
  14. 14. • Iatrogenic causes: symptoms start after medication/therapy started CONDITION Anticoagulant treatment Chemotherapy disrupt the normal menstrual cycle, which is restored easily upon cessation of the products Intrauterine contraceptive device (Conventional types can cause excessive bleeding) OCP’s (inadequate dose/compliance)
  15. 15. Management
  16. 16. Acute bleeding
  17. 17. Acute bleeding Orthostatic hypotension/ hb<10 gm/dl•Premarin 2.5 mg PO qid pluspromethazine 25 mg PO or IM or PR •Premarin 25 mg IV q4h x 24h +q4-6h as needed (nausea) promethazine 25mg PO or IM or PR NO Yes hosp q4-6h as needed for nausea outpatient mx admission•No improvement in 2-4 doses ofpremarin/bleeding soaking 1 •Transfuse 2 pint packed rbc if Hb<pad/hour or more after 7.5mg/dltreatment D&C •1-2 doses no response D &C•Bleeding stopsswitch toOCP/cycle provera •Simultnoeus with premarin start OCP/cycle provera•Oral iron •Oral ion
  18. 18. MEDICAL
  19. 19. Surgical
  21. 21. Indications•Failed medical treatment(minimum 3-6 months)•Intolerable side effects ofmedical treatment• Organic causes warrantingsurgery (e.g. fibroid, cancer)•Patients preference•Co-existing conditions (e.g.adenomyosis withdysmenorrhoea)
  22. 22. Secondary menorrhagia
  23. 23. CONDITION TREATMENTUterine fibroids Tx: Asymptomatic(- tx) •medical hormonal/non-hormonal -non-hormonal: transnemic acid/NSAID (during menstruation) -hormonal : OCP, progestogens, androgens, levonogestral releasing IUD, GnRH,GnRH and hormonal add-back •Surgical: myomectomy (hysteroscopic ,laparoscopic, tans abd resection,)hysterectomy, uterine artery embolization, MRI-guided focused USendometriosis Tx: Medical: hormonal Surgical: Excision, endometrial ablation ,TAHBSO
  24. 24. adenomyosis •tx: -medical -surgical hysterectomy(without oophorectomy),UAE ,endometrial ablation,Pelvicinflammatory tx:disease -medical: broad spectrum AB, clindamycin and gentamicin administered intravenously every 8 hoursUterine polyps •tx: hysteroscopy + polypectomyEndometrial •Total abdominal hysterectomy with bilateral salpingo-oophorectomy iscarcinoma required both as a primary treatment and for the purpose of stagingEndometrial Medicalhyperplasia Simple endometrial hyperplasia without atypia responds to high-dose progestogens, with repeat histology after three months (IUD) Surgical Endometrial ablation or transcervical resection of the endometrium Hysterectomy - usually advised for atypical endometrial hyperplasia
  25. 25. Coagulation Vitamin k/FFP/coagulation factors/desmopressindisordersHypothyroid Thyroid hormone replacement therapyAnticoagulant’s levonorgestrel releasing intrauterine device (Mirena coil) hysterectomyIUCD (mx chart)OCP’s (mx chart)
  27. 27. Hx and pe B-HCG Correct anemia +/- acute Menarche FBC bleeding mx onset screen for coagulation disorders Pregnancy exclude Non uterine source (cervical ca, lacerations, anus, rectal,Miscarriage urethral)Ectopic preg.Antepartum Mx accordinglyhaemorrhage(pp,Abruptio placenta,vasa previa)Etc. pap smear (esp if + postcoital bleed)Mx accordingly FOBT UFEME
  28. 28. Symptoms suggests •TVS MENORRHAGIA + underlying pathology •Endometrial •Hysteroscop hyperplasia/ y/transvaginal carcinoma - sonohysterogr •Submucosal Uterus>10 aphy/ Fibroid weeks in size, 1st line Abd - •endometrial pelvic mass, USS •Biopsy polyps Normal/bulky tenderness uterus 8-10 •d & c weeks Mx accordingly iatrogenic Normal Symptoms/signs of Low risk hypothyroid group (most likely DUB) Mx accordingly treat TFT hypothyroidism hormonal therapyHIGH RISK GROUP Pelvic pain Secondary dysmenorrheaSymptoms suggestsunderlying pathology Risk factorsAge > 40 TamoxifenIrregular/intermenstrual/ Unopped estrogenpostcoital bleeding PCOS ( Hirsutism)Sudden change in bleeding obesitypatternDyspareunia
  29. 29. -LevonogestrelEvaluate intrauterine hormonal therapy in 6 devicemonths -Norethisterone no ovulatory Evaluate Oral in 3 contraceptive yes Need contraception months pill Yes/does not want No improvement add no hormone therapy mefenemic acid(NSAIDS) and evaluate in 3 months Tranexamic acid NSAID Cyclic oral progestin (ist 5 days of (luteal phase) menstruation) No improvement treatment Treatment Successful failure Continue improve management Further assestment Continue medical hysteroscopy and therapy biopsy
  30. 30. CASE STUDY• A 14-year-old girl was referred for assessment of heavy menses. Menses commenced at the age of 12 years and were unremarkable until the past six months when she noticed an increased amount and duration of bleeding. The menses were regular but had increased from four to seven days of bleeding and she was now using up to 10 pads/day for the first three days. She denied any sexual activity.
  31. 31. • Review of systems was positive for fatigue but negative for change in weight, cold intolerance, shortness of breath, easy bruising or prolonged bleeding• Past medical history was unremarkable other than for asthma, and a family history could not be obtained because the patient was adopted..• On physical examination the patient was pale but in no distress. Vital signs were normal. General physical and external genital examination was normal, with no evidence of bruising.
  32. 32. • Laboratory investigation showed hemoglobin concentration of 74 g/L (normal 120 to 153 g/L), mean corpuscular volume and mean corpuscular hemoglobin were both slightly below normal, UPT (-)
  33. 33. • Bleeding time was slightly prolonged at 10 min (normal 2 to 9 min).• Factor VIII was normal, von Willebrand factor (vWf) antigen was 0.28 IU/mL (normal 0.50 to 1.50 IU/mL).• The ristocetin cofactor (a measure of vWf activity) was 0.36 IU/mL (0.50 to 1.50 IU/mL).• Based on these results a diagnosis of von Willebrand’s disease (vWD) type I (vWf is quantitatively reduced but not absent) was made.
  34. 34. Amenorrhea
  35. 35. Definition• Amenorrhea – Absence of menstruation• Oligomenorrhea – Menstrual cycles of 35 days - 6 months (and cycle length typically irregular)
  36. 36. Types of amenorrhea• Primary• Secondary
  37. 37. Primary amenorrhea• absence of menstrual bleeding and secondary sexual characteristics (breast development and pubic hair) in a girl by age 14 years• absence of menstrual bleeding with normal development of secondary sexual characteristics in a girl by age 16 years
  38. 38. Secondary amenorrhea• cessation of menses after menstruation established – 3 months in woman with previously normal menstruation – 9 months in woman with previous oligomenorrhea
  39. 39. Incidence• Secondary more common than primary• 20% vigorously exercising women, up to 50% elite female athletes• Most affecting – Competitive athletes – Ballet dancers – Gymnasts
  40. 40. Causes for primary amenorrheaBreast + Uterus Breast + Uterus Breast + Uterus Breast + UterusGonadal failure Androgen 17,20-desmolase Hypothalamic 50% 45 X, 25% 46 Xabnormal X (deletion), insensitivity deficiency causes25% mosaicism, pure XY (testiculargonadal dysgenesis, XY feminization - Pituitary causesgonadal dysgenesis normal female(Sawyers Syndrome - XYkaryotype, palpable phenotype, 46 XY, Ovarian causesMullerian system, normal normal or slightlyfemale testosterone increased male Uterine causeslevels, lack of sexualdevelopment), 17- testosterone levels,hydroxylase deficiency X-linked recessive)(with 46 XX)CNS-hypothalamic- Congenital absence Agonadism 1. Physiologicalpituitary disorder - CNS delaylesion, inadequate GnRH of uterus (utero- vaginal atresia) 2. Weight loss/release, isolatedgonadotropin deficiency anorexia 3. Imperforate hymen
  41. 41. Causes of secondary amenorrhea• Hypothalamic-pituitary - destructive lesions, Sheehan syndrome, hyperprolactinemia, hypothalamic-pituitary dysfunction, weight loss• Virilizing disorder - PCOS, hyperthecosis, ovarian tumor, congenital adrenal hyperplasia, adrenal tumor, Cushing syndrome• Psychogenic - anorexia nervosa, change in environment (stress), adolescence• End organ cause - uterine adhesions, cervical stenosis, vesicovaginal fistula, hormone-resistant endometrium• Ovarian - gonadal dysgenesis with limited menstrual function, premature ovarian failure, resistant ovaries syndrome• Thyroid disease
  42. 42. Management
  43. 43. Treatment• Initial mx – Exclude pregnancy – Perimenopausal symptoms (flushings, vaginal dryness) – History of weight changes, drugs, medical disorders and thyroids symptoms – Examination assessing the height, weight, visual fields, presence of virilisation or hirsutism, pelvic examination – Serum for LH, FSH, prolactin, testosterone, TFT – TVS – polycystic ovaries
  44. 44. Investigations Results TreatmentUltrasound scan PCOS – small, peripheral If pregnancy desired – placed follicular ovarian cysts clomiphine surrounded by thickened If not desired – COCP echodense stroma (supported by LH:FSH ratio >3 and testosterone >3)Elevated PL level PL> 800 mU/L on 2 occasion – MRI pituitary and treat with hyperprolactinemia dopamine agonist – bromocriptineElevated FSH level FSH > 30 U/L, for patient HRT above 40 is menopause and patient less than 40 is premature ovarian failureAbnormal TFT Treat according to the pathology
  45. 45. • If all the test is normal – Weight loss – Depression, emotional disturbances, extreme exercise – Asherman’s syndrome – Idiopathic amenorrhea
  46. 46. Reference• Cpg menorrhagia kkm malaysia• Acess medicine• Ten teachers• Dutta gynecology• Shaw’s gynaecology