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Menorrhagia - an overview

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(Germany);Dip.Ultrasound (New Zealand)

            Diversity of Menorrhagia

•5% women aged 30-49 consult their Gynaecologists annually with menorrhagia.
•Only 58% of women receive medical therapy for menorrhagia before referral to a
• 60% of women with menorrhagia will have a hysterectomy within five years.
• One in five women will have a hysterectomy before the age of sixty.
• In 50% who undergo hysterectomies menorrhagia is the main presenting problem.
•Upto 50% of women who present with menorrhagia have blood losses within a
          normal range
• 30% of all women undergoing hysterectomy for menorrhagia have a normal uterus
•Such variation in the management of a common complaint is an indication for
          guideline development
        How do we define menorrhagia                                     ?

Menorrhagia can be defined objectively or subjectively
Objectively, menorrhagia is taken      Subjectively, menorrhagia is
to be a total menstrual blood loss –   defined as a complaint of
                                       excessive menstrual blood loss
80 ml per menstruation                 occurring over
                                       several consecutive cycles in a
                                       woman of reproductive years
Complexity of menorrhagia?
          •   Menorrhagia— is the medical term for
              excessive or prolonged menstrual
              bleeding or both
          •   The condition also is known as
          •   The menstrual cycle isn't the same for
              every woman
          •   Normal menstrual flow occurs about every
              28 days, lasts about 5 days and produces
              a total blood loss of 30 to 40 milliliters
          •   Some women have frequent menstrual
              spotting, while others find that heavy
              bleeding is normal
          •   Between 15 and 20 percent of healthy
              women experience debilitating
              menorrhagia that interferes with their
              normal activities
          •   Bleeding heavily and/or if periods last
              more than seven days is considered
              excessively heavy menstruation
•    Doctors generally define menorrhagia as
     menstrual bleeding that lasts more than eight
     to ten days or a blood loss of over 80
     milliliters (about 1/3 cup). This would be
     considered dysfunctional uterine bleeding
     (DUB), and could lead to an iron deficiency or
     anemia if not attended to promptly

     DUB Variations

•    Other types of dysfunctional uterine bleeding
     include metorrhagia (bleeding in between
     periods or menstrual spotting) and
     polymenorrhea (having a period more often
     than every 21 days)

•    Although 30 percent of premenopausal
     women complain of heavy menstrual
     bleeding, only 10 percent experience blood
     loss severe enough to be defined as
Assessment of blood loss
          •   How does one measure the amount of
          •        A little blood can seem like much
              more than it actually is. One way to
              gauge the bleeding is to see if she is
              soaking through enough sanitary
              protection products to require changing
              more than every one to two hours
                    Blood clots are normal during
              menstruation. One must remember that
              in addition to blood loss, the
              endometrium is also being shed

          •          26% of women with normal
              menstrual loss ( < 60 mL) considered
              their periods heavy, while 40% of those
              with heavy losses ( > 80 mL) considered
              their periods to be moderate or light
Subjective Assessment
         •   Menstrual flow that soaks through one or
             more sanitary pads or tampons every hour
             for several consecutive hours
         •   The need to use double sanitary protection
             to control your menstrual flow
         •   The need to change sanitary protection
             during the night
         •   Menstrual period that lasts longer than 7
         •   Menstrual flow that includes large blood
         •   Heavy menstrual flow that interferes with
             your regular lifestyle
         •   Constant pain in the lower abdomen during
             menstrual period
         •   Irregular menstrual periods
         •   Tiredness, fatigue or shortness of breath
             (symptoms of anemia)

• The volume of blood lost at menstruation is
  controlled by local uterine vascular tone,
  haemostasis, and regeneration of endometrium

• Patients with menorrhagia have shown a greater
  endometrial concentration of the vasodilator
  prostaglandin E (PGE),

• and a relationship between total prostaglandin
  (PGE, PGI 2 and PGF F2 a ) concentration and
  average blood loss

• Increased endometrial fibrinolysis may be of
     Causes of Menorrhagia
• Hormonal imbalance    • Intrauterine device
• Uterine fibroids        (IUD
• Polyps                • Other medical
• Ovarian cysts           conditions
• Dysfunction of the    • Cancer
  ovaries               • Pregnancy
• Adenomyosis             complications
• Pelvic Inflammatory   • Medications
Protocol for Clinical Evaluation

      • Blood tests
      • Pap test
      • Endometrial sampling
        and hysteroscopy
      • Vaginal ultrasound
      • Sonohysterogram
      • Endometrial biopsy
      • Dilatation and
        curettage (D&C)
Excessive or prolonged menstrual bleeding can
  lead to other medical conditions, including:
•   Severe pain
•   Infertility
•   Toxic shock syndrome
•   Anemia
    Specific treatment for menorrhagia is based on a
    number of factors including:
•   Overall health and medical history
•   Extent of the condition
•   Cause of the condition
•   Tolerance for specific medications, procedures
    or therapies
•   Expectations for how the condition will progress
•   Effects of the condition on the lifestyle
•   Personal preference
                      Drug therapy
Drug therapy for menorrhagia may include:

• Recent studies have shown tranexamic acid to be more effective
  (54% reduction in blood loss) than mefenamic acid (20% reduction),
  whereas ethamsylate (a clotting agent) was ineffective.

•    Second line drugs such as danazol, gestrinone, and gonadotrophin
    releasing hormone analogues are effective in reducing heavy
    menstrual blood loss but side effects limit their long-term use.

    Others include:

•   Iron supplements
•   Prostaglandin inhibitors
•   Oral contraceptives
•   Progesterone
Protocol for Management

Surgical Options

         • Dilation and
           curettage (D and C)
         • Operative
         • Endometrial ablation
         • Endometrial
         • Hysterectomy
       Abdominal Hysterectomy Vs Endometrial Resection
    Abdominal hysterectomy vs. endometrial resection
•   .Abdominal hysterectomy requires longer theatre times and hospital stay, whereas
    resection (ablation) is a day-stay or overnight procedure.
•   Abdominal hysterectomy has a higher complication rate (45%) compared with
    transcervical endometrial resection (0-15%)
•    Reported mortality rates for abdominal hysterectomy are two to five times higher
    than those for endometrial resection, and major complication rates are five to twelve
    times .
•   Resumption of normal activities after abdominal hysterectomy takes two to three
    months versus two to three weeks for resection.
•   The probability of requiring a hysterectomy four years after endometrial resection has
    been estimated to be 12%.
•   Hysterectomy is preferable if the patient has a large uterus, severe endometriosis
•   Endometrial resection/ablation avoids possible ovarian dysfunction and the
    psychological effects of hysterectomy.
•   Endometrial resection has a 47% cost advantage over hysterectomy because of
    shorter theatre time and hospital stay, but the cost advantage diminishes with time to
    29% because of the need for repeat surgery.
•   Compared with abdominal hysterectomy, vaginal hysterectomy is associated with
    less pain and morbidity, shorter hospital stays and faster recovery periods.
•   Laparoscopic hysterectomy results compared with abdominal hysterectomy,
    postoperative pain is reduced and hospital stays (one to four days) and recovery
    periods (one to four weeks) are shorter

  The diversity of possible surgical
  treatments indicates the need for
  flexibility in choosing techniques
  to resolve an individual patient's
  problem, and the possible
  advantage for gynaecologists to
  learn the new minimal invasive
  techniques for removal of the
  endometrium or the uterus

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