OPTIMISING APPROACH TO MENORRHAGIA

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OPTIMISING APPROACH TO MENORRHAGIA

• Dr Sheila Balakrishnan MD, DNB, MRCOG
• Medical College, Trivandrum

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Dysfunctional uterine bleeding

• DUB is defined as abnormal uterine bleeding in
  the absence of organic pelvic pathology
• Can be ovulatory or anovulatory
• Menorrhagia
• Subjective definition
• Heavy cyclical menstrual bleeding over several
• consecutive cycles
• Objective definition
• MBL more than BO ml per menstruation

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• A 15 year old girl with irregular heavy periods
  presents at your clinic. She went through the
  menarche at the age of 13 and since then is
  having unpredictable irregular periods with
  prolonged bleeding every 2-3 months. She is
  slightly overweight for her height.

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Most likely diagnosis?

• Anovulatory Dysfunctional uterine bleeding the
  commonest cause in 95
• Initial cycles are anovulatory
• Regular ovulation takes 1-2 years
• Menstruation as such is stressful for the
  teenager and so excessive bleeding even mild may
  be distressing

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Causes of Abnormal bleeding

• Dysfunctional bleeding
• Bleeding disorders -ITP,VWD etc Endocrine causes
• Medications
• Local pathology -TB, FB, malignancies Pregnancy
  complications
• No further significant features are found on
  history or clinical examination. What next?

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Investigations

• Haematological
• Full blood count and peripheral smear Platelet
  count
• Coagulation screen If indicated
• Endocrine
• TFT, PRL
• Ultrasound

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Mild Cases

• Reassurance explanation of self limiting nature
  
• Menstrual calendar
• Iron supplementation
• Periodic re evaluation
• Lifestyle modification by diet and exercise
• Majority convert spontaneously in 1-2 years

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Moderate cases

• Hormonal treatment is the mainstay
• 2 alternatives
• MPA10 mg daily for 10 days every month
• Combined pills like Novelon or Femilon
• Iron supplementation
• Revaluate every 6 months

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Severe DUB

• Hospitalisation is a must Re exclude assoc
  pathology Fluid d blood replacement
• Hormonal haemostasis
• Hormonal haemostasis
• Medical Curettage
• 19 nor testosterone derivatives like Primalut-N
• 10 - 2O mg in divided doses
• Taper down over three weeks
• Continue with low dose combined pills like
  Navelon
• Rarely estrogens for haemostasis

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Refractory to hormones

• Re evaluate
• are you missing something?
• Examination under anaesthesia for local pathology
  
• Diagnostic DC as a last resort
• Tuberculosis is a rare possibility
• Prognosis of adolescent bleeding
• 50 attain normal pattern by 2 years
• Reassure regarding queries for the future

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If anovulatlon persists for more than 4
years-chance of spontaneous correction is
low Likely to be frank PCOS They have all the
attendant risks Consider other modalities of
treatment
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• A 34 year old lady complaining of increasingly
  heavy periods since the last one year attends
  your clinic. She has two children 10 and 8 years
  and underwent lap sterilisation 4 years back. She
  finds that the bleeding is so heavy that it
  interferes with her daily ' routine.

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History of regular heavy periods Speculum and
bimanual examination normal Recent cervical smear
normalHb level 9 gm/ 100 nilOrganic pathology
to be ruled out Pregnancy complicationsFibroids
and adenomyosis Endometriosis and pelvic
Infection
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• Testing for endocrine problems and bleeding
  disorders not routinely recommended
• unless there are specific pointers in the history

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Routine DC or endometrial sampling?

• Not Indicated this age as first line management
  If a woman has regular cycles
• Probability of an abnormal endometrial histology
  in a woman under 40 with DUB and regular cycles
  is lt1

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Indication for first line endometrial sampling

• Irregular periods with obesity and other features
  of PCOS as they are candidates at high risk for
  endometrial cancer at a young age
• Risk of cancer increases to 14

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Most likely diagnosis

• Ovulatory DUB or
• first time therapies tried
• Idiopathic menorrhogia
• Mofenamic acid
• Traexalic acid
• Oral contraceptive pill

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What next?

• Confirm diagnosis or Idiopathic menorrhagia
• Check for cycle irregularity, Intermenstrual or,
  postcoltal bleeding
• Woman With failed first Iine medical management
  are more Iikely in have intrauterine pathology
  and so TVS arid If needed hysteroscopy and
  endometrial sampling are Indicated (RCOS
  guidelines)

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TVS

• polyps
• submucous fibroids
• Endometrial hyperplasia An endometrial Thickness
  of 12 mm is used as the cut off paint for
  endometrial hyperplasia on TVS (RCOG)
• Optimal time !s the proliferative phase.

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Sonohysterography

• TVS may miss small polyps
• Difficult to distinguish from thickened
  endometrium
• SHG helps in accurate diagnosis

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Adv of SHG

• Helps In performing a guided hysteroscopy
• Difference between focal lesions and endometrial
  thickening
• Accurate diagnosis of location arid the
  Intramural component of a fibroid even more than
  hysteroscopy
• Sensitivity 99 and specificity 89

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Endometrial sampling

• All women with persistent menorrhogia
• To diagnose or exclude endometrial carcinoma or
  hyperplasia
• Probability of abnormal histology lt 1 in this
  age with regular cycles

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Sampling How?

• Endometrial aspiration
• Conventional DC
• Hysteroscopy and directed biopsy

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Hysteroscopy and directed biopsy -gold standard

• DC alone may miss 10 endometrial pathology
  Including malignancy
• Hysteroscopy allows direct visualization of
  endometrial cavity
• Detects more Intrauterine pathology
• Along with endometrial biopsy detect, more
  endometrial hyperplasia
• Treatment at the some sitting

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Further management of menorrhagia

• Medical and surgical methods
• Quality of life is the key goal
• Woman's preferences to be taken Into account

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Medical - second line drugs

• Danazol
• GnRH analogues
• Disadv - temporary effect
• cannot be used long term due to side effects
• best for short term use prior to surgery

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LNG releasing IUD or Mirena

• Alternative to medical and surgical therapy
• Fertility can be preserved If needed
• Duration and amount of bleeding less
• By 1 year 15 are amenorrhoeic and most bleed
  lightly for one day in a month
• High patient satisfaction

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Surgical methods

• Hysteroscopic removal of polyps or submucous
  fibroids
• Conventional treatment is hysterectomy
• Conservative endometrial ablation procedures are
  now a well established alternative

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Endometrial ablation

• TCRE and laser ablation good results
• 30 become amenorrhoeic
• Most of the rest have hypomenorrhoea
• 10 may continue to have menorrhagia
• Adequate prior counseling a must

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• 20 will need a second procedure or Hysterectomy
  later
• Immediate and delayed complications
• Endometrial sampling a must before TCRC

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Alternative procedures

• Thermal balloon ablation
• Radiofrequency induced ablation
• Microwave ablation
• Photodynamic therapy
• All are still under evaluation

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• A 47 year old woman gives a 2 year history of
  irregular periods. She has always had regular
  cycles until 3 years ago. She has three children
  all delivered normally.

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• No significant finding in the history
• On examination she is a little overweight
• Not anaemic
• Pelvic examination reveals a normal sized
  anteverted mobile uterus
• Cervical smear is normal.

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Likely diagnosis?

• Anovulatary dysfunctional bleeding
• Common at the extremes of reproductive life
• But malignancy is to be ruled out
• Endometrial sampling a must to detect endometrial
  carcinoma and hyperplasia

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Endometrial hyperplasia

• Simple hyperplasia with without atypia
• Complex hyperplasia with without atypia
• Atypia present - hysterectomy better
• No atypia - progesterone in the second half

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• The approach to DUB differs in the different age
  groups and in particular depends on whether the
  bleeding is cyclical or not.
• The current RCOG recommendations in premenopausal
  women with regular cycles is to delay endometrial
  sampling till medical management has failed.
• Also the numbers of hysterectomies being done for
  normal sized uteri are coming down with
  Increasing acceptance of Mirena and endometrial
  ablation