Menorrhagia, or heavy menstrual bleeding, is excessive menstrual blood loss over several consecutive cycles which interferes with a woman’s physical, emotional, social and material quality of life.
The amount of blood constituting menorrhagia varies between patients, but the upper limit ranges from 60-80mls (certainly <10% of women have menses >80mls). Severe menorrhagia (>120ml) is more likely to cause anaemia. Another alternative definition is menses lasting >7 days / 28 day cycle.
History
- Name, DOB, Age, Introduction etc
- You may want to ask about parity (number of pregnancies) now or later
- After identifying the presenting complaint, begin by taking a menstrual history
- Age of menarche
- Cycle pattern: duration of bleeding, duration between bleeding
- What has changed?- Have periods always been heavy?
- Ask whether she uses tampons/towels? How often does she change them? Does she need to change at night? Any flooding?
- Any clots?
- Does it prevent her from doing any activities?
- Ask about any other bleeding- intermenstrual, or postcoital bleeding?
- NB Intermenstrual bleeding is not normal and warrants referral for further investigation
- Ask about any other symptoms
- Pain (and describe- e.g. crampy, sharp etc)
- Dyspareunia
- Discharge
- Fatigue, breathlessness
- Weight loss
- Heat intolerance or cold, skin/hair changes, constipation
- Any urinary symptoms
- Ask about contraception and family planning
- Ask about smear history
- Ask about any past medical history
- Gynae problems; Thyroid disease; blood disorders
- including easy bruising/bleeding (e.g. gums)
- Also ask about drug history
- Gynae problems; Thyroid disease; blood disorders
- Ask about Family History
- In particularly any breast or gynaecological cancer, endometriosis
- Ask about social history- smoking, alcohol, drugs, sexual history
Examination
- As part of a general examination, look for
- obesity
- any signs of anaemia (e.g. pallor)
- any signs of thyroid disease (any dry skin, hair loss, limb swelling or weakness)
- any bruising or rashes
- any acne or hirsutism
- Examine the abdomen (particularly lower abdomen/pelvis) for any masses and/or tenderness.
- Also look for any organomegaly
- A pelvic examination should also be done:
- Before starting, explain the process, offer a chaperone and gain consent from the patient.
- Ask the patient to undress from the waste down (offer an enclosed/private space). If there are leg supports, ask the patient if they could use these; if not- positions the patient so that their feet are together and knees bent down to the side.
- Offer a sheet to cover the patient.
- Ask the patient to undress from the waste down (offer an enclosed/private space). If there are leg supports, ask the patient if they could use these; if not- positions the patient so that their feet are together and knees bent down to the side.
- Inspect the external genitalia
- Any lesions, excoriations, lichenification, whitening, discharge
- Before using the speculum, make sure to lubricate it with some lubricant
- Using you non-dominant hand, part the labia to visualise the introitus, insert the speculum at almost vertical, then rotate it horizontally, such that the handle is anteriorly
- Gently open the speculum and direct it slightly downwards (30-45°) to visualise the cervix
- Comment on appearance, any erosions (ectropion), any warty lesions etc.
- Take any smear and/or swabs that may be required
- Smears should ideally be done mid-cycle (day 14)
- Remember to rotate the brush clockwise 5 times and push the brush into the pot 10 times
- Take care when removing the speculum: don’t actively close the speculum but retract it slowly, letting it close itself.
- For bimanual examination, again use lubrication and a gloved hand
- Use you non-dominant hand to palpate the abdomen and your dominant hand for internal examination (NB or vice versa depending on what side of the patient you are on)
- If it is not uncomfortable, use two fingers
- Palpate the vaginal wall for any abnormalities; if possible, palpate the cervic for any abnormalities also (note specifically any cervical excitation (tenderness))
- Assess the position, size, mobility, consistency and any tenderness of the uterus by attempting to capture the uterus between your internal hand (pushing up) and external hand on the abdomen (pushing down)
- NB In a retroverted uterus this is often not possible
- Palpate the adnexae (tubes/ovaries) in a similar fashion, with your internal fingers in the lateral fornices (right and left, respectively)
- You should be able to feel the ovaries ‘slip’ between your fingers; normal fallopian tubes should not be palpable. This can be very difficult in obese women
- Consider a rectal examination also
- Thank the patient and let the patient redress in a ‘private’ space
Investigations
- Complete Blood Count- check for anaemia and/or bleeding disorders (primary or secondary to liver/other cause)
- Cervical smear- screen for cervical (and endometrial) cancer
- Swab for Chlamydia (if suggestive)
- TFTs (NB only if patient has other symptoms of thyroid dysfunction), LFT, U&E, Coag screen (other systemic causes)
- Transvaginal USS of the uterus
- Endometrial thickness
- Presence of intrauterine disease e.g. fibroids/cancer
- Endometrial sampling (NB not necessary for initial investigation but is if failed medical management or suspicious history), particularly in patients >45 or patients <45 with a family/personal history of concerning features e.g. intermenstrual bleeding
- Pipelle biopsies (NB if woman is of reproductive age- a pregnancy test should be done before biopsy to exclude pregnancy; also contraindicated in severe pelvic inflammatory disease and bleeding disorders)
- Hysteroscopy- most effective but also most invasive, ideally should be performed after a pipelle biopsy has been done and results received
- Dilation and Curettage
Causes
- NB In around half (40-60%) of patients, no underlying cause will be found:
- Dysfunctional Uterine Bleeding
- Local disorders include:
- Fibroids
- Adenomyosis
- Endocervical or endometrial polyps
- Cervical eversion
- Endometrial hyperplasia
- IUCD
- Pelvic inflammatory disease
- Endometriosis
- Uterine/cervical malignancy
- Hormone producing tumours
- Trauma
- Other e.g. AV malformations
Systemic causes include
- Endocrine causes
- Hyper-/hypothyroid (ask about weight, malaise)
- Diabetes mellitus
- Adrenal Disease
- Prolactin disorders
- Bleeding disorders (consider in primary menorrhagia / FHx / Signs e.g. bruising)
- von Willebrand’s disease
- ITP (Idiopathic thrombocytopaenic purpura)
- Factor Deficiency
- Liver or renal disease
- Anticoagulant therapy
Management
- Correct any iron deficient anaemia
- Treat any systemic disorders
- Medical management
- Mirena coil is preferred first line treatment- provided long-term contraception and an intra-uterine device is acceptable for the patient
- Tranexamic acid (antifibrinolytic), NSAIDs (preferably mefenamic acid, naproxen or ibuprofen), or the COC pill can be used second line
- NSAIDs particularly useful if menorrhagia is accompanied by abdominal pain
- Oral norethisterone/long-acting progestogens (e.g. depot injection) can be used third line (providing contraception is acceptable)
- Can be used first line for patients who require rapid cessation of heavy bleeding
- Combination therapy can be used at any stage if initial treatment fails e.g. Tranexamic acid + NSAIDs
- Refer patients if there are ‘red-flag’ symptoms e.g. intermenstrual bleeding, abdominal mass, findings of cervical/vulval cancer (suspected); if bleeding persists despite trials of medical treatment; if there is significant anaemia; or if the woman would prefer surgical treatment (e.g. endometrial ablation/hysterectomy) over medical management
Notes on Medicine/Surgery 