menorrhagia – an overview

8/14/2019 Menorrhagia an Overview

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MENORRHAGIA AN OVERVIEW

Dr. MUKESH CHANDRAM.S;FICOG;FICMU,FICMCH,Dip.Lap.Surg(Germany);Dip.Ultrasound (New Zealand)

ASSOCIATE PROFESSOR ,

Dept.of OB/GYN, S.N.MEDICAL COLLEGE,AGRA

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Diversity of Menorrhagia

5% women aged 30-49 consult their Gynaecologists annually with menorrhagia.Only 58% of women receive medical therapy for menorrhagia before referral to a

specialist. 60% of women with menorrhagia will have a hysterectomy within five years. One in five women will have a hysterectomy before the age of sixty. In 50% who undergo hysterectomies menorrhagia is the main presenting problem.Upto 50% of women who present with menorrhagia have blood losses within anormal range 30% of all women undergoing hysterectomy for menorrhagia have a normal uterus

removed.Such variation in the management of a common complaint is an indication for guideline development

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How do we define menorrhagia

Menorrhagia can be defined objectively or subjectively Objectively , menorrhagia is takento be a total menstrual blood loss

80 ml per menstruation

Subjectively , menorrhagia isdefined as a complaint of excessive menstrual blood lossoccurring over several consecutive cycles in awoman of reproductive years

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Complexity of menorrhagia?

Menorrhagia is the medical term for excessive or prolonged menstrualbleeding or both

The condition also is known ashypermenorrhea

The menstrual cycle isn't the same for

every woman Normal menstrual flow occurs about every28 days, lasts about 5 days and producesa total blood loss of 30 to 40 milliliters

Some women have frequent menstrualspotting, while others find that heavybleeding is normal

Between 15 and 20 percent of healthywomen experience debilitatingmenorrhagia that interferes with their normal activities

Bleeding heavily and/or if periods lastmore than seven days is consideredexcessively heavy menstruation

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DUB

Doctors generally define menorrhagia asmenstrual bleeding that lasts more than eightto ten days or a blood loss of over 80milliliters (about 1/3 cup). This would beconsidered dysfunctional uterine bleeding (DUB), and could lead to an iron deficiency or anemia if not attended to promptly

DUB Variations

Other types of dysfunctional uterine bleedinginclude metorrhagia (bleeding in betweenperiods or menstrual spotting) andpolymenorrhea (having a period more often

than every 21 days)

Although 30 percent of premenopausalwomen complain of heavy menstrualbleeding, only 10 percent experience bloodloss severe enough to be defined asmenorrhagia .

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Assessment of blood loss How does one measure the amount of

bleeding?

A little blood can seem like muchmore than it actually is. One way togauge the bleeding is to see if she issoaking through enough sanitaryprotection products to require changingmore than every one to two hours

Blood clots are normal during

menstruation. One must remember thatin addition to blood loss, theendometrium is also being shed

26% of women with normalmenstrual loss ( < 60 mL) consideredtheir periods heavy, while 40% of thosewith heavy losses ( > 80 mL) consideredtheir periods to be moderate or light

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Subjective Assessment Menstrual flow that soaks through one or

more sanitary pads or tampons every hour for several consecutive hours

The need to use double sanitary protectionto control your menstrual flow

The need to change sanitary protection

during the night Menstrual period that lasts longer than 7days

Menstrual flow that includes large bloodclots

Heavy menstrual flow that interferes withyour regular lifestyle

Constant pain in the lower abdomen duringmenstrual period

Irregular menstrual periods Tiredness, fatigue or shortness of breath

(symptoms of anemia)

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Pathogenesis

The volume of blood lost at menstruation iscontrolled by local uterine vascular tone,haemostasis, and regeneration of endometrium

Patients with menorrhagia have shown a greater endometrial concentration of the vasodilator prostaglandin E (PGE),

and a relationship between total prostaglandin

(PGE, PGI 2 and PGF F2 a ) concentration andaverage blood loss

Increased endometrial fibrinolysis may be of importance

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Causes of Menorrhagia

Hormonal imbalance Uterine fibroids Polyps Ovarian cysts Dysfunction of the

ovaries

Adenomyosis Pelvic Inflammatory

Disease.

Intrauterine device(IUD

Other medical

conditions Cancer Pregnancy

complications Medications

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Protocol for Clinical EvaluationM UK E S H


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Investigations

Blood tests Pap test

Endometrial samplingand hysteroscopy

Vaginal ultrasound

Sonohysterogram Endometrial biopsy Dilatation and

curettage (D&C)

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Complications

Excessive or prolonged menstrual bleeding canlead to other medical conditions, including :

Severe pain Infertility Toxic shock syndrome

Anemia

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TreatmentSpecific treatment for menorrhagia is based on anumber of factors including:

Overall health and medical history Extent of the condition Cause of the condition Tolerance for specific medications, procedures

or therapies Expectations for how the condition will progress Effects of the condition on the lifestyle Personal preference

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Drug therapy Drug therapy for menorrhagia may include:

Recent studies have shown tranexamic acid to be more effective(54% reduction in blood loss) than mefenamic acid (20% reduction),whereas ethamsylate (a clotting agent) was ineffective.

Second line drugs such as danazol, gestrinone, and gonadotrophinreleasing hormone analogues are effective in reducing heavymenstrual blood loss but side effects limit their long-term use.

Others include:

Iron supplements Prostaglandin inhibitors Oral contraceptives Progesterone

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Protocol for Management M UK E S H


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Surgical Options

Dilation andcurettage (D and C)

Operativehysteroscopy

Endometrial ablation Endometrial

resection Hysterectomy

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Abdominal Hysterectomy Vs Endometrial Resection Abdominal hysterectomy vs. endometrial resection

.Abdominal hysterectomy requires longer theatre times and hospital stay , whereas

resection (ablation) is a day-stay or overnight procedure. Abdominal hysterectomy has a higher complication rate (45%) compared withtranscervical endometrial resection (0-15%)

Reported mortality rates for abdominal hysterectomy are two to five times higher than those for endometrial resection, and major complication rates are five to twelve times .

Resumption of normal activities after abdominal hysterectomy takes two to threemonths versus two to three weeks for resection.

The probability of requiring a hysterectomy four years after endometrial resection hasbeen estimated to be 12%.

Hysterectomy is preferable if the patient has a large uterus, severe endometriosis Endometrial resection/ablation avoids possible ovarian dysfunction and the

psychological effects of hysterectomy.

Endometrial resection has a 47% cost advantage over hysterectomy because of shorter theatre time and hospital stay, but the cost advantage diminishes with time to29% because of the need for repeat surgery.Hysterectomy

Compared with abdominal hysterectomy, vaginal hysterectomy is associated withless pain and morbidity, shorter hospital stays and faster recovery periods .

Laparoscopic hysterectomy results compared with abdominal hysterectomy,postoperative pain is reduced and hospital stays (one to four days) and recoveryperiods (one to four weeks) are shorter

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Conclusion

The diversity of possible surgicaltreatments indicates the need for

flexibility in choosing techniquesto resolve an individual patient'sproblem, and the possibleadvantage for gynaecologists tolearn the new minimal invasivetechniques for removal of theendometrium or the uterus

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menorrhagia – an overview

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