Flashcards in Menorrhagia Deck (69)
1
What is the techinical definition of menorrhagia?
> 80ml/month of loss
2
What % of women are affected by menorrhagia?
10%
3
What is the clinical definition of menorrhagia?
Excessive menstrual loss leading to interference with physical, emotional, social or material quality of a woman's life
4
What type of conditions are most commonly causing menorrhagia?
Benign ones
5
What can menorrhagia often lead to?
Iron deficiency anaemia
6
What can iron-deficiency have an impact on?
Woman's work, family and social life
7
What are the groups of causes of menorrhagia?
- Structural
- Non-structural
- Iatrogenic
8
What are the possible structural causes of menorrhagia?
- Leiomyomata
- Endometrial carcinoma
- Adenomyosis
- Polyps
- Endometrial hyperplasia
9
What is the more common term for leiomyomata?
Fibroids
10
What is the most common structural cause of menorrhagia?
Fibroids
11
When is endometrial cancer more rare?
Under 40 years
12
What is endometrial cancer more likely to cause before menorrhagia?
Irregular bleeding
13
What is adenomyosis usually associated with?
Uniformly enlarged, tender uterus, menorrhagia and dysmenorrhoea
14
What do polyps usually cause as well as menorrhagia?
IMB
15
What can endometrial hyperplasia be associated with?
Irregular anovulatory cycles and overlap with disturbed ovulation
16
What can endometrial hyperplasia be a precursor of?
Endometrial cancer
17
What are the non-structural causes of menorrhagia?
- Disturbed ovulation or anovulation
- Disturbed mechanisms of endometrial haemostasis
18
How else can disturbed ovulation or anovulation affect the menstrual cycle?
- Irregular
- Infrequent
- Prolonged
- Potentially life-threatening bleeding
19
What often leads to disturbed ovulation causing menorrhagia?
Unopposed oestrogen leading to thickening and hyperplasia of the endometrium which then breaks down in a patchy and erratic fashion
20
When do most cases of ovulatory disorders occur?
- Menopause transition
- Adolescence
- Due to endocrinopahties
21
What endocrinopahties can cause ovulatory disorders?
- PCOS
- Hypothyroidism
22
What can cause disturbed mechanisms of endometrial haemostasis?
- Excessive local production of fibrinolytic factors e.g. TPA
- Deficiencies in local vasoconstrictors
- Increased local vasodilators
23
What is a common iatrogenic cause of menorrhagia?
Copper IUD
24
Why should women with menorrhagia have a general examination?
For signs of anaemia or thyroid disease
25
What additional examinations may women with menorrhagia require?
- Pelvic
- Speculum
- Smear
26
What is the first line test for menorrhagia?
Bloods
27
What bloods are useful when assessing menorrhagia?
- FBC
- Serum ferretin
- Serum transferrin receptor
28
When can treatment be started after blood tests alone for menorrhagia?
If examination and history were not of a sinister nature
29
When should patients with menorrhagia be referred for further investigation?
- Risk factors for endometrial cancer
- Persistent IMB
- Abnormal cervical smear
- Significant pelvic pain
- Not responding to first-line treatment after 6 months
30
What is the purpose of further investigations for menorrhagia?
To exclude pelvic pathology, particularly malignancy
31
What are the main forms of additional investigation for menorrhagia?
- Transvaginal USS
- Endometrial biopsy
- Hysteroscopy
- Investigations for systemic causes
- Thyroid screening
32
What can transvaginal USS identify in menorrhagia?
Presence of structural lesions e.g. polyps
33
What does hysteroscopy provide in menorrhagia?
View of uterine cavity
34
How can hysteroscopy be performed?
Under local or general anaesthetic
35
What is an important investigation for systemic causes of menorrhagia?
Coagulation screen for disorders of haemostasis
36
Give an example of a clotting disorder that can cause menorrhagia?
Von Willebrand's disease
37
When is coagulation screening indicated in menorrhagia?
- Young women
- History/family history of coagulopathies
38
When is a thyroid screening indicted in menorrhagia?
Suggestive features in history or on examination
39
What are the main types of treatment for menorrhagia?
- Medical
- Surgical
40
What does the medical management of menorrhagia in the absence of malignancy depend on?
- If contraception is required
- If irregularity is an issue
- Presence of any contraindications
41
How can the medical treatments of menorrhagia be divided?
- Hormonal
- Non-horomonal
42
What is the advantage of non-hormonal treatments for menorrhagia?
Only need to be taken when menstruating
43
What are some non-hormonal medications used in menorrhagia?
- NSAIDs
- Tranexamic acid
44
What are some examples of NSAIDs used in menorrhagia?
- Megenamic acid
- Ibuprofen
45
What is the mechanism of action of NSAIDs?
Reduce prostaglandin synthesis
46
By how much can NSAIDs reduce blood loss in menorrhagia?
30%
47
What is a secondary advantage of NSAIDs for menorrhagia?
Analgesic properties
48
What is the main side effect of NSAIDs?
Gastric irritation
49
What sort of drug is tranexamic acid?
Antifibrinolytic
50
By how much does tranexamic acid reduce blood loss in menorrhagia?
50%
51
Who should tranexamic acid be avoided?
People with a history of thromboembolic disease
52
What are the options for the hormonal management of menorrhagia?
- COCP
- Levonorgestrel IUS
- Synthetic oral progesterones
53
What % of monthly blood loss reduction can COCP give?
~30%
54
What % of monthly blood loss reduction can levonorgestrel IUS give?
~90%
55
In what regime are oral progesterones given to treat menorrhagia?
21/28 days
56
When can oral progesterones be given in higher doses for menorrhagia?
In an acute situation to control excessive bleeding
57
What is the problem with oral progesterones for menorrhagia?
Associated with more side-effects
58
What is the recommended first line treatment for menorrhagia?
IUS
59
What are the main surgical treatments for menorrhagia?
- Endometrial resection
- Endometrial ablation
- Hysterectomy
60
What is endometrial resection?
Removal of the endometrium with hysteroscope
61
What is endometrial ablation?
Destruction of the endometrium using intrauterine heating/cooling devices
62
What treatment can be given prior to endometrial ablation?
GnRH analogues to thin the endometrium
63
What are the potential complications of endometrial ablation?
- Intraoperative uterine perforation
- Damage to other organs
- Fluid overload
- Need for further surgery
64
What new techniques for endometrial ablation are emerging?
Balloon ablation
65
What is the advantage of balloon ablation?
Allow for precise destruction of the endometrium reducing side effects
66
What % of patients who have ablation will be amenorrhoeic post-op?
30-70%
67
What % of patients will have significant reduction in menstrual bleeding after ablation?
20-30%
68
What is the definitive surgical treatment for menorrhagia?
Hysterectomy
69