Menorrhagia

• >80 mls menstrual blood loss

Menstruation

1. Spiral arteries contract for 4-24 hours

2. Spiral arteries dilates

3. blood lakes form, haemorrhage into endometrium

4. fibrin plugs, platelet aggregation

5. spiral arteries constrict

6. epithelium shed

7. re-epithelisation (under oestrogen control)

History

• > 7days bleeding

• passing clots

• flooding through protection

Causes

• may be due to organic cause
• may be due to alteration of endocrine / local endometrial control of menstruation
  • dysfunctional uterine bleeding
• may be anovulatory

Organic causes

• fibroids, esp. if intramural / submucous
• diffuse adenomyosis
• endometrial polyps
• chronic pelvic infection / pelvic inflammatory disease (rarely)
• blood dyscrasia
• hypothyroidism

Pathologies

• Cystic glandular hyperplasia

  • simple hyperplasia

  • due to overstimulation by oestrogens

  • long cycles

  • heavy bleeds

• Complex hyperplasia

  • ? pre-malignant

  • crowding of glands

  • abnormal gland architecture

• Atypical hyperplasia

  • pre-malignant

  • very crowded glands

  • little stroma

  • cytological abnormalities

• adenocarcinoma

  • back to back glands

  • invasion into myometrium

  • post-menopausal bleeds

• endometrial polyps

  • up to 6% may be pre-malignant

• leiomyoma

  • fibroids

• adenomyosis

  • misplaced endometrium within uterine muscle (myometrium)

  • not cyclical pain / bleeding

• endometriosis

  • misplaced endometrium

  • cyclical pain / bleeding

• dysfunctional uterine bleeding (DUB)

  • diagnosis of exclusion

Examination

• Anaemia

• Thyroid

• Breasts

• Abdominal exam

  • pelvic mass

    • pregnancy

    • tumour

    • fibroids

    • ovarian cyst

  • surgery scars

  • hair distribution

  • tenderness

  • striae

  • ascites

• Vaginal exam

  • inspection

    • discharge

  • Palpation

    • scarring

    • reduced mobility

    • nodules

    • masses

    • tenderness

Investigations

(guided by history and examination)

• Ultrasound

• FBC

• TFTs

• Clotting

• Pregnancy Test

• hysteroscopy

• Endometrial biopsy

• coagulation screen

• transvaginal ultrasound
  • endometrium >5mm width postmenopausally needs biopsy / curettage
• curettage

Treatment

Medical Treatment of Menorrhagia

• Progestogens
• NSAIDS
  • mefanamic acid
• Oral contraceptives
• Danazol
• Intra-uterine system
  • mirena - levonorgestrel

Surgical Treatment of Menorrhagia

• Curettage
• Endometrial ablation
• Hysterectomy