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HEAVY MENSTRUAL BLEEDING BY TASHI CARMICHAEL (5 YEAR MEDICAL STUDENT) ZARTASHT.CARMICHAEL@STUD ENT.MANCHESTER.AC.UK ¡ Basic anatomy + physiology WHAT WE WILL ¡ Gynae history + examination ¡ Heavy Menstrual bleeding (Menorrhagia) COVER… ¡ Common causesANATOMYPHYSIOLOGY25-YEAR-OLD FEMALE PRESENTS TO GP WITH HEAVY MENSTRUAL BLEEDING ¡ MOSC GYNAE HISTORY ¡ Menstrual ¡ LMP, age of menarche, menopause, cycle – length, regularity, heaviness, flooding or clots and any change in volume? ¡ Presenting Complaint ¡ Have periods always been this heavy? ¡ History of presenting complaint ¡ Obstetric ¡ SOCRATES ¡ Number of children (>24 weeks - Parity)/ Any plans to have children? ¡ Duration ¡ Number of pregnancies, miscarriages, termination of pregnancy ¡ Gynae 4 Ps: ¡ Sexual ¡ Pain/ dysmenorrhea ¡ Partners last 3/6/ 12 months ¡ Pregnancy ¡ Unprotected intercourse ¡ PV bleed – PCB, IMB ¡ PV discharge ¡ Any known STI/STD ¡ Cervical smears ¡ ContraceptionGYNAE HISTORY CONT… ¡ PMH ¡ Thyroid/ Diabetes/HTN ¡ Systems review ¡ Any known gynecological problems ¡ Urinary ¡ Medication history ¡ Gastro ¡ Contraception devices ¡ Thyroid ¡ HRT ¡ Symptoms of anemia – SOB, pallor, fatigue etc. ¡ FHx ¡ Cancer - night sweats, weight loss, fatigue ¡ Bowel/Breast/Ovarian cancer ¡ Fever ¡ Clotting disorders ¡ Social history – Impact on quality of LIFE ¡ ICE patient early on!! ¡ Smoking – 5X more likely to have abnormal menstruation ¡ AlcoholCASE 1 CONT… ¡ G0P0 ¡ Has always had heavy periods since menarche at 13, however over past 1.5 years they have become increasingly heavy with patient changings sanitary products at least 9 times a day and passes blood clots size of 50p ¡ Cycle is getting shorter with a longer bleeding time – lasting around 7 days ¡ LMP one week ago ¡ Pain is moderate, requires ibuprofen on days 2-4 of menses ¡ Got to the point where she can’t leave the house for the first two days ¡ No IMB or PCB, no abnormal discharge ¡ Sexual history, PMH, FH – nil significant ¡ Contraception: mirena (10 months ago) What examination and investigations would you do next? ¡ Smears up to date and NADEXAMINATION ¡ General examination ¡ BMI ¡ Any signs of anaemia ¡ Abdominal examination for any masses ¡ Pelvic examination – speculum + bimanual ¡ Speculum – inspect cervix (lesions, lacerations, ectropion, colour, bleeding, discharge, os open or closed) ¡ Bimanual – cervical excitation, irregularity, mobility, firmness, assess uterus (size, masses, tenderness, mobility, anteverted) and fornices ¡ Looks pale but otherwise well CASE 1 CONT… ¡ Abdomen SNT – pelvic mass felt ¡ Speculum – patient finds this very uncomfortable ¡ Os closed ¡ Cervix healthy ¡ Bimanual ¡ No cervical excitation or forniceal tenderness ¡ Large bulky and tender uterusINVESTIGATIONS Bedside ¡ Pregnancy test ¡ Urine dipstick +/- MSU Bloods ¡ FBC (Hb for anaemia) ¡ TFTs ¡ Clotting if indicated in history ¡ U+Es if considering NSAID management Imaging ¡ GOLD STANDARD: TV-USSRED FLAGS ¡ Heavy bleeding and hemodynamically unstable ¡ Postmenopausal bleeding ¡ Bleeding during pregnancy ¡ Pelvic mass ¡ Hb < 80 ¡ Findings on USS ¡ >5mm endometrium in perimenopausal women ¡ Bloods – Hb 104 ¡ Swabs NAD ¡ TV-USS CASE 1 CONT… ¡ Endometrial thickness 3mm ¡ Bulky appearance of uterus ¡ Normal ovaries What are your differentials?HEAVY MENSTRUAL BLEEDING DIFFERENTIALS Gynae Iatrogenic ¡ Dysfunctional Uterine Bleeding (DUB) ¡ IUD (Copper coil) ¡ Extremes of reproductive age ¡ Contraceptives ¡ PCOS ¡ Anticoagulants ¡ Fibroids ¡ Endometriosis Systemic ¡ Adenomyosis ¡ Thyroid disease ¡ Pelvic inflammatory disease ¡ Diabetes ¡ Endometrial polyp ¡ Clotting disorders ¡ Endometrial hyperplasia or carcinomaDIAGNOSIS IS BASED ON SYMPTOMS AND SELF REPORT OF ‘VERY HEAVY PERIODS’ • CHANGINGS SANITARY PRODUCTS EVERY 1-2 HOURS • BLEEDING >7 DAYS • BLOOD CLOTSEPIDEMIOLOGY ¡ 30% of women report heavy periods but only 5% will consult their doctor ¡ Often a problem with extremes of reproductive ages ¡ Menstrual disorders are the second most common reason for gynaecology referral ¡ About 50% of cases then present medically have no cause identified – and as such are diagnosed as Dysfunctional Uterine Bleeding (DUB) – a diagnosis of exclusion ¡ Bleeding of unknown cause ¡ Diagnosed by excluding pregnancy, iatrogenic causes, systemic conditions and genital tract infections DYSFUNCTIONAL ¡ Investigations are often all normal UTERINE ¡ May present with IMB or PCB, clots or flooding or symptoms of BLEEDING (DUB) anaemiaTREATMENT OF HEAVY MENSTRUAL BLEEDING Contraception Contraception not required: desired: ¡ In primary care ensure to exclude underlying pathology such as anaemia, fibroids, bleeding • Mirena coil (first line) • Tranexamic disorders and cancer. • Combined oral acid when no contraceptive pill associated pain ¡ The next step is to establish whether • Cyclical oral (antifibrinolytic – contraception is required or acceptable. progestogens, such as reduces bleeding) ¡ Referral to secondary cafor further norethisterone 5mg • Mefenamic investigation and management is indicated if three times daily acid when there is from day 5 – 26 associated pain treatment is unsuccessful, symptoms are severe or Progesterone only (NSAID – reduces there are large fibroids (more than 3 cm). contraception (e.g. bleeding and pain) ¡ The final options when medical management has depo injection or failed are endometrial ablation and hysterectomy. implant).UTERINE FIBROIDS ¡ Benign tumors of smooth muscle ¡ Affect 40-60% of women in later reproductive years ¡ More common in black women ¡ Oestrogen sensitive ¡ Often asymptomatic ¡ May present with: ¡ Menorrhagia ¡ Abdominal pain often during menstruation ¡ Bloating ¡ LUTS or subfertility if large ¡ Pelvic mass on examinationUTERINE FIBROIDS Investigations: Fibroids <3cm Fibroids >3cm ¡ FBC (Hb for anaemia) • Treated same as HMB • Refer to gynae ¡ Pelvic or TV-USS • Cyclic USS • Treated same as HMB • Surgery – endometrial • Surgery – uterine artery ¡ Hysteroscopy for submucosal fibroids ablation, resection embolization, myomectomy, ¡ MRI if considering surgery during hysteroscopy, hysterectomy (GnRH agonists hysterectomy can be used before to shrink Complications: size of fibroid prior to ¡ Red degeneration – insufficient blood supply can surgery) cause haemorrhage and necrosis (often during pregnancy) ¡ Torsion of pedunculated fibroids Severity of endometriosis may not always ENDOMETRIOSIS correspond to the symptoms a patient may be experiencing ¡ Symptoms often include pelvic pain which can be ¡ Endometrial like tissue grows outside of the uterus cyclical or chronic ¡ POD, uterosacral ligaments, ovaries, rectum, ¡ Deep dyspareunia peritoneum ¡ A lump of endometrial tissue on the ovaries are ¡ Dysmenorrhea ¡ IMB known as endometriomas or ‘chocolate cysts’ ¡ Aetiology unknown however there are several ¡ Haematuria theories ¡ Painful bowel motions or blood in stool ¡ Retrograde menstruation, lymphatic spread, ¡ Chronic fatigue metaplasia or impaired immunity Complications ¡ Oestrogen dependent ¡ Reduced fertility ¡ Associated with reduced fertility ¡ AdhesionsENDOMETRIOSIS ¡ Often a delay in diagnosis and commonly Primary Care: Secondary Care: misdiagnosed • NSAIDs for 3-6 months • GnRH analogues + • Contraception if HRT ¡ Examination may reveal visible endometriosis pregnancy undesired • Surgical excision or tissue, fixed cervix on bimanual, tenderness on speculum (hormonal treatment ablation with may improve symptoms adhesiolysis for ¡ USS often normal unless extensive disease on but not fertility) adhesions • Fertility management ovaries and support ¡ Laparoscopy is gold standard for diagnosisADENOMYOSIS ¡ Refers to endometrial tissue inside the myometrium of the uterus ¡ More common in later reproductive years and those that have had several pregnancies ¡ Occurs in 10% of women alone or alongside fibroids or endometriosis ¡ Oestrogen dependent and symptoms tend to resolve after menopause ¡ Symptoms similar to endometriosis ¡ Diagnosis with TV-USS (FIRST LINE) ¡ Management same for HMBANY QUESTIONS SO FAR?MCQ PRACTICE… A young girl (23 years old) presents with abdominal pain and menorrhagia. On abdominal palpation, there is an 18-week size mass arising from the hypogastrium. The most likely diagnosis is: A) Endometriosis B) Pelvic Inflammatory Disease C) Ovarian cyst D) Fibroid/ leiomyoma E) Mesenteric cystMCQ PRACTICE… A young girl (23 years old) presents with abdominal pain and menorrhagia. On abdominal palpation, there is an 18-week size mass arising from the hypogastrium. The most likely diagnosis is: A) Endometriosis B) Pelvic Inflammatory Disease C) Ovarian cyst D) Fibroid/ leiomyoma E) Mesenteric cystMCQ PRACTICE… A patient is being investigated for menorrhagia, which of these investigations are not first line investigations? A) FBC B) Clotting profile C) Bimanual examination D) Speculum examination E) MRIMCQ PRACTICE… A patient is being investigated for menorrhagia, which of these investigations are not first line investigations? A) FBC B) Clotting profile C) Bimanual examination D) Speculum examination E) MRIMCQ PRACTICE… A 43-year-old lecturer has come to you with complaints of heavy but regular menstrual bleeding, with flooding and clots. There is no anatomical reason for the heavy flow. The most effective remedy for reducing her menstrual flow is: A) Tranexamic Acid B) Dilatation And Curettage C) Misoprostol D) Depomedroxy progesterone acetateMCQ PRACTICE… A 43-year-old lecturer has come to you with complaints of heavy but regular menstrual bleeding, with flooding and clots. There is no anatomical reason for the heavy flow. The most effective remedy for reducing her menstrual flow is: A) Tranexamic Acid B) Dilatation And Curettage C) Misoprostol D) Depomedroxy progesterone acetateMCQ PRACTICE… The most likely cause of abnormal uterine bleeding in 13-year-old girls is: A) Uterine cancer B) Ectopic pregnancy C) Anovulation D) TraumaMCQ PRACTICE… The most likely cause of abnormal uterine bleeding in 13-year-old girls is: A) Uterine cancer B) Ectopic pregnancy C) Anovulation D) TraumaOSCE STATIONS ¡ First-line management of Menorrhagia e.g., IUS counselling ¡ Pelvic pain history ¡ PV bleed historyREFERENCES ¡ NICE – heavy Menstrual Bleeding ¡ Oxford handbook of clinical specialties ¡ OSCEstop ¡ Geeky Medics ¡ Zero to finals