A Family Doctor's Tale - MENORRHAGIA

DOC I HAVE HEAVY MENSES

Menorrhagia is a symptom defined as heavy, prolonged and/or irregular menstruation .


The most common cause is hormonal:


Excessive menstrual bleeding occurs when no ovulation takes place in a menstrual cycle with resultant excess estrogen stimulation of the endometrium that results in the shedding of the thickened uterine lining and heavy bleeding when the estrogen drops.


A defective persistent corpus luteum which results from an abnormal ovulation can also cause the shedding of the endometrium for a longer period resulting in  prolonged bleeding.


Less important causes of heavy menstrual bleeding are:
Uterine Pathology:
polyps,
fibroids
endometriosis
infection
carcinoma


Systemic Diseases:
Bleeding diseases
Hypothyroidism
liver disease
Pelvic inflammatory Disease(PID)
Poly Cystic Ovarian Syndrome(PCOS)


Medical causes:
anticoagulants which are preventing clotting of blood
intrauterine device for contraception


It is important to know the previous menstrual history:
cycle length, number of bleeding days, degree of blood loss(number of pads used per day), presence of blood clots, dysmenorrhea


Any use of contraception:
IUD
contraceptive pills


Any symptoms suggesting underlying pathology:
Metabolic disorders:
hypothyroidism
polycystic ovarian syndrome


Any bleeding disorders:
easy bruising
anticoagulants


Any pelvic inflammatory Disease:
pelvic pain especially during intercourse
vaginal discharge
dysmenorrhea


In physical examination look for signs of underlying diseases:
bruising
hypothyroid features
pallor(anaemia)
PCOS features (hirsutism,acne,overweight)


Abdominal examination:
tenderness,
palpable uterine or ovarian masses


Pelvic examination:
vulval and vaginal examination
bimanual palpation for masses
cervical smear


Investigation:
Full blood count including hemoglobin (to exclude anemia from loss of blood) and platelets (low platelets can cause bleeding)
Transvaginal ultrasound to exclude uterine fibroids and polyps -postmenstrual scans is best when the endometrium is at its thinest.

Treatment is by :

Medications:

1.Tranexamic acid- oral antifibrinolytic (clotting agent) given only when there is heavy bleeding


2.Combined oral contraceptives - prevent proliferation of the endometrium, reduces blood flow. Inform patient of side effects such as fluid retention, nausea, headache,deep vein thrombosis, mood changes, breast tenderness


3.oral progesterone - also prevent proliferation of the endometrium-usually less side effects bloating, headache, mood changes, breast tenderness


4. Levonorgestrel-releasing (hormone) intrauterine system(LNG-IUS)
-also prevent proliferation of the endometrium
-side effects includes irregular bleeding up to 6 month,  or amenorrhea(no menses), breast tenderness, and headache.


5.Treatment of Underlying causes:
hypothyroidism with thyroxine tablets
intrauterine device removal
reduce anticoagulant treatment if possible
treat any bleeding disease with platelets or blood factor deficient infusion
treatment of endometriosis,
antibiotic treatment of pelvic inflammatory disease

If the bleeding do not stop, refer to the gynecologist for surgery:
1.Endometrial ablation involve the removal of the endometrium through the cervical opening.

 a.if medications has failed
 b.if no desire to conceive
 c.if the uterus is normal


First generation:
hysteroscopy with general anaesthesia
-Rollerball ablation
-Transcervical resection of the endometrium


Second Generation:
non-hysteroscopy, no general anaethesia, day surgery,fast recovery
-Impedance-controlled bipolar radiofrequency ablation
-balloon thermal ablation
-microwave ablation
-free fluid thermal ablation


2. Hysterectomy is used only as a last resort in treatment of menorrhagia:
if other treatment are contraindicated
there is a desire for amenorrhea
there is no desire to retain uterus and fertility
treatment of uterine carcinoma
surgical removal of fibroids and polyps

Menorrhagia can usually be controlled with hormones but may be dangerous in cases of uterine carcinoma or non stop bleeding.