Department of Obs and Gynae,Chittagong Medical College For 4th Year MBBS student,

1. Menorrhagia
(Heavy menstrual bleeding)
DR Fahmida Rashid
Assistant Professor
CMC

2. Definition
Cyclical bleeding at normal
interval ; the bleeding is either
excessive in amount(>80 ml) or
duration(>7 days) or both

3. DEFINITION
DEFINITION
Menorrhagia is excessive menstrual blood loss
over several consecutive cycles which interferes
with the woman's physical, emotional, social,
and material quality of life. (Nice 2007)
Commonest cause of iron deficiency anaemia in
women of reproductive age

4. OTHER IMPORTANT DEFINITION…
TERMS DEFINITION
Metrorrhagia Menstrual flow at irregular
intervals
Menometrorrhagia Irregular and excessive flow
Polymenorrhoea Bleeding at intervals of less
than 21 days
Postcoital bleeding Is non-menstrual bleeding
that occurs immediately after
sexual intercourse

5. ClassificationClassification
Primary/FunctionalPrimary/Functional Secondary/OrganicSecondary/Organic
Idiopathic /
DUB
Idiopathic /
DUB
ovulatoryovulatory Non-
ovulatory
Non-
ovulatory
-Uterine and
ovarian
pathologies
-Systemic
diseases
-Iatrogenic
causes
-Uterine and
ovarian
pathologies
-Systemic
diseases
-Iatrogenic
causes

6. Symptoms
• Soaking through 1 or > sanitary pads or tampons
every hour for several consecutive hours
• Needing to use double sanitary protection to
control menstrual flow
• Needing to wake up to change sanitary protection
during the night
• Bleeding for longer than a week
• Passing blood clots with menstrual flow for more
than one day
• Restricting daily activities due to heavy menstrual
flow
• Symptoms of anemia, such as tiredness, fatigue or
shortness of breath

7. When to see a doctor
• Vaginal bleeding so heavy it soaks at least
one pad or tampon an hour for more than a
few hours
• Bleeding between periods or irregular
vaginal bleeding
• Any vaginal bleeding after menopause

8. Risk factors
• Adolescent girls who have recently started
menstruating.
• Girls are especially prone to anovulatory cycles in the
first year after their first menstrual period
(menarche).
• Older women approaching menopause.
• Women ages 40 to 50 are at increased risk of
hormonal changes that lead to anovulatory cycles.

9. Complications
Iron deficiency anemia:
Menorrhagia may decrease iron levels enough
to increase the risk of iron deficiency anemia.
Severe pain.
with heavy menstrual bleeding, one might
have painful menstrual cramps
(dysmenorrhea).

10. Common causes of Menorrhagia
• Dysfunctional Uterine Bleeding
• Fibroid Uterus
• Adenomyosis
• Chronic Tubo-Ovarian Mass

11. PRIMARY/FunctionalPRIMARY/Functional

12. • Disturbed Hypothalamo-Pituary-
Ovarian-Endometrial axis

13. DUB
•Heavy or irregular menstrual
bleeding , not caused by an underlying
anatomical abnormality, such as a fibroid, or
tumor (abnormal uterine bleeding without any
obvious structural or systemic pathology)
•Dx of exclusion
•Hormonal imbalance, hypothalamus-pituitary-
ovary axis
•Women who Just started
menstruation/perimenopausal
•Heavy or irregular menstrual
bleeding , not caused by an underlying
anatomical abnormality, such as a fibroid, or
tumor (abnormal uterine bleeding without any
obvious structural or systemic pathology)
•Dx of exclusion
•Hormonal imbalance, hypothalamus-pituitary-
ovary axis
•Women who Just started
menstruation/perimenopausal
Anovulatory
90%
Anovulatory
90%
Ovulatory
10%
Ovulatory
10%
Unopposed
estrogen
Unopposed
estrogen
Associated with increased
prostaglandin release
(hemostatic deficiency)
Associated with increased
prostaglandin release
(hemostatic deficiency)
Mx:
1.Medical
2.Surgical
Hysterectomy
endometrial
ablation

14. • Anovulatory cycles
Unpredictable cycle
length
•
Unpredictable
bleeding pattern
•
Frequent spotting
•
Infrequent heavy
bleeding
Monophasic
temperature curve
•Ovulatory cycles
Regular cycle length
Presence of premenstrual
symptoms
-Dysmenorrhea
-Breast tenderness
-Change in cervical mucus
-Mittleschmertz Pain
Biphasic temperature
curve
Positive result from use of
luteinizing-hormone
predictor kit

15. SECONDARY CAUSES/OrganicSECONDARY CAUSES/Organic

16. PCOS
Uterine and ovarian
pathologies /Pelvic
Uterine and ovarian
pathologies /Pelvic
Pelvic
endometriosis
Fibroid Uterus
Adenomyosis
Tubercular
Endometritis
Chronic Tubo-Ovarian
Mass
IUCD in Utero
Retroverted Uterus
Granulosa cell tumor of Ovary

17. • Systemic:
• Liver Dysfunction(Cirrhosis)
• Congestive Cardiac Failure
• Severe Hypertension
• Endocrinal :
• Hypothyroidism
• Hyperthyroidism

18. • Haematological:
• Idiopathic thrombocytopenic Purpura
• Leukemia
• Von Willebrand,s Disease
• Platelet deficiency
(thrombocytopenia)
• Emotional Upset

20. Endome
triosis
Age: reproductive
age
Bleeding pattern:
menorrhagia,
usually lasts more
than 7 days short
interval
Ass.symp:
dysmenorrhoea/
chronic pelvic pain,
dyspareunia,
difficulty
conceiving
Examination:
wide spectrum,
depends
menstruating/n
ot
abdominal
tenderness,
mass
Speculum:
red,
hypertrophic
lesions ,
bleeding on
contact seen at
post.fornix
Inv:
laparoscop
ic, TVUS,

21. Adenomy
osis
•Age: 40 and 50
years
old,parous/prior
uterine surgery
•bleeding pattern:
menorrhagia
,postccoital,
Intermenstrual
•ass, Symp.:
dysmenorrhea,
dyspareunia
•Exam:
•The uterus
is enlarged
and boggy
•Tenderness
•mass
(adenomyo
ma)
Inv :
TAS/TVS
(diffuse
thickening
within
wall),
MRI,
hysterosco
pic/laparos
copic
biopsy

22. • Systemic diseases and disorders:

24. • Iatrogenic causes:
symptoms start after medication/therapy started

25. Diagnosis
• Long duration Of flow
• Passage of big clots
• Use of incresed number of
thick sanitary pads
• Pallor
• Low level of Hemoglobin

26. History
• Full gynaecological history
• Notoriously inaccurate amount of blood loss
• Number of pads/tampons used
• Clots/ flooding
• Frequency of accidents
• Menstrual chart can be useful

27. Examination
• Weight
• Any signs of endocrine disturbance
• Abdominal and pelvic examination
• Cervical smear if indicated

28. Tests and diagnosis
 Blood tests. evaluate for iron deficiency (anemia)
and other conditions, such as thyroid disorders or
blood-clotting abnormalities.
 Pap test. cells from cervix are collected and
tested for infection, inflammation or cancerous
changes.
 Endometrial biopsy.
 Ultrasound scan. For uterus, ovaries and pelvis.
Based on the results of initial tests, you may
recommend further testing, including:

29.  Sonohysterogram.
During this test, a fluid is injected through a
tube into uterus by way of vagina and
cervix. using ultrasound to look for
problems in the lining of uterus.
 Hysteroscopy.
This exam involves inserting a tiny camera
through vagina and cervix into uterus,
which allows to see the inside of uterus.

30. Management

31. • Drug Used to treat Menorrhagia:
• NSAID- Mefenamic Acid
• Ibuprofen
• Indomethacin
• Antifibrinolytic – Tranexamic Acid
• Amino caproic Acid
• Hormones-Progesterone
• Norethisterone
• Combined Estrogen –Progesterone
• Other- Danazol
• GnRH A

34. Treatment
• If any pathology is found it must be treated, rest
aim to treat dysfunctional uterine bleeding
• Anovulatory- extremes of age.
• OCP can help.
• Cyclical progestogens used to induce regular
withdrawl bleeds.
• Acute arrest for heavy bleeding- high dose
reducing course of progestogen

35. Treatments and drugs
 Iron supplements. If have anemia, recommend
iron supplements regularly.
 Nonsteroidal anti-inflammatory drugs. such as
ibuprofen or naproxen - reduce menstrual
blood loss.
relieving painful menstrual cramps
(dysmenorrhea).
 Mefanamic acid, given for a few days during
menstruation

36. Treatment
• Antifibrinolytic drugs-
• reduce enhanced fibrinolytic activity within
the uterus.
• Up to 50% reduction.
Tranexamic acid

37. hormone

38.  Oral contraceptives-
 ovulation suppressed .
oestrogen levels remain constant. Help
regulate menstrual cycles and reduce episodes
of excessive or prolonged menstrual bleeding.
 Oral progesterone. help correct hormone
imbalance and reduce menorrhagia.

39.  The hormonal IUD (Mirena).
Can cause amenorrhoea
 releases a type of progestin
called levonorgestrel,
• makes the uterine lining thin
• decreases menstrual blood
flow & amenorrhoea
• decrease cramping.

40. • Danazol:
anti gonadotrophin.
Induces atrophy of endometrium due to low
level of circulating sex steroids.
Androgenic side effects not tolerated well-
virilizing effects

41. Surgical Treatment
 Dilation and curettage (D&C).
 Uterine artery embolization.
Fibroids-
goal to shrink it in uterus by blocking the
uterine arteries and cutting off their blood
supply.

42.  Myomectomy. surgical
removal of uterine fibroids.
 Endometrial
ablation. permanently
destroying the lining of
uterus .
hysteroscopically and
ablated.
Many methods-laser,
rollerball, hydrothermal,
cryoablation, microwave.
amenorrhoeic .

43.  Endometrial resection
 Hysterectomy.
surgery to remove your uterus and cervix .
permanent procedure , causes sterility and
ends menstrual periods.
definative treatment if family complete.