Management of Menorrhagia


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Management of Menorrhagia

  1. 1. Management of Menorrhagia (Heavy Menstrual Bleeding) Dr Tan Yiap Loong Obstetric and Gynaecology Department Sarawak General Hospital
  2. 2. Definition <ul><li>Heavy menstrual bleeding (menorrhagia) is diagnosed when menstrual blood loss is considered excessive by the woman, interferes with women’s physical, social emotional, and/or quality of life </li></ul><ul><li>Highly subjective and personal issue </li></ul>
  3. 3. Definition <ul><li>In research studies- between 60 ml and 80 ml per menstruation </li></ul><ul><ul><li>not practical in the clinical setting </li></ul></ul><ul><li>Accompanied by other symptoms, such as menstrual pain (dysmenorrhoea) </li></ul>
  4. 4. How common is it? <ul><li>Between 4% and 51.6% </li></ul>
  5. 5. Normal Menstrual Cycle <ul><li>Cycle length </li></ul><ul><ul><li>average 29 days </li></ul></ul><ul><ul><li>Range 23 - 39 days </li></ul></ul><ul><li>Duration of flow </li></ul><ul><ul><li>Average 4 days </li></ul></ul><ul><ul><li>3 to 7 days </li></ul></ul><ul><li>Amount </li></ul><ul><ul><li>Average 35 mls </li></ul></ul><ul><li>Quality </li></ul><ul><ul><li>Non-clotting blood, endometrial debris </li></ul></ul>
  6. 6. Previously…………. <ul><li>In the early 1990s it was estimated that at least 60% of women presenting with HMB would have a hysterectomy to treat the problem, often as a first line. </li></ul><ul><li>Emotive procedure </li></ul><ul><ul><li>womb and fertility often seen as being part of a woman ’ s identity </li></ul></ul><ul><ul><li>undesirable for some people </li></ul></ul>
  7. 7. Now…………. <ul><li>Things have changed and the number of hysterectomies is decreasing rapidly. </li></ul><ul><li>In the UK, aim to be managed by primary health care </li></ul><ul><li>Nevertheless, clinically, hysterectomy is associated with a very high satisfaction rate by those who have undergone the operation </li></ul>
  8. 8. Risk Factors <ul><li>While HMB may occur in the presence of histological abnormality, the association does not necessarily imply causality </li></ul><ul><li>Uterine fibroids (30%) </li></ul><ul><ul><li>epidemiological study in the UK found that site, size and number of fibroids are linked to the level of MBL </li></ul></ul><ul><ul><li>(Sulaiman S, Khaund A, McMillan N, et al. 2004) </li></ul></ul>
  9. 9. Risk Factors <ul><li>Age </li></ul><ul><ul><li>? an increase in MBL with age </li></ul></ul><ul><li>Polyps </li></ul><ul><ul><li>No studies linked the presence of uterine polyps with HMB. </li></ul></ul><ul><li>Blood disorders </li></ul><ul><ul><li>von Willebrand disease (vWD) </li></ul></ul><ul><ul><ul><li>13.0-15.4% in women with menorrhagia compared with the general population </li></ul></ul></ul><ul><ul><ul><li>(Woo YL, White B, Corbally R, et al. 2002) </li></ul></ul></ul>
  10. 10. Risk Factors <ul><li>Thyroid disorders </li></ul><ul><li>Endometriosis/ Adenomyosis </li></ul><ul><ul><li>usually dysmenorrhoea but two studies have found that HMB may be a significant secondary symptom </li></ul></ul><ul><li>Racial groups </li></ul><ul><li>Lifestyle </li></ul><ul><ul><li>observational studies showed impact on MBL </li></ul></ul>
  11. 11. Risk Factors <ul><li>Uterine Pathology? </li></ul><ul><ul><li>Results of 20 observational and diagnostic studies show that the majority of women with HMB have no histological abnormality that can be implicated in causing HMB </li></ul></ul><ul><ul><li>Rare for a woman who has presented with HMB and has undergone investigations to have an underlying pre-malignant or malignant condition </li></ul></ul><ul><ul><li>RCOG </li></ul></ul><ul><ul><ul><li>women aged between 35 and 54 years, eight of every 10,000 women who presented with HMB in primary care would have endometrial carcinoma. </li></ul></ul></ul>
  12. 12. Risk Factors <ul><li>Dysfunctional uterine bleeding </li></ul><ul><ul><li>No organic cause </li></ul></ul><ul><ul><li>Frequently due to anovulation </li></ul></ul><ul><li>Others </li></ul><ul><ul><li>PID </li></ul></ul><ul><ul><li>Malignancy </li></ul></ul><ul><ul><li>IUCD </li></ul></ul><ul><ul><li>Medications (Tamoxifen, Unapposed oestrogen treatment) </li></ul></ul>
  13. 13. What is our goal? <ul><li>Heavy menstrual bleeding (HMB) should be recognised as having a major impact on a woman ’ s quality of life, and any intervention should aim to improve this rather than focusing on menstrual blood loss. [C] </li></ul><ul><li>(NICE 2007) </li></ul>
  14. 14. How should I assess a woman with menorrhagia?
  15. 15. History and Physical Examination <ul><li>Nature of the bleeding (flooding, clots, double padding,etc) and related symptoms (anaemia) </li></ul><ul><li>Directed to identify potential pathology </li></ul><ul><li>Explore women’s prespective, ideas, concerns </li></ul><ul><li>Previous treatments </li></ul>
  16. 16. History and Physical Examination <ul><li>Physical examination if an abnormality is suspected (e.g. if there is intermenstrual or postcoital bleeding, or pelvic pain or pressure) </li></ul><ul><ul><li>Recommended before all ; </li></ul></ul><ul><ul><ul><ul><li>LNG-IUS fittings </li></ul></ul></ul></ul><ul><ul><ul><ul><li>investigations for structural abnormalities </li></ul></ul></ul></ul><ul><ul><ul><ul><li>investigations for histological abnormalities </li></ul></ul></ul></ul>
  17. 17. History and Physical Examination <ul><li>Measurement of MBL </li></ul><ul><ul><li>Direct- alkaline haematin </li></ul></ul><ul><ul><ul><li>Accurate and precise </li></ul></ul></ul><ul><ul><ul><li>Impractical </li></ul></ul></ul><ul><ul><ul><li>Little impact on management </li></ul></ul></ul><ul><ul><li>Indirect- Pictorial Blood Loss Assessment Chart (PBAC) </li></ul></ul><ul><ul><ul><li>Highly variable </li></ul></ul></ul><ul><ul><li>NOT RECOMMENDED ROUTINELY </li></ul></ul><ul><ul><li>SHOULD BE DETERMINED BY PATIENT HERSELF </li></ul></ul>
  18. 18. Investigations (Laboratory) <ul><li>FBC test - in all women with HMB </li></ul><ul><li>Coagulation profile -if HMB since menarche/ family history </li></ul><ul><li>Serum Ferritin - not routinely </li></ul><ul><li>Hormone testing - not recommended </li></ul><ul><li>Thyroid function test - when signs and symptoms present </li></ul>
  19. 19. Investigations (Structural and Histological) <ul><li>Ultrasound </li></ul><ul><ul><li>sensitivity 48 - 100% </li></ul></ul><ul><ul><li>specificity 12 - 100% </li></ul></ul><ul><ul><li>better at identifying fibroids than hysteroscopy </li></ul></ul><ul><ul><li>less accurate for identifying polyps or endometrial disease </li></ul></ul><ul><ul><li>should be undertaken in the following circumstances: </li></ul></ul><ul><ul><ul><li>uterus is palpable abdominally </li></ul></ul></ul><ul><ul><ul><li>vaginal examination reveals a pelvic mass of uncertain origin </li></ul></ul></ul><ul><ul><ul><li>pharmaceutical treatment fails </li></ul></ul></ul><ul><li>Hysteroscopy </li></ul><ul><ul><li>when ultrasound results are inconclusive </li></ul></ul><ul><ul><li>to determine the exact location of a fibroid or the exact nature of the abnormality </li></ul></ul>
  20. 20. Investigations (Structural and Histological) <ul><li>Magnetic resonance imaging (MRI) </li></ul><ul><li>Dilatation and curettage </li></ul><ul><ul><li>alone should not be used as a diagnostic tool </li></ul></ul><ul><li>Endometrial biopsy </li></ul><ul><ul><li>persistent intermenstrual bleeding </li></ul></ul><ul><ul><li>in women aged 45 and over </li></ul></ul><ul><ul><li>treatment failure or ineffective treatment </li></ul></ul>
  21. 21. What advice and counselling should I give to a woman with menorrhagia?
  22. 22. Discuss……. <ul><li>Natural variability and range of menstrual blood loss and reassure the woman (if appropriate) </li></ul><ul><li>Different treatment options </li></ul><ul><ul><li>acceptability </li></ul></ul><ul><ul><li>effectiveness of treatments </li></ul></ul><ul><ul><li>adverse effects </li></ul></ul><ul><ul><li>contraception </li></ul></ul><ul><ul><li>implications of treatment on fertility </li></ul></ul>
  23. 23. Give…….. <ul><li>The opportunity to review and agree any treatment decision. </li></ul><ul><li>Adequate time and support from healthcare professionals in the decision-making process </li></ul>
  24. 24. When should I prescribe pharmaceutical treatment in women presenting with menorrhagia?
  25. 25. Drug Treatment <ul><li>Pharmaceutical treatment (recommended first-line) </li></ul><ul><ul><li>no symptoms or signs suggestive of underlying pathology (structural or histological uterine abnormalities </li></ul></ul><ul><ul><li>are awaiting the results of investigations </li></ul></ul>
  26. 26. Drug Treatment <ul><li>If either hormonal or non-hormonal treatments are acceptable (descending order) </li></ul><ul><ul><li>levonorgestrel-releasing intrauterine system (Mirena®) provided long-term (at least 12-months) use is anticipated </li></ul></ul><ul><ul><li>tranexamic acid or non-steroidal anti-inflammatory drugs (NSAIDs) or combined oral contraceptives </li></ul></ul><ul><ul><li>norethisterone (15 mg) daily from days 5 to 26 of the menstrual cycle, or injected long-acting progestogens ( Depo-Provera®) . </li></ul></ul>
  27. 27. Drug Treatment <ul><li>Levonorgestrel-releasing intrauterine system (Mirena®) </li></ul><ul><ul><li>RCTs reduction between 71% and 96% </li></ul></ul><ul><ul><li>Full benefit of treatment may not be seen for 6 months </li></ul></ul><ul><ul><li>30% amenorrhoea </li></ul></ul><ul><ul><li>RCT (ECLIPSE) </li></ul></ul><ul><ul><ul><li>LNG-IUS vs other pharmaceutical treatments </li></ul></ul></ul>
  28. 28. Drug Treatment <ul><li>Tranexamic acid </li></ul><ul><ul><li>1 g (2 X 500 mg tablets) three to four times daily, from the onset of bleeding for up to 4 days </li></ul></ul><ul><ul><li>reductions in MBL (29% to 58%) </li></ul></ul><ul><li>NSAIDs (mefenamic acid or naproxen) </li></ul><ul><ul><li>reductions in MBL (20% to 49%) </li></ul></ul><ul><ul><li>dysmenorrhoea </li></ul></ul>
  29. 29. Drug Treatment <ul><li>COCs </li></ul><ul><ul><li>reduction of MBL of 43% </li></ul></ul><ul><li>Oral progestogen </li></ul><ul><ul><li>used long-term reduces MBL by 83% </li></ul></ul><ul><li>Etonogestrel implant (Implanon ® ) </li></ul><ul><ul><li>no licence for the treatment of HMB </li></ul></ul><ul><li>Depot medroxyprogesterone acetate (DMPA) </li></ul><ul><ul><li>No evidence </li></ul></ul><ul><ul><li>Amenorrhea is a side effect (NICE) </li></ul></ul>
  30. 30. Drug Treatment <ul><li>If hormonal treatments are not acceptable to the woman, then either tranexamic acid or NSAIDs can be used </li></ul><ul><li>GnRH analogue </li></ul><ul><ul><li>prior to surgery </li></ul></ul><ul><ul><li>other treatment options for uterine fibroids, including surgery or uterine artery embolisation (UAE), are contraindicated </li></ul></ul><ul><ul><li>‘ add-back ’ therapy </li></ul></ul><ul><ul><li>amenorrhea rates of 89% </li></ul></ul>
  31. 31. What should I do if initial drug treatment is ineffective in a woman with menorrhagia? <ul><li>A second pharmaceutical treatment </li></ul><ul><li>Add on another drug rather than immediate referral to surgery. </li></ul><ul><li>Use of NSAIDs and/or tranexamic acid should be stopped if it does not improve symptoms within three menstrual cycles </li></ul>
  32. 32. How can I rapidly stop heavy bleeding, if necessary? <ul><li>Oral norethisterone, 5 mg three times daily (licensed use) or, in very severe cases, 10 mg three times daily (unlicensed use), then tapering down to 5 mg three times daily for a further week </li></ul>
  33. 33. Not Recommended <ul><li>Oral progestogens in the luteal phase only </li></ul><ul><li>Danazol (side effects) </li></ul><ul><li>Etamsylate </li></ul>
  34. 34. When should I refer? <ul><li>Malignancy is suspected </li></ul><ul><ul><li>refer urgently (within 2 weeks) </li></ul></ul><ul><li>Significant negative impact on her quality of life despite adequate trials of pharmaceutical treatment </li></ul><ul><li>Anaemia - not improved despite treatment (other causes excluded) </li></ul><ul><ul><li>make a routine referral. </li></ul></ul><ul><li>Wants to consider surgical options </li></ul>
  35. 35. Surgical Treatment <ul><li>Used as the initial treatment for HMB? </li></ul><ul><ul><li>Unclear </li></ul></ul><ul><ul><li>Endometrial ablation may be offered </li></ul></ul><ul><ul><li>Hysterectomy should not be used as a first-line treatment solely for HMB </li></ul></ul><ul><li>Whether a pharmaceutical intervention should always be tried first? </li></ul>
  36. 36. Surgical Treatment <ul><li>Non-hysterectomy or interventional radiology </li></ul><ul><li>Hysterectomy </li></ul>
  37. 37. Non-hysterectomy or interventional radiology <ul><li>Endometrial ablation </li></ul><ul><ul><li>1st generation (TCRE, Rollerball) </li></ul></ul><ul><ul><li>2nd generation (MEA, Inpedence-controlled bipolar radiofrequency, balloon thermal) </li></ul></ul><ul><ul><li>Affects fertility </li></ul></ul><ul><ul><li>Use of effective contraception following procedure </li></ul></ul><ul><ul><li>50% amenorrhoea, 95% satisfaction rate </li></ul></ul>
  38. 38. Non-hysterectomy or interventional radiology <ul><li>Uterine artery embolisation (UAE) </li></ul><ul><ul><li>Fertility is potentially retained </li></ul></ul>
  39. 39. Non-hysterectomy or interventional radiology <ul><li>Hysteroscopic myomectomy </li></ul><ul><li>Myomectomy </li></ul>
  40. 40. Hysterectomy <ul><li>Fibroids >3cm + severe impact on QoL </li></ul><ul><li>Desire for amenorrhoea </li></ul><ul><li>Other treatments failed, contraindicated, declined </li></ul><ul><li>No desire to retain uterus or fertility </li></ul><ul><li>Fully informed women request it </li></ul>
  41. 41. Hysterectomy <ul><li>Route </li></ul><ul><ul><li>First line : Vaginal </li></ul></ul><ul><ul><li>Second line : Abdominal </li></ul></ul><ul><li>Ovaries may also be removed </li></ul><ul><li>100% amenorrhoea </li></ul><ul><li>95% satisfaction rate </li></ul>
  42. 43. Many Thanks
  43. 44. Referrences <ul><li>Sulaiman S, Khaund A, McMillan N, et al. Uterine fibroids - do size and location determine menstrual blood loss? European Journal of Obstetrics and Gynecology 2004;115(1):85 - 9 </li></ul><ul><li>Woo YL, White B, Corbally R, et al. Von Willebrand ’ s disease: an important cause of dysfunctional uterine bleeding. Blood Coagulation and Fibrinolysis 2002;13(2):89 - 93 </li></ul>