Menorrhagia - Clinicals, Diagnosis, and Management

General Gynecology

Clinicals - History

Fact Explanation
Excessive blood loss/ passage of large blood clots during the regular monthly menstrual cycle >80 ml of blood loss is considered as menorrhagia; This may occur as a prolonged menstrual period which is menstruation lasting more than 7 days
Number of sanitary pads/ tampons used maybe used as a rough guide.
Excessive blood loss/ passage of large blood clots during the regular monthly menstrual cycle
>80 ml of blood loss is considered as menorrhagia; This may occur as a prolonged menstrual period which is menstruation lasting more than 7 days
Number of sanitary pads/ tampons used maybe used as a rough guide.
Fatigue, shortness of breath on exertion Anaemia results due to excessive menstrual blood loss Fatigue, shortness of breath on exertion
Anaemia results due to excessive menstrual blood loss
History of currently inserted intrauterine contraceptive device Foreign body within uterine cavity is a known cause of mennorhagia History of currently inserted intrauterine contraceptive device
Foreign body within uterine cavity is a known cause of mennorhagia
Features of hypothyroidism: cold intolerence, constipation, coarse dry hair Hypothyroidism causes a reduction in the basal metabolic rate of the body, which increases the time needed for endometrial regeneration, causing increased and prolonged menstrual flow. Features of hypothyroidism: cold intolerence, constipation, coarse dry hair
Hypothyroidism causes a reduction in the basal metabolic rate of the body, which increases the time needed for endometrial regeneration, causing increased and prolonged menstrual flow.
Bleeding manifestation: Bruises found in skin surface Patients with inherited coagulopathies may present in their adolescent period with menorrhagia. Bleeding manifestation: Bruises found in skin surface
Patients with inherited coagulopathies may present in their adolescent period with menorrhagia.
History of bleeding disorders Poor control of existing bleeding disorders may result in menorrahgia. History of bleeding disorders
Poor control of existing bleeding disorders may result in menorrahgia.
History of anticoagulant use. Anticoagulant such as warfarin usage is known to cause mennorhagia History of anticoagulant use.
Anticoagulant such as warfarin usage is known to cause mennorhagia
Associated dysmenorrhoea Endometriosis and adenomyosis are known to cause both dysmenorrhoea and menorrhagia. Associated dysmenorrhoea
Endometriosis and adenomyosis are known to cause both dysmenorrhoea and menorrhagia.
Associated dyspariunea Endometriosis causes both dyspareunia and menorrhagia. Associated dyspariunea
Endometriosis causes both dyspareunia and menorrhagia.

Clinicals - Examination

Fact Explanation
Pallor Anaemia caused by excessive blood loss Pallor
Anaemia caused by excessive blood loss
Coarse facies/ lateral eyebrow thinning/ macroglossia/ goiter/ delayed deep tendon reflexes/ bradycardia Features of hypothyroidism Coarse facies/ lateral eyebrow thinning/ macroglossia/ goiter/ delayed deep tendon reflexes/ bradycardia
Features of hypothyroidism
Any bruises on general examination Indicative of bleeding disorders. Any bruises on general examination
Indicative of bleeding disorders.
Abdominal examination A large fibroid maybe able to be palpated abdominally. Abdominal examination
A large fibroid maybe able to be palpated abdominally.
Bimanual pelvic examination Polyps protruding through cervical os maybe visualised or felt.
A fibroid maybe felt as a confined enlarged mass in the uterus
Tender uterus/ adenexae indicates endometriosis
Bimanual pelvic examination
Polyps protruding through cervical os maybe visualised or felt.
A fibroid maybe felt as a confined enlarged mass in the uterus
Tender uterus/ adenexae indicates endometriosis
Speculum examination Abnormal cervix may indicate cervical cancer.
Polyps maybe visualised.
Speculum examination
Abnormal cervix may indicate cervical cancer.
Polyps maybe visualised.

Investigations - Diagnosis

Fact Explanation
Transvaginal ultrasonography (TVS) Uterine abnormalities such as fibroids can be diagnosed but has low sensitivity than saline infusion sonohysteroscopy Transvaginal ultrasonography (TVS)
Uterine abnormalities such as fibroids can be diagnosed but has low sensitivity than saline infusion sonohysteroscopy
Saline infusion sonohysteroscopy Infusion of sterile saline/ isotonic solution allows easy visualisation with transvaginal ultrasound scan. Fibroids, intra uterine polyps can be visualized with high sensitivity than in plain TVS. Saline infusion sonohysteroscopy
Infusion of sterile saline/ isotonic solution allows easy visualisation with transvaginal ultrasound scan. Fibroids, intra uterine polyps can be visualized with high sensitivity than in plain TVS.
Endometrial biopsy Used to exclude cancer in adult women. Can be done even as outpatient procedure since anaesthesia, cervical dilatation is not required.
Higher sensitivity and negative predictive value is yield when used in combination with saline infusion sonohysteroscopy.
Endometrial biopsy
Used to exclude cancer in adult women. Can be done even as outpatient procedure since anaesthesia, cervical dilatation is not required.
Higher sensitivity and negative predictive value is yield when used in combination with saline infusion sonohysteroscopy.
Hysteroscopy This is the preferred method as intracavitatary anatomy can be directly viewed; but is of high cost. This is usually done when menorrhagia persists despite normal endometrial biopsy and saline infusion sonohysteroscopy. Hysteroscopy
This is the preferred method as intracavitatary anatomy can be directly viewed; but is of high cost. This is usually done when menorrhagia persists despite normal endometrial biopsy and saline infusion sonohysteroscopy.
Thyroid function test Should be done if other features of thyroid disease is observed in the patient Thyroid function test
Should be done if other features of thyroid disease is observed in the patient
Coagulation profile/ test for von Willebrand's disease Patients with inherited coagulopathies may present in adolescent period with menorrhagia.
Recommended in adolescent and adult women with severe menorrhagia.
Coagulation profile/ test for von Willebrand's disease
Patients with inherited coagulopathies may present in adolescent period with menorrhagia.
Recommended in adolescent and adult women with severe menorrhagia.

Investigations - Management

Fact Explanation
Full blood count Haemoglobin maybe low due to menorrhagia and the woman should be optimised, if necessary, with iron supplement/ blood transfusion prior to surgery. Full blood count
Haemoglobin maybe low due to menorrhagia and the woman should be optimised, if necessary, with iron supplement/ blood transfusion prior to surgery.
Chest x-ray, renal function tests, blood gases, lung function These should be done according to patient's symptoms and according to the ASA (American society of anesthesiologists) category patient falls in; this should be performed in preparation for any operative intervention. Chest x-ray, renal function tests, blood gases, lung function
These should be done according to patient's symptoms and according to the ASA (American society of anesthesiologists) category patient falls in; this should be performed in preparation for any operative intervention.

Management - Supportive

Fact Explanation
Iron supplements/ Blood transfusion To treat anaemia which is usually present. Iron supplements/ Blood transfusion
To treat anaemia which is usually present.

Management - Specific

Fact Explanation
Combined oral contraceptive pills This is used in menorrhagia associated with anovulatory cycles, but evidence on its effect on menorrhagia is insufficient. Combined oral contraceptive pills
This is used in menorrhagia associated with anovulatory cycles, but evidence on its effect on menorrhagia is insufficient.
Progestogens (Oral Norethisterone 5 mg tds from day 5 to day 26, for 21 days continuously or oral/ IM medroxyprogesterone acetate Known to be the most effective medical treatment; useful in short term or bridging therapy; breast tenderness and irregular menstrual bleeding are known side effects. Progestogens (Oral Norethisterone 5 mg tds from day 5 to day 26, for 21 days continuously or oral/ IM medroxyprogesterone acetate
Known to be the most effective medical treatment; useful in short term or bridging therapy; breast tenderness and irregular menstrual bleeding are known side effects.
Levonorgestrel-releasing intrauterine device Effective long term therapy; Patient satisfaction is higher than in oral progesterone use. Pregnancy can be achieved after removal of the device. Levonorgestrel-releasing intrauterine device
Effective long term therapy; Patient satisfaction is higher than in oral progesterone use. Pregnancy can be achieved after removal of the device.
First generation endometrial ablation (endometrial resection and rollerball or laser ablation) Endometrial ablation is considered if childbearing is completed and if patient is not willing to undergo major surgery such as hysterectomy. Higher rates of amenorrhoea is achieved when compared to levonorgestrel-releasing intrauterine device.
Preoperative gonadotropin-releasing hormone analogues or danazol thins the endometrium resulting in better outcome.
First generation ablation is done under direct vision with hysteroscope and a distension medium is used to enhance the visualization. Thus there is a high risk of fluid overload, therefore this method is not used in patients with renal/ heart failure. General or regional anesthesia is needed and longer time is needed than in second generation ablation methods.
First generation endometrial ablation (endometrial resection and rollerball or laser ablation)
Endometrial ablation is considered if childbearing is completed and if patient is not willing to undergo major surgery such as hysterectomy. Higher rates of amenorrhoea is achieved when compared to levonorgestrel-releasing intrauterine device.
Preoperative gonadotropin-releasing hormone analogues or danazol thins the endometrium resulting in better outcome.
First generation ablation is done under direct vision with hysteroscope and a distension medium is used to enhance the visualization. Thus there is a high risk of fluid overload, therefore this method is not used in patients with renal/ heart failure. General or regional anesthesia is needed and longer time is needed than in second generation ablation methods.
Second generation endometrial ablation (cryo/ thermal balloon/ radiofrequency/ microwave ablation or diode laser thermotherapy) This is done "blindly" without the use of hysteroscope to visualise the procedure. Thus, cervical dilation is not necessary. Therefore can be done as an outpatient procedure with local anesthesia and minimum cervical dilatation. Second generation endometrial ablation (cryo/ thermal balloon/ radiofrequency/ microwave ablation or diode laser thermotherapy)
This is done "blindly" without the use of hysteroscope to visualise the procedure. Thus, cervical dilation is not necessary. Therefore can be done as an outpatient procedure with local anesthesia and minimum cervical dilatation.
Hysterectomy This is the definitive treatment for menorrhagia, however the cost is higher and is used if childbearing is completed. Hysterectomy
This is the definitive treatment for menorrhagia, however the cost is higher and is used if childbearing is completed.
Nonsteroidal anti-inflammatory drugs (NSAIDs) Mefenamic acid is the most commonly used NSAIDs, but the evidence in relation to the efficacy is insufficient. Nonsteroidal anti-inflammatory drugs (NSAIDs)
Mefenamic acid is the most commonly used NSAIDs, but the evidence in relation to the efficacy is insufficient.
Tranexamic acid This is an antifibrinolytic agent, but the evidence in relation to the efficacy is insufficient. Tranexamic acid
This is an antifibrinolytic agent, but the evidence in relation to the efficacy is insufficient.
Danazol Danazol acts on oestrogen and progesterone receptors in endometrium inhibiting its action, resulting in thinning of the endometrium resulting in reduced menstrual blood loss. But this is not a preferred agent since evidence regarding its efficacy is insufficient. Danazol
Danazol acts on oestrogen and progesterone receptors in endometrium inhibiting its action, resulting in thinning of the endometrium resulting in reduced menstrual blood loss. But this is not a preferred agent since evidence regarding its efficacy is insufficient.
Novel oral contraceptive: Estradiol valerate (E2V) and dienogest (DNG) This is a new drug recommended for menorrhagia, given for 6 months it shows 65% reduction in mean blood loss Novel oral contraceptive: Estradiol valerate (E2V) and dienogest (DNG)
This is a new drug recommended for menorrhagia, given for 6 months it shows 65% reduction in mean blood loss
If secondary menorrhagia is suspected underlying cause should be treated. Hypothyroidism treated with thyroxine supplements.
Submucosal fibroids can be removed by hysteroscopic myomectomy.
If secondary menorrhagia is suspected underlying cause should be treated.
Hypothyroidism treated with thyroxine supplements.
Submucosal fibroids can be removed by hysteroscopic myomectomy.

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