MENORRHAGIA A 38 YEAR

OLD P4 WITH HEAVY MENSES

NurSalia Hanum Bt Md. Sidek
Faizatul Hamizah Bt Hassim
Mohamad Faiz Bin Azis

Normal Menstrual Cycle

Terminology

Oligomenorrhea
Infrequent (or, in occasional usage, very light)menstruation.
It is menstrual periods occurring at intervals of greater than 35 days, with
only four to nine periods in a year
Polymenorrhea
Menstruation occur regularly with intervals of less than 21 days
Metrorrhagia
Uterine bleeding at irregular intervals, particularly between the expected
menstrual periods.
Menorrhagia
heavy menstrual bleeding which is defined as a blood loss of greater than
80ml per period or prolonged interval
Menometrorrhagia = menorrhagia+ metrorrhagia
Menstrual bleeding occuring at irregular intervals with excessive flow or
duration

Etiology
Menorrhagia

Systemic
disease

Coagulopathy
- Platelet deficiency
- Von willebrand disease
-prothrombin deficeincy
Hypothyroidism
Liver cirrhosis

Iatrogenic

Local disease

IUCD
Warfarin

Fibroid
Endometrial polyps
PID
Edometrial/cervical
carcinoma

Clinical Features of
Menorrhagia

Increased number of
fully soaked sanitary
pads used daily
Passage of significant
clots
Heavy bleeding that it
spills over the sanitary
pads and on to the
pants, clothes or bedding
Heavy menstrual
bleeding that disturb
daily activities

Signs and
symptoms of
anemia

Pale
Shortness of breath
Chest pain
Palpitation
Dizziness
Lethargy

History taking

Assess severity of
menorrhagia
Irregular bleeding
Intermenstrual bleeding
Postcoital bleeding
Does she had menorrhagia
since menarche
History of easily bruised or
bleeding from other sites
Unusual vaginal discharge
Weight changes, skin
changes, fatigue
Drug history
Past medical thyroid
problem

Physical examination

General examinationsigns of anemia,

ecchymosis, purpura
Abdominal and pelvic
examinationpalpable pelvic
masses, polyps/
carcinoma of cervix
Thyroid examination

Investigations

Full blood count

Look for drop hemoglobin

Coagulation profile
Rule out coagulation disorder

Pelvic ultrasound scan

This should be performed when:
A pelvic mass is palpated on examination
(suggestive of fibroids)
Symptoms suggest and endometrial polyp (e.g.
irregular or intermenstrual bleeding)
Drug therapy for heavy menstrual bleeding is
unsuccessful

Investigations

High vaginal and endocervical swabs

Should be taken when:
Unusual vaginal discharge is reported or observed on
examination
Presence of risk factor for PID

Endometrial biopsy
Should be performed:
In those aged >45 years
Presence of irregular or intermenstrual bleeding
Drug therapy has failed
Biopsy can be done through
Pipelle sampling
Hysteroscopy with endometrial biopsy

Hysteroscopy with endometrial biopsy may be

indicated if:
Pipelle biopsy attempt fails
Pipelle biopsy sample was in sufficient for

histopathology assessment
There is an abnormality on ultrasound (e.g. suggested
endometrial polyp or fibroid)
Patient is known to poorly tolerate speculum
examinations

Thyroid function test

To rule out thyroid disorder

MANAGEMENT OF HEAVY
MENSTRUAL BLEEDING
MOHAMAD FAIZ BIN AZIS

MEDICAL TREATMENT
1.
2.
3.
4.
5.
6.

Mefanemic acid and other NSAIDs

Tranexaminc acid
Combined oral contraceptive pills
Norethisterone
Levonogestrel intrauterine system
GnRH agonists

MEFANEMIC ACID AND

OTHER NSAIDS
1.
2.
3.

Reduction in mean menstrual blood loss ~

20-25%
Recommended dose: 500mg p.o. TDS taken
during heavy menses or dysmenorrhea
Benefits:
Effective analgesia
First line treatment of choice where

dysmenorrhea coexists
4.

Disadvantage:
Contraindicated in duodenal ulcer and bronchial

asthma

TRANEXAMIC ACID
1.
2.
3.

Reduction in mean menstrual blood loss

~ 50%
Recommended dose: 1g p.o. QDS taken
when menstruating heavily
Benefits:
Taken only on the day when the menses is

particularly heavy
Compatible with attempts at conception
4.

Disadvantages:
1. May associated with venous thrombosis

COMBINED ORAL
CONTRACEPTIVE PILLS
1.

Benefits:
Doubles up as a contraceptive method

when taken properly

2.

Not suitable for:

Risk factors for thromboembolism

Over 35 years old
Smoking patient
Family history of breast cancer
Grossly overweight

NORETHISTERONE
1.
2.
3.

Effective taken from day 6 to day 26 of

menstrual cycle
Recommended dose: 5-10mg TDS
Benefits:

4.

Safe
Regulate bleeding pattern

Disadvantages:

Can cause breakthrough bleeding

LEVONOGESTREL
INTRAUTERINE SYSTEM
1.
2.
3.

Mean reductions in menstrual blood loss

after one year ~ 95%
30% become amenorrheic by one year
Benefits:
Effective alternative to surgical treatments
Provides contraceptive cover
Effective for associated dysmenorrhea

4.

Disadvantages:
Irregular menses
Breakthrough bleeding

GnRH AGONISTS
1.
2.
3.

Acts on the pituitary gland to stop

production of oestrogen
Used for short term as it predisposes
to osteoporosis
Benefits:
Effective against dysmenorrhea

4.

Disadvantages:
Irregular bleeding
Flushing and sweating

GnRH AGONISTS
1.

Dose:
Goserelin
: 3.6mg monthly S/C implant
Decapeptyl : 3mg monthly or 11.25mg

three-monthly by S/C or IM
Buserelin
: 300g nasal spray TDS

SURGICAL TREATMENT
1.
2.
3.

Only restricted for whom medical

treatments have failed
Must be certain their family is
complete
Choices under surgical treatment:

Endometrial ablation
Hysterectomy

ENDOMETRIAL ABLATION

INTRODUCTION
1.
2.
3.
4.

Ablation of the endometrial lining of

the uterus to sufficient depth
Prevents regeneration of the
endometrium
Mean reduction in mestrual blood
loss~ 90%
Previously, transcervical resection of
endometrium done with electrical
diathermy loop

TECHNIQUE
1.

Impedence controlled endometrial ablation

(NovasureTM)

2.

Thermal uterine balloon therapy

(ThermachoiceTM)

3.

Microwave ablation (MicrosulisTM )

SUCCESS RATES
1.

All women undergoing this ablation

will:
40% will become amenorrheic
40% marked reduced menstrual loss
20% will have no difference in bleeding

2.

Ablation should be encouraged before

opting for hysterectomy

PRE-PROCEDURE
1.
2.
3.
4.
5.
6.

Appropriately counselled the women prior

to the procedure
Description of endometrial ablation
procedure
Success rates
Risk of the procedure e.g. uterine
perforation, hemorrhage and fluid overload
Recovery time
Need for contraception

PROCEDURE
1.
2.
3.
4.
5.

Takes place as an outpatient or daycase procedure

Performed either under local or
general anaesthetic
Performed through the cervix
Full thickness of endometrium is
ablated
By controlled application of energy in
form of heat or wave

POST-PROCEDURE
1.

Symptoms to expect:
Crampy pain for the first 24 hours
Light bleeding/greyish vaginal discharge

for up to few weeks

2.

Plan for contraception

HYSTERECTOMY

INTRODUCTION
1.
2.

Surgical removal of the uterus

Some patients preferred subtotal
hysterectomy:

3.

Cervix remains
Require cervical smears

Bilateral salphingo-oopherectomy:
Both ovaries and fallopian tubes removed
Removal of ovaries leading to post-

menopausal state immediately

PRE-PROCEDURE
1.

Counsel the patient regarding:

Description of the procedure
Removal or retaining the ovaries and

cervix
Risk of the procedure e.g. anesthetic risk,
hemorrhage, infection, DVT, bladder or
ureteric damage
Recovery time

PROCEDURE
1.

Abdominal approach

2.

Involves transverse incision on the lower

abdomen

Vaginal approach
Removal of uterus and cervix via the vagina

with no abdominal incision

STAH cannot be performed by this method
3.

Laparoscopy
Laparoscopy-assisted vaginal hysterectomy
Total laparoscopic hysterectomy

POST-PROCEDURE
1.
2.
3.
4.
5.

Regular observations
Regular analgesia
Patient remain in hospital for 3-5 days
Recovery time 6-12 weeks
Thrombo-embolic prophylaxis