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Physiology of
menstruation
Causes of
menorrhagia
Clinical
assessment
Treatment
The authors
DR DAVID KNIGHT,
senior staff specialist in obstetrics
and gynaecology, Canberra
Hospital; and clinical lecturer in
obstetrics and gynaecology,
Australian National University
(ANU), Canberra, ACT.
ASSOCIATE PROFESSOR
STEVE ROBSON,
senior staff specialist in obstetrics
and gynaecology, Canberra
Hospital; and associate professor
in obstetrics and gynaecology,
ANU, Canberra, ACT.
Menorrhagia
Background
resents the natural cessation of the
menstrual cycle and many women
will seek treatment near the age of
menopause. Trying to find a simple
treatment that will provide sufficient
relief until nature takes over can be
hard to sell to the patient. Thirdly,
many treatments for menorrhagia are
incompatible with becoming pregnant, so management of the younger
woman desiring fertility imposes further therapeutic restrictions.
Definition of menorrhagia
The oft-quoted definitions of menorrhagia (loss of more than 80mL of
menstrual fluid over the course of a
period) are almost completely valueless in the clinical setting. Precise
measurement of menstrual blood
BETTER TOGETHER
volume is very difficult, to the point
where it is only really used in certain
clinical studies. Although values of
between 30mL and 80mL are said to
be the normal limits of menstrual
loss, there is no practical way of
making such measurements and only
slightly more than 50% of menstrual
fluid is actually blood.
cont’d next page
DR PETER SCOTT,
senior staff specialist in obstetrics
and gynaecology, Canberra
Hospital; and clinical lecturer in
obstetrics and gynaecology,
ANU, Canberra, ACT.
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THE management of menorrhagia
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gynaecologist as well as for the
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usually little objective evidence of
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6 March 2009 | Australian Doctor |
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HOW TO TREAT Menorrhagia
from previous page
To add to the difficulty, studies
have shown that more than onethird of women with documented
menstrual loss of more than 80mL
describe their periods as normal,
while a quarter of women with true
loss of less than 60mL describe
their periods as ‘heavy’. Yet about
5% of women in the UK will consult their GP each year with a principal complaint of menstrual disorders, and it has been estimated that
sick leave for menstrual problems
represents 3% of total wages in the
UK.1
For these reasons, a more useful
definition of menorrhagia is excessive menstrual blood loss that has a
significant impact on lifestyle or
that results in iron deficiency.
Effects on lifestyle should not be
underestimated, and can include the
Effects on lifestyle
should not be
underestimated, and
can include the
embarrassment
associated with blood
soaking through
clothing, and
disruption to work.
embarrassment associated with
blood soaking through clothing,
disruption to work associated with
frequent pad or tampon changes,
mood changes associated with the
stress of heavy bleeding and lack of
concentration at work or when
travelling. Many women describe
becoming socially isolated during
menstruation because of fears about
leaving the house.
For those who experience prolonged dysfunctional uterine bleeding, the situation can be even
worse. The inability to predict the
onset, amount and duration of
bleeding can cause major disruption to normal activities, including
the cancellation of social outings
and postponement of travel plans.
If there is significant iron-deficiency
anaemia, symptoms such as
lethargy, weakness, dizziness, pallor
and feeling cold may be present.
Both iron deficiency and anaemia
are easy to measure in clinical practice and this helps to define the
severity of the problem.
Incidence of menorrhagia
Menorrhagia is a very common
symptom. Approximately 5% of
referrals of premenopausal women
to specialist gynaecologists are for
evaluation and treatment of menorrhagia. Because menstrual disorders are usually managed conservatively by general practitioners, the
actual prevalence is likely to be
much greater and could be as high
as 20% of the reproductive-age
female population. In addition, a
great many women who might otherwise complain of heavy menstrual
periods are currently taking oral
contraceptive pills (OCPs) in order
to avoid pregnancy. Such women
are already using an extremely
effective treatment for menorrhagia
and some of them will continue to
take the pill right up until the onset
of menopause, thus avoiding the
problem altogether.
Although menorrhagia can occur
as an isolated symptom, it is commonly associated with other menstrual problems such as dysmenorrhoea, abnormal cyclicity and
premenstrual dysphoric disorder.
These additional symptoms should
always be taken into account when
formulating a management plan.
There is little point in effectively
reducing menstrual blood flow if
the woman continues to experience
unacceptable period pain or severe
premenstrual symptoms such as
mastalgia, mood change, bloating
and headache.
The physiology of menstruation
DURING the reproductive
years, women who do not regulate their cycles with hormones usually have a regular
and predictable menstrual
cycle. The precision of this
cyclicity results from regular
ovulation, the onset of which
is controlled by a finely tuned
set of hormonal feedback
mechanisms.
The cells of the arcuate
nucleus of the hypothalamus
secrete gonadotrophin-releasing hormone (GnRH) into the
vessels of the hypothalamicpituitary portal system in a
pulsatile fashion. Changes in
the frequency and amplitude
of the GnRH pulses control
the release of follicle-stimulating hormone (FSH) from
gonadotrophic cells in the
anterior pituitary. FSH then
acts on the ovarian follicles to
bring about growth and development of the egg. As the egg
and its surrounding cells
tained, a transient surge of
luteinising hormone (LH)
from the anterior pituitary initiates ovulation. After ovulation, the remnants of the dominant follicle compact to form
the corpus luteum, which
begins producing progesterone
in addition to oestrogen
(figure 1). If pregnancy does
not occur, the corpus luteum
fails and the abrupt withdrawal of oestradiol and progesterone results in endometrial
breakdown with its accompanying blood loss.
Oestrogens have a strong
vasodilatory effect, and the
sudden reduction in oestrogen levels leads to spasm in
the spiral arterioles of the
endometrium. This causes a
relative ischaemia in the
superficial layers of the
endometrium (the ‘functionalis’ layer), which leads to the
release of inflammatory factors, including prostaglandins,
Figure 1: Laparoscopic view of an ovary with a typical corpus
luteum, indicative of recent ovulation.
develop, oestradiol is released
into the circulation and this
provides negative feedback to
the pituitary and hypothalamus. Oestrogens act to
thicken and prepare the
endometrial lining to accept
an embryo. Once a critical
threshold of oestrogen is sus-
that may cause painful
myometrial contractions.
These factors further
increase ischaemia and
inflammation
in
the
endometrium, leading to
shedding down to a layer
known as the ‘basalis’.
Many women of reproductive age will have anovulatory
menstrual cycles. These are
more common in the years
leading up to menopause, due
to depletion of the stores of
primordial follicles in the
ovary. Anovulatory cycles are
commonly associated with a
thickened
disordered
endometrium that results
from oestrogen stimulation
without the secretory effect of
progesterone. As a result, the
cycles are frequently irregular
in timing and, when menstrual bleeding occurs, it can
be prolonged. Therefore it is
not unusual for such women
to experience persistent bleed-
ing, which is most commonly
light and painless but can be
heavy at times.
By contrast, the administration of artificial hormones
(such as a combination of
ethinyloestradiol and a
progestogen) causes the
endometrium to grow in a
less orderly way. The result
is a uterine lining that is generally thinner and more
stable than natural secretory
endometrium. Thus, when
the exogenous hormones are
stopped, the resulting withdrawal bleed is usually much
less than the loss associated
with natural ovulatory menstruation because a lesser
volume of endometrium is
shed. For those women who
stop the pill after having
taken it for many years, the
onset of normal ovulatory
menstrual cycles (which they
had long forgotten) can be
interpreted as menorrhagia.
The causes of menorrhagia
IN general, menorrhagia is usually
associated with processes that
increase
the
volume
of
endometrium being shed. The
common conditions associated
with menorrhagia are classified in
figure 2.
It is important to remember that
menorrhagia is a symptom, not a
diagnosis. For some women it
means unacceptably heavy bleeding that occurs over 2-3 days in an
otherwise normal, regular menstrual cycle. For others it can mean
prolonged bleeding during cycles
that may be regular or irregular in
timing. The former situation is
usually associated with normal
ovulation and there may be no
underlying pathology. The latter,
which is usually referred to as
“dysfunctional uterine bleeding”
is usually the result of anovulatory
cycles, which occur commonly in
the peri-menopausal period. Both
types of excessive bleeding may be
regarded as physiological if no
other cause is found. Even though
their occurrence might be physiological, they still cause much physical distress to the patient.
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| Australian Doctor | 6 March 2009
used in China and may be present
in patients who have recently
arrived from that country.
Figure 2: Classification of causes of menorrhagia.
CAUSES OF MENORRHAGIA
LOCAL
IATROGENIC
Non-hormonal IUD
Coagulation and
platelet disorders
Fibroids
Adenomyosis
GENERALISED
Anticoagulants
Liver, renal disease
Polyps
Dysfunctional
uterine bleeding
Thyroid disease
Pelvic inflammatory
disease
Physiological
Anovulatory
Ovulatory
Iatrogenic causes
Iatrogenic causes of menorrhagia
include the use of anticoagulants
such as warfarin for conditions
such as prosthetic heart valves and
thrombophilia. The use of non-hormonal intrauterine contraceptive
devices, which can also be associated with heavy menstrual bleeding, has recently declined in Australia. However devices such as the
Grafenberg ring are still widely
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Generalised causes
Menorrhagia can be found in association with thyroid disease — most
commonly with hypothyroidism —
and also with bleeding disorders
such as immune thrombocytopenic
purpura, von Willebrand’s disorder
and haemophilia. In general, these
conditions will have been diagnosed
long before the woman attends for
review of her periods. However,
heavy menstruation in young
women can sometimes lead to a
first diagnosis of these conditions,
so although they are relatively
uncommon they should not be
overlooked.
Local causes
Up to one-third of women will have at
least one uterine fibroid present during
their lifetime. Most of these are small
and are located within the wall of the
uterus, or on the serosal surface,
where they are unlikely to be symptomatic. However, fibroids growing
close to the endometrial lining, even
small ones, can be associated with
menorrhagia because they enlarge and
distort the endometrial cavity. Large
fibroids can cause both menorrhagia
and pressure symptoms but fibroids
are rarely, if ever, associated with pain
except during pregnancy.
Adenomyosis uteri is a condition
where endometrial tissue is found
within the myometrium itself. It is a
common condition in the late reproductive phase of life but it regresses
after menopause. If symptomatic, it
may present with painful periods but
it can also cause menorrhagia, diffuse uterine enlargement and rarely,
deep dyspareunia. Endometriosis, on
the other hand, may cause pain and
intermenstrual discharge but it is not
usually associated with heavy menstrual loss as an isolated symptom.
Occasionally menorrhagia is found
in association with a benign endometrial polyp. The relationship is uncertain but the bleeding sometimes
improves following removal of the
polyp.
The term ‘endometrial hyperplasia’
refers to the presence of a hyperplastic
uterine lining that is usually the result
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HOW TO TREAT Menorrhagia
from page 32
of hyperstimulation by unopposed
oestrogens in cases of anovulatory dysfunctional uterine bleeding. This is especially common in overweight women,
since peripheral fat contains aromatase
enzymes that convert androgens (such
as dehydroepiandrosterone [DHEA])
to weakly stimulatory oestrogens (such
as oestrone) that act on the
endometrium without being countered
by the cyclic progesterone that would
occur with ovulation. Endometrial
cancer can occasionally occur in this
setting, but is usually associated with
prolonged vaginal bleeding rather
than with menorrhagia.
Chronic pelvic inflammatory disease
is a common cause of chronic pelvic
pain but it can also be associated with
heavy menstrual blood loss in rare cases.
Figure 3: Submucous fibroid (photograph taken at hysteroscopy).
Figure 4: Photograph taken at laparotomy of a uterus grossly enlarged by
multiple fibroids. The uterus was subsequently removed.
The clinical approach
History
A COMPREHENSIVE medical history is the first and the
most important step in the
evaluation of the woman who
presents with menorrhagia.
Indeed, there may be no
abnormal findings and treatment will need to be based
entirely on the history. For this
reason it is absolutely critical
to take a detailed history.
Many women will give a
long and confusing history of
their menstrual cycle, and it
can be difficult to obtain a
clear picture of what is happening. After the woman has
given her initial description of
the problem, it is often worth
drawing a diagram to explain
what a normal cycle should be
like, and to have the woman
describe her cycle. There are
three common patterns, as
shown in figure 5.
It is important to determine
when the woman’s periods
first started and what their initial pattern was like. Ask
about recent periods including
their regularity, duration of
bleeding, clots, pain, mid-cycle
and postcoital bleeding, dyspareunia and premenstrual
symptoms. Be sure to check
that the patient is describing
real periods and not oral contraceptive withdrawal bleeds.
Ask for the date of the last
period, as this can be useful in
planning investigations and
treatment.
Contraception
Ask about past use of hormone contraception and
enquire about any use of
intrauterine devices. Etonogestrel (Implanon) is a
common cause of irregular
bleeding, and medroxyprogesterone acetate (Depo-Provera)
injections can cause prolonged
periods of amenorrhoea followed by irregular bleeding.
Pregnancies
It is important to know if the
woman has completed her
child bearing because many
treatments for menorrhagia
also prevent pregnancy. A past
history of antepartum or postpartum haemorrhage can
sometimes be helpful as it may
34
Figure 5: Simple diagram of a normal cycle for a woman, and the most common patterns of
abnormality described by women.
5-7 days of bleeding, occurring
regularly each month
NORMAL
Figure 6: Ultrasound image taken after injection of the
endometrial cavity with saline. A single endometrial polyp is
seen. Its feeder blood vessel has been defined on colour
Doppler imaging.
REGULAR, BUT HEAVY ± PROLONGED
IRREGULAR, OFTEN HEAVY WHEN THEY OCCUR
Figure 7: Ultrasound image showing the typical features of
multiple fibroids, namely the discrete rounded masses with a
hypoechoic periphery.
INTERMENSTRUAL BLEEDING
point to a bleeding tendency. It
is important to exclude an
existing pregnancy, especially
if the current bleeding is irregular.
Medical history
Bleeding disorders, endocrine
disorders, sexually transmitted
diseases, liver disease and renal
disease are all important to
elicit. Don’t forget to enquire
about the patient’s Pap smear
history.
Medications
Enquire particularly about
hormone therapy and anticoagulants. Be sure to ask about
over-the-counter and herbal
medicines as these can be overlooked. If a woman is taking a
herbal medicine, then it may
be helpful to consult a reputable source because some
herbal remedies have anticoagulant properties.
Surgical history
If the woman has had a previous hysteroscopy or laparoscopy then an effort should be
made to obtain the result of
these investigations as the findings may be relevant to the
present condition. Sometimes
the onset of menorrhagia has
been preceded by a sterilisation operation associated with
| Australian Doctor | 6 March 2009
cessation of hormonal contraception.
Family history
It is important to enquire
about hereditary bleeding disorders but it is also worth
asking about menstrual periods in first-degree female relatives, as there can be a familial
tendency to bleed heavily
during menstruation.
Physical examination
The physical examination
should always be appropriate
for the clinical situation. A
general clinical examination
should include checking for
pallor, examination of the thyroid gland and an abdominal
examination for masses (eg, an
enlarged fibroid uterus). Vaginal examinations should be
restricted to those women who
are, or have been, sexually
active. Cervicitis can cause
abnormal bleeding, so checking a swab for chlamydia (if
indicated) may be appropriate.
If the Pap smear is nearly due,
or if there is any suggestion of
postcoital or intermenstrual
bleeding, it is wise to take a
Pap smear at the same time.
The presence of a cervical
polyp may indicate the concurrent presence of endometrial polyps.
Investigations
Haematology
The first and most basic investigation is an FBC. If a microcytic, hypochromic anaemia is
present then this is highly likely
to be due to iron deficiency
resulting from excessive blood
loss. (In the presence of normal
iron studies it is most likely due
to beta thalassaemia). The
presence of thrombocytopenia
will obviously require further
investigation. Coagulation
studies will need to be done if a
bleeding disorder is suspected.
If a patient is taking warfarin
then her INR will need to be
measured.
Biochemistry
Full iron studies are expensive
but a serum ferritin is relatively cheap and this test offers
a reasonable estimate of total
body iron stores. Other biochemical tests such as liver
and renal function may be
appropriate depending on the
clinical situation.
Hormones
Hormone assays are not usually needed in the evaluation
of menorrhagia. However, if
there are clinical signs of thyroid disease, then thyroid function tests should be ordered.
A luteal-phase progesterone
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can be used to confirm ovulation and a serum FSH can
sometimes be helpful in the
perimenopausal period — particularly if there has been
heavy bleeding following a
period of amenorrhoea. A
serum beta-hCG should
always be done to exclude
pregnancy in cases of abnormal bleeding.
Pelvic ultrasound scan
Unless the patient is a virgin,
this should always be performed both transabdominally
and transvaginally. High quality grey-scale ultrasound
images have revolutionised the
management of menorrhagia
by providing a detailed, noninvasive survey of the anatomy
of the pelvis. Endometrial
polyps (figure 6), uterine
fibroids (figure 7) and adenomyosis (figure 8, page 36), can
often be diagnosed on ultra-
sound although saline hysterography may be needed to
distinguish a polyp from
endometrial hyperplasia. Differentiating multiple small
fibroids from adenomyosis in a
bulky uterus can sometimes be
difficult but there are now
well-established ultrasonic differences between the two conditions. Both ovaries can be
visualised during the examination and uterine blood flow
studies can be done using
colour Doppler imaging. However, a scan may not be needed
in a young woman with regular periods who is keen to start
taking an oral contraceptive
anyway.
Other medical imaging
This is rarely required. However, an unusual pelvic mass
may require further evaluation
with CT or MRI scanning.
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HOW TO TREAT Menorrhagia
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Hysteroscopy
Visual inspection of the uterine
cavity with a hysteroscope is
commonly performed after
failed conservative management or when there has been
an abnormal ultrasound scan.
It can sometimes be undertaken as an outpatient procedure but it is more commonly
done under anaesthesia. This
allows the operator to take
photographs, to sample the
endometrium and to remove
any polyps. If appropriate, a
levonorgestrel intrauterine
device (Mirena) can be
inserted at the same time.
Figure 9: Photograph taken at hysteroscopy of the
same endometrial polyp as was seen in figure 6.
Figure 8: Ultrasound image showing the typical
features of adenomyosis, namely ill-defined,
asymmetric myometrial thickening with cysts.
Figure 10: Photograph taken at hysteroscopy of
endometrial hyperplasia, showing irregular,
thickened, polypoidal endometrium. The histology
was benign.
Treatment of menorrhagia
THE main principles of management
are to identify and treat any underlying pathology, to correct anaemia
and to improve quality of life.
Specialist referral is particularly
important if there has been a failure
of conservative management or if
there is suspicion of serious pathology (for example, an abnormal ultrasound scan).
The various available treatment
modalities are summarised in figure
11.
Table 1. Medical management of menorrhagia
Class of drug
NSAIDs
Tranexamic acid
Ancillary measures
Explanation and reassurance
For many women who complain of
heavy menstrual loss but who are
not iron deficient, an explanation of
the physiology of menstruation and a
reassurance that their periods are, in
fact, normal is an important part of
management. Because regular ovulatory menstrual periods are necessary to fall pregnant, many women
who wish to conceive may be content
with just such an explanation. This
can be reinforced with appropriate
reading material which can be
acquired from a number of reputable
sources such as the Royal College of
Obstetricians and Gynaecologists (see
Online resources).
Dietary advice and iron supplements
Iron-deficiency anaemia requires correction and this is most commonly
achieved with oral iron and ascorbic
acid supplements. Patients need to
be advised that it usually takes several weeks for a normal haemoglobin
level to be achieved with oral iron
therapy. On the other hand, severe,
symptomatic anaemia may require a
blood transfusion. Dietary advice
regarding iron-rich foods is equally
important and this is especially true
for vegetarians and vegans.
Medications
Fortunately there are a number of different drugs which can be used to
manage heavy menstrual bleeding
and these are summarised in Table 1.
Drug therapy is almost always the
first line of treatment and about 50%
of women will have a satisfactory
response. The choice of drug will
depend on several factors including:
• If pregnancy is wanted in the
immediate future, tranexamic acid
and NSAIDs are the only practical
alternatives.
• If oestrogen is contraindicated
(because of a previous DVT, or the
patient is a smoker over age 40 or
because of side effects such as
migraine) an OCP should not be
36
| Australian Doctor | 6 March 2009
Combined oral
contraceptive pill
Gonadotrophin-releasing
hormone agonist
Advantages
May be used long term
Do not prevent pregnancy
Inexpensive
Available over the counter
Very effective for period pain
Can be used in conjunction with other
agents eg, OCP or tranexamic acid
May be used long term
Does not prevent pregnancy
Can reduce blood loss by 50%
Can be used together with other therapy
Rapid onset of action
Only needs to be taken for 2-3 days in
each cycle
Useful in acute episodes
Usually very effective
May be used long term
Inexpensive (subsidised brands)
Can be used to block menstruation
Regulates cycle
Relieves dysmenorrhoea
Provides contraception
Very effective in blocking menstruation
Can reduce the size of fibroids
Break-through bleeding is uncommon
Oral progestogen
May be used long term
Inexpensive
Very effective in high doses
Depot injection of progestogen Convenient
(Depo-Provera)
Inexpensive
Usually effective
Etonogestrel implant (Implanon) Convenient — can last for three years
Inexpensive
Can be removed if side effects occur
Levonorgestrel IUD (Mirena)
Convenient – can last for five years
Inexpensive if used as contraception
Progestogen side effects uncommon
Can be removed if side effects occur
60% of recipients avoid ablation or
hysterectomy
Usually easy to insert as an outpatient
Disadvantages
Not as effective as most other agents
GI side effects are common
Headache and tinnitus may occur
Allergic reactions — especially in asthma
Contraindicated with a history of thrombosis
or presence of thrombophilia
Skin rash may occur
GI side effects may occur
Does not relieve period pain
Break-through bleeding not uncommon
Cannot be used if pregnancy is wanted
Common side effects can include nausea,
weight gain, depression, migraine, acne,
mastalgia, vaginal monilia, loss of libido,
chloasma
Contraindicated in smokers >40 years old
Risk of DVT increased
Very expensive
Risk of osteoporosis with long-term use
Menopausal and androgenic side effects
are uncommon but do occur
Break-through bleeding is common
Side effects include weight gain, mood
changes, acne, loss of libido
Same side effects as oral progestogen
Side effects can last for up to 12 months
Must be repeated every three months
Same side effects as oral progestogen
Can be very difficult to remove if not
inserted properly
Break-through bleeding very common —
especially in the first three months
Insertion can be difficult in some patients
Expulsion and perforation are rare
Efficacy is less with submucous fibroids or
adenomyosis
prescribed. However, progestogens
can still be used in many of these
cases.
• If progestogens have caused unacceptable side effects in the past, a
Mirena IUD can still be used in
some cases.
• If there is proven endometriosis
then a GnRH agonist (goserelin
[Zoladex] and nafarelin [Synarel])
can be used and, in this situation,
the drug carries a subsidy for six
months’ treatment.
Surgery
Surgical treatment may be needed in
cases of failed medical management
or where there are other co-existing
problems such as pressure from large
fibroids, prolapse, atypical endometrial hyperplasia or high-grade CIN.
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Endometrial ablation
Over the last couple of decades surgical methods of destruction of the
endometrium have become increasingly quicker, easier, safer and more
effective. The original hysteroscopic
diathermy resections required considerable operator skill and had the
dual risks of operative complications
and fluid overload due to the need to
distend the uterine cavity with
glycine. Since then a number of
refinements have occurred including
microwave, cryotherapy and various
hot-water balloon devices. In our
unit we now exclusively use Novasure, which is a radio-frequency
device. It combines safety and ease of
use with very impressive rates of
amenorrhoea (50% at 12 months)
avoidance of hysterectomy (95%)
and patient satisfaction (over 90%).
We counsel patients that the aim of
endometrial ablation is eumenorrhoea, that is, a satisfactory reduction in the amount of bleeding rather
than complete amenorrhoea.
One of the advantages of Novasure is that the device aspirates the
coagulated endometrium as the procedure is occurring, resulting in less
postoperative discharge and potential for infection. This also produces
a more predictable depth of ablation
and obviates the need for pretreatment with agents such as danazol or
GnRH agonists. It also means that
the procedure can be done at any
time in the cycle, including while the
patient is bleeding. It is effectively a
pro-coagulant procedure, and can
therefore be performed on women
with bleeding disorders or those who
are taking anticoagulant medication.
Endometrial ablation does not
confer contraception and, in fact, a
subsequent pregnancy could involve
significant risk to both the woman
and the fetus including placenta percreta and intrauterine growth retardation. Therefore it is imperative that
the patient have adequate contraception such as a tubal ligation (which
can be done at the same time).
Endometrial ablation is contraindicated in patients with previous uterine surgery such as a classical caesarean section or a significant
myomectomy, or a uterine abnormality. It should be avoided in patients
with unusually small or large cavities or if there is significant intrauterine pathology. In addition, most
methods are not licensed for repeat
ablations. In our experience, all of
the “failures” with endometrial ablation have been in women who have
been eventually found to have adenomyosis. Obviously it is essential that
endometrial hyperplasia and cancer
are excluded before treatment, so we
routinely do a hysteroscopy and
endometrial sampling before the
endometrial ablation.
Treatment of fibroids
The removal of one or more fibroids
(as opposed to the removal of the
whole uterus) is usually undertaken
in women who have menorrhagia,
pressure symptoms or fertility issues
and who wish to become pregnant.
Fibroids can be surgically removed
at laparoscopy or laparotomy but
small submucosal fibroids can also
be resected via a hysteroscope.
Fibroids can also be reduced in size
with uterine artery embolisation or
by using GnRH agonists.
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Figure 11: Treatment modalities for menorrhagia.
TREATMENT MODALITIES FOR MENORRHAGIA
MEDICAL
SURGICAL
Uterine artery
embolisation
Myomectomy
ANCILLARY
Endometrial
ablation
Hysterectomy
Diet, iron supplements
NSAIDs
Tranexamic
acid
Mirena IUD
GnRH
agonist
Combined oral
contraceptive
Implanon
Explanation
Progestogens
Depo-Provera
injection
Oral
Hysterectomy
One piece of unequivocal advice
which we can give patients with
menorrhagia is that hysterectomy
will certainly cure the problem.
Against this must be balanced the
availability of effective, less invasive treatments and the possible
morbidity and even mortality of
this major operation. Possible
adverse effects include operative
complications such as major organ
damage, bleeding, postoperative
pain, infection, DVT and, in some
women, significant psychological
effects. We also need to consider
the cost of hospitalisation and the
long recovery time. There is also a
relationship between hysterectomy
and earlier ovarian failure, which
may necessitate hormone replace-
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PM
ment therapy. Despite all this, quality-of-life scores compare favourably
with other methods of management
of menorrhagia.
On the other hand, there are
patients in whom hysterectomy is
relatively contraindicated such as
those with a past history of operative difficulty (for example
endometriosis, multiple caesarean
sections or other pelvic pathology)
or who constitute a major anaesthetic risk because of a medical
condition. Such patients are usually better off with conservative
management.
The type of hysterectomy is determined both by the indication and by
the operator’s experience. Vaginal
hysterectomy and laparoscopically
assisted vaginal hysterectomy have
the advantage of less postoperative
pain, faster recovery and a shorter
hospital stay. Often these patients
have had vaginal deliveries in the past
and are suitable for a non-abdominal approach. However, many of the
patients who require hysterectomy
are those with larger fibroids or adenomyosis which will often necessitate
an abdominal approach.
The question of ovarian conservation depends on the individual
patient and is particularly debatable in perimenopausal women and
in those with a family history of
ovarian and breast cancer. However, as a general rule, we would
counsel ovarian conservation in
younger women where there is no
evidence of malignancy.
Summary
• Menorrhagia is a common symptom in women of reproductive age.
• The diagnosis is usually made with a detailed history, basic investigations
and an understanding of the physiology of menstruation.
• Conservative management with a wide variety of drugs is usually effective
and is commonly undertaken in general practice without the need for
specialist referral.
• Surgery is reserved for more complex cases and for failed medical
management.
Evidence-based guidelines*
Level A requires at least one randomised controlled trial as part of a body of
literature of overall good quality and consistency.
Level B requires well-controlled studies but no randomised clinical trials.
Level C requires evidence obtained from expert committees or expert
opinions from respected authorities.
Assessment guidelines
History (particularly exclude intermenstrual or postcoital bleeding)
Abdominal and pelvic examination
FBC
Thyroid function tests only if clinically indicated
Other hormones, coagulation studies only if clinically indicated
Endometrial biopsy not necessary in initial assessment
Referral if uterus >10-week size, pelvic mass or tenderness
C
C
B
C
B
C
C
Treatment guidelines
Medical treatments
Oral contraceptives
Mefenamic acid
Tranexamic acid
Low-dose luteal-phase progesterone not effective
Progesterone-releasing IUD
Endometrial ablation
Hysterectomy (if other methods unsuitable or ineffective)
A
A
A
A
A
A
A
*Based on Royal College of Obstetricians and Gynaecologists and National Institute for
Health and Clinical Excellence published guidelines
Authors’ case studies
Severe menorrhagia due to
multiple fibroids and other
complications
EMILY, 38, presented to her
GP complaining of very heavy
menstrual periods. She
reported that she had a regular 31-day cycle, that her periods lasted nine days and that
the bleeding was very heavy,
with moderately large clots for
four days. When the bleeding
was heavy she would soak
through her pads and she
needed to wear a towel at
night to avoid soaking the
bed. The heavy bleeding was
accompanied by mild cramping pain that was not particularly troublesome. There were
no premenstrual symptoms
and, in fact, the heavy bleeding often started suddenly and
unexpectedly. She had not
experienced any postcoital or
intermenstrual bleeding.
Her menarche occurred at
age 13 and she had light irregular periods until she had her
first child. She had two
uncomplicated pregnancies
ending in normal vaginal
deliveries at age 27 and 29
and she then had a laparoscopic tubal clip sterilisation.
She was told at the time of the
surgery that she had a few
small fibroids.
Since that time her menstrual loss had gradually
increased but her cycles were
regular. Her Pap smears had
been collected regularly and
were always negative but she
was now due for her next one.
Her medical history was oth-
erwise unremarkable, she was
not taking any medication
and there was no significant
family history.
On examination Emily
looked pale and tired. There
was a palpable abdominal
mass consistent with an
enlarged uterus with a size
equivalent to an 18-week
pregnancy. Vaginal examination confirmed an enlarged
uterus with a healthy cervix
and a Pap smear was collected.
The results of her investigations were as follows.
Haematology and biochemistry
FBC: Haemoglobin 102g/L
(normal range 115-160g/L);
MCV 75fl (80-96fl); MCH
25.7pg (27-33 pg); Platelets
9
335 × 10 /L (150-400 ×
9
10 /L). Ferritin 2μg/L
(normal range 20-120μg/L).
gynaecologist at the local
public hospital. Further investigation was undertaken with
results as follows.
Colposcopy and cervical
punch biopsy
There was a small area of
aceto-white change with no
abnormal blood vessels on the
upper lip of the cervix. One
punch biopsy was collected.
Histology
“The punch biopsy is from the
transformation zone and
shows changes consistent with
low-grade dysplasia (CIN1)
and HPV infection. The glandular epithelium is normal.
There is no evidence of malignancy.”
“Low-grade squamous epithelial lesion. The appearances
are consistent with CIN 1 and
HPV changes. Colposcopy is
recommended.”
The treating specialist recommended that Emily
undergo total abdominal hysterectomy with ovarian conservation because of multiple
fibroids, iron-deficiency
anaemia, severe menorrhagia
and low-grade cervical dysplasia with HPV infection. The
procedure was carried out
within three months and the
uterus and cervix were sent for
histological examination. Histology confirmed the presence
of multiple benign fibroids,
normal endometrium and
CIN1 with HPV changes on
the cervix. Emily was discharged home on day five post
operatively and was started on
oral iron and ascorbic acid.
Emily was referred to a
Emily made a full recovery
Pelvic ultrasound scan
“The uterus is grossly
enlarged by multiple fibroids.
The endometrial stripe is distorted by fibroids and measures 8mm in its maximum
diameter. Both ovaries are
visualised and appear normal.
There is no free fluid in the
Pouch of Douglas.”
Pap smear
and, at her six-week postoperative check, her abdominal
and vaginal vault wounds had
completely healed. She was
discharged back to her GP
with a recommendation that
she have annual vaginal vault
smears.
Menorrhagia worsening
after childbirth
Jane was referred to the gynaecology clinic for ongoing
management of prolonged,
heavy menstrual periods.
Although regular, the periods
lasted for up to two weeks
and were sometimes so
heavy that she was fearful of
leaving the house. Pain was
not a major feature of the
presentation. Her menorrhagia was also causing major
problems with her work.
Jane was 37 years old and
had two children, the
youngest being five years
old. Her menstrual problems had gradually worsened since the birth of her
youngest child. She was otherwise in good health — a
non-smoker with an unremarkable past history. She
had divorced three years
ago, and although she was
not in a relationship, preservation of fertility was a
major issue for her.
A trial of oral contraception (Microgynon 30 ED)
for several months had provided little relief, and her
family doctor then advised
her to run the active pills
together to space the peri-
www.australiandoctor.com.au
ods out. Unfortunately, this
provoked torrential breakthrough bleeding requiring
admission to hospital for
high-dose oral progestogens
and a blood transfusion. She
was then started on a reducing dose of progestogen
(Provera 10mg tds for a
week, reducing to bd for a
week, then daily). Unfortunately, when she stopped
this regime the bleeding
started again. A trial of
cyclic progestogen in the
luteal phase had no effect.
At the clinic, she was found
to be slim and healthy. No specific abnormality was found
on examination. Investigations
revealed iron deficiency with
a mild microcytic anaemia.
Her menstrual phase FSH was
6 U/L. Platelets were plentiful,
and coagulation studies
normal. A pelvic ultrasound
revealed a slightly enlarged
uterus but no other abnormality.
In view of her motivation to
maintain fertility if at all possible, the options of endometrial
ablation or hysterectomy were
considered treatments of last
resort. A hysteroscopy was
performed, which showed a
slightly enlarged cavity with
no specific abnormality. The
endometrial biopsy was diagnosed as normal endometrium
with a progestogenic effect. A
Mirena IUD was inserted.
Unfortunately, the IUD was
expelled within three weeks of
insertion. Another heavy
period ensued, requiring treat-
ment with high-dose progestogen again. To regulate the
cycle, Jane was started on a
high-dose combined pill
(Microgynon 50 ED) with
instructions to take tranexamic
acid 500mg qid with meals
together with the inactive pills.
At her most recent visit,
this regime had been effective for six months (she is
now 39). She is aware that
her treatment is incompatible with pregnancy, but at
least her fertility is still theoretically preserved. She will
be reviewed in a year, at age
40, and if there is still no
prospect of a partner and
pregnancy, she intends to
seek an endometrial ablation.
Acknowledgement
Ultrasound photographs
provided courtesy of Dr
Meiri Robertson of the fetal
medicine unit, Canberra
Hospital.
Reference
1. Blanchard K. Life without
menstruation. The
Obstetrician and
Gynaecologist 2003;
5:34-37.
Online resources
• Royal College of
Obstetricians and
Gynaecologists:
rcog.org.uk
• Royal Australian and
New Zealand College of
Obstetricians and
Gynaecologists:
ranzcog.edu.au
cont’d next page
6 March 2009 | Australian Doctor |
37
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HOW TO TREAT Menorrhagia
GP’s contribution
Case study
DR CAROLYN BLOCK
Double Bay, NSW
REBECCA had always experienced heavy periods but
after the birth of her third
child when she was 28, this
worsened significantly. The
flow was so heavy that her
husband would need to stay
home and help look after
their three children on the
first day of her cycle.
When she came to see me
she looked exhausted, and
blood tests confirmed severe
iron deficiency anaemia but
no other abnormalities. A
pelvic ultrasound scan was
also normal and she had no
fibroids.
Although she did want to
continue breastfeeding, we
agreed that something
needed to be done, as the
effect on her health was
impacting on her ability to
look after the children. She
joked that she had been very
puffed when she tried to
mow the lawn! We discussed
all her options and she chose
to try the contraceptive pill.
Initially this was of some
benefit, but soon the flooding was as bad as ever and
despite changes to her pill,
the menorrhagia continued.
I had suggested Mirena when
we had first discussed treatment options, but because of
her religious beliefs she was
concerned about the possibility of an irregular bleeding pattern, which would
impact on her spiritual
cleansing and sexual relationship with her husband.
How to Treat Quiz
Eventually, despite all her
efforts she remained anaemic
and exhausted and so
decided to have a Mirena
inserted. To help try to
combat the possibility of an
irregular bleeding pattern,
she was started on a lowdose OCP concurrently and
thus far is extremely happy.
She only wishes she had
done it sooner.
Questions for the author
Supplementing with vitamin
A is an example of a sug-
gestion made to one of my
patients to help control her
bleeding. Is there any evidence that ‘natural’ or
herbal therapies have a role
to play in menorrhagia?
The only ‘natural’ remedy
shown scientifically to be of
any benefit is oral iron.
Other remedies that have
been tried are based solely
on traditional use — in
other words, there are no
scientific studies confirming
efficacy. Such remedies
include vitamins A, C and
E, black horehound, cinnamon, cranesbill, oak, periwinkle, vitex agnus-castus
and witch hazel. Chinese
herbs have also been used
without any scientific evidence of their efficacy.
What would you suggest
for an adolescent, who is
still growing, to treat menorrhagia?
Oral contraceptive pills
have been used in growing
adolescents without any
real evidence of harm. The
obvious concern is premature closure of the epiphyseal growth plates due to
the effect of exogenous
oestrogen, which could theoretically stunt growth.
Other treatment options
could include tranexamic
acid, progestogens and
NSAIDs.
Apart from the possibility of
some irregular bleeding, are
there any long-term implications for continuous use
of the OCP to suppress
menstruation?
There is no evidence that
the continuous use of the
OCP to suppress menstruation is harmful. Indeed, this
is the preferred treatment
option for endometriosis as
recommended by the Royal
College of Obstetricians and
Gynaecologists. The patient
does not need any withdrawal bleeds at all.
INSTRUCTIONS
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Menorrhagia — 6 March 2009
1. Which THREE statements about the
definition and incidence of menorrhagia are
correct?
a) A useful definition of menorrhagia is
excessive menstrual blood loss that has a
significant impact on lifestyle or that results
in iron deficiency
b) Only slightly more than 50% of menstrual
fluid is actually blood
c) More than one-third of women with
menstrual loss of more than 80mL describe
their periods as normal
d) It is estimated that up to 5% of the
reproductive-age female population may
have menorrhagia
2. Which TWO statements about the
physiology of menstruation are correct?
a) After ovulation, remnants of the dominant
follicle compact to form the corpus luteum,
which begins producing progesterone as
well as oestrogen
b) Menstruation occurs as a result of failure of
the corpus luteum and the abrupt
withdrawal of oestradiol and progesterone
c) The sudden reduction in progesterone levels
leads to spasm in the spiral arterioles of the
endometrium
d) The sudden reduction in hormone levels
leads to relative ischaemia in the basalis
layer of the endometrium
3. Which THREE statements about causes
of menorrhagia are correct?
a) Adenomyosis uteri may present with painful
periods but it can also cause menorrhagia
b) Endometriosis often presents with heavy
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menstrual loss as an isolated symptom
c) Benign endometrial polyps may occasionally
be associated with menorrhagia
d) In rare cases chronic pelvic inflammatory
disease may be associated with heavy
menstrual blood loss
4. Kay, 39, presents with regular, heavy
menstrual loss. Which TWO statements
about taking a history from women with
menorrhagia are correct?
a) Menstrual history should include enquiry
about mid-cycle and postcoital bleeding
b) A history of past hormonal contraceptive
use is not relevant
c) Family history is not important when
assessing women with menorrhagia
d) Enquiry about medications should include
herbal remedies
5. Kay’s periods have been heavy since the
birth of her youngest child five years ago.
She is tired but otherwise well, and takes
no medication. There is no irregular
bleeding, nor any features suggestive of a
bleeding disorder. Currently she and her
husband use condoms. Her last Pap smear
two years ago was normal (as always).
Which TWO statements about investigating
patients with menorrhagia are correct?
a) A Pap smear should be taken if it is nearly
due, or if there is any suggestion of
postcoital or intermenstrual bleeding
b) A serum beta-hCG should always be done
in cases of abnormal bleeding
c) Hormone assays including oestrogen and
LH levels should be routinely performed in
all women with menorrhagia
d) Pelvic ultrasound is best performed via a
transabdominal approach alone in all
patients with menorrhagia
6. Which THREE statements about the
treatment of menorrhagia are correct?
a) The principles of management are to treat
any underlying pathology, correct anaemia
and improve quality of life
b) Only about 25% of women will have a
satisfactory response to pharmacological
therapy
c) If pregnancy is wanted in the immediate
future, NSAIDs and tranexamic acid are the
only practical alternatives
d) Surgery may be needed in cases of failed
medical management or when there are
coexisting problems such as large fibroids
or high-grade CIN
7. Which TWO statements about tranexamic
acid are correct?
a) Tranexamic acid has a slow onset of action
b) Tranexamic acid may reduce blood loss by
up to 50%
c) As well as reducing blood loss, tranexamic
acid also relieves period pain
d) Tranexamic acid is contraindicated in
patients with a history of thrombosis or
thrombophilia
8. Which TWO statements about fibroids
are correct?
a) Up to 10% of women will have at least one
uterine fibroid during their lifetime
b) Even small fibroids located on the serosal
surface of the uterus are likely to cause
menorrhagia
c) Fibroids can be reduced in size with uterine
artery embolisation or by using GnRH
agonists
d) Small submucosal fibroids can be resected
via a hysteroscope
9. Which TWO statements about
endometrial ablation for treatment of
menorrhagia are correct?
a) It is essential that endometrial hyperplasia
and cancer are excluded before endometrial
ablation
b) Endometrial ablation can be performed in
patients who have had a classic caesarean
section
c) Endometrial ablation is contraindicated in
women who wish to become pregnant in the
future
d) Most methods of endometrial ablation are
licensed for repeat ablations
10. Which TWO statements about
hysterectomy for the treatment of
menorrhagia are correct?
a) The type of hysterectomy is determined
both by the indication and by the operator’s
experience
b) Advantages of abdominal hysterectomy
include less postoperative pain and faster
recovery
c) There is no relationship between
hysterectomy and earlier ovarian failure
d) In addition to operative complications,
possible adverse effects of hysterectomy may
include significant psychological effects
CPD QUIZ UPDATE
The RACGP now requires that a brief GP evaluation form be completed with every quiz to obtain category 2 CPD or PDP points for the 2008-10 triennium. You
can complete this online along with the quiz at www.australiandoctor.com.au. Because this is a requirement, we are no longer able to accept the quiz by post
or fax. However, we have included the quiz questions here for those who like to prepare the answers before completing the quiz online.
HOW TO TREAT Editor: Dr Wendy Morgan
Co-ordinator: Julian McAllan
Quiz: Dr Wendy Morgan
NEXT WEEK Palpitations are a common symptom in primary practice and 20-39% of patients presenting with palpitations will be found to be have rhythms requiring further investigation and/or
management. The next How to Treat looks at assessing palpitations and use of cardiac monitoring strategies. The authors are Dr Susan Corcoran, cardiologist, Bayside Health, Prahran; and
Dr David Lightfoot, emergency physician, Monash Medical Centre, Clayton, Victoria.
38
| Australian Doctor | 6 March 2009
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