D R MANAL IDRISmenorrha gia

Introduction

Menorrhagia is one of the commenest gynaecological complaints seen in practice and accounts for approximately 12% of all referrals to gynaecology clinic.

Among women aged 16-35 yr it has an incidence of around 30%.

D efinetionThe average menses lasts for 3-7 days with interval 21-35 days and mean blood loss of 35 ml.

Menorrhagia is generally defined as prolonged and increased menstrual flow of greater than 80 ml.

Aetiology

-Non organic causes : dysfunctional uterine bleeding (DUB).

-Organic causes.

-Systemic disorders.

DUB Non –organic causes

anovulatory :occure in women at the extremes of reproductive age ,menorrhagia with irregular interval.

Ovulatory:(90%) common in women aged 35-45yr and it is regular period.

It may be due to inadequate production progesterone in luteal phase or due to imbalance between PGs on the myometrial and endometrial vasculature.

Organic causes

-fibroids -adenomyosis

-endocervical \endometrial polyps -endometrial hyperplasia

-IUCD -pelvic inflammatory disease(PID)

-malignancy of CX or uterus -hormone producing tumours:eg,granulosa cell

of the ovary.

Systemic disorders

-endocrine disease :DM,hyper or hypothyroidism ,adrenal disease.

-disorders of haemostasis:eg ,von willebrands disease ,ITP.

-liver disease.

-renal disease.

-drugs:steroid hormones,anticoagulants.

HISTORY.

EXAMINATION.

INVESTIGATION.TREATMENT.

Management:

H istory include the following-:

-Age - menses pattern

- Quantity and quality of bleeding involves the presence of clots and flooding

- exclusion of pregnancy - pelvic pain and pathology.

- sexual activity and post coital bleeding . - contraceptive use IUCD or hormonal

- hirsutism - galactorrhea

-Systemic disease (hepatic \renal failure , DM,)

-S ymptoms of thyroid dysfunction -E xcesive brusing or bleeding disorders

-Current medications hormonal or anticoagulant

ExaminationGeneral examination:

-Signs of anemia -Obesity

-Signs of androgen excess -Ecchymosis and purpura

-Visual field -Thyroid evaluation

Abdominal examination:

-abdomino-pelvic mass -Enlarged liver or spleen

Pelvic examination:

speculum ex,bimanual palpation

Investigation

-CBC -Serum BhcG

-Thyroid function test -Prolactin

-Serum androgen -Coagulation screen

-Renal \liver function test-

-US(abdominal-transvaginal)

Endometrial sampling

It is an integral component of evaluating abnormal uterine bleeding ,particularly in

women more than 35yr old :

- hystroscopical directed biopsy .- D\C.- endometrial aspiration.

Treatment

Medical treatment :-PG synthesis inhibitors (eg:mefanamic acide)

reduces mean blood loss 20-40%-antifibrinolytics eg,tranxenamic acide reduces

blood loss 50%.-progestogens :eg,medroxyprogesterone acetate

( provera)reduces blood loss 15-30%-COCs :reducing blood loss 50%-danazol:reduces blood loss 60%

-GnRH analogues:eg,goserelin-levenorgestral –releasing IUCD

Surgical treatment

Endometrial resection and ablation:eg-TCRE(transcervical endometrial resection)

-laser-diathermy

-thermal balloon ablation-radiofrequency endometrial ablation

-microwave endometrial ablationCriteria:

-age more than 35 yr old-ut less than 10 week in size

-performed during proliferative phase-DUB,no endometriosis or adenomyosis

Hysterectomy:

-total abdominal hysterectomy

-subtotal hysterectomy-vaginal hysterectomy

-laparoscopic –assisted vaginal hysterectomy

-laparoscopic hysterectomy

THANKS