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MENORRHAGIA
Dr A.ABUDABER, CONSULTANT
OBSTETRICIAN&GYNAECOLOGIST,KHADRA
HOSPITAL
ASS PROFESSOR ,ALFATEH UNIVERSITY
Dept.of OB/GYN
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 a
normal 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
How do we define menorrhagia
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Menorrhagia can be defined objectively or subjectively
Objectively, menorrhagia is taken
to be a total menstrual blood loss –
80 ml per menstruation
Subjectively, menorrhagia is
defined as a complaint of
excessive menstrual blood loss
occurring over
several consecutive cycles in a
woman of reproductive years
Complexity of menorrhagia?
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Menorrhagia— is the medical term for
excessive or prolonged menstrual
bleeding or both
The condition also is known as
hypermenorrhea
The menstrual cycle isn't the same for
every woman
Normal menstrual flow occurs about every
28 days, lasts about 5 days and produces
a total blood loss of 30 to 40 milliliters
Some women have frequent menstrual
spotting, while others find that heavy
bleeding is normal
Between 15 and 20 percent of healthy
women experience debilitating
menorrhagia that interferes with their
normal activities
Bleeding heavily and/or if periods last
more than seven days is considered
excessively heavy menstruation
DUB
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Doctors generally define menorrhagia as
menstrual bleeding that lasts more than eight
to ten days or a blood loss of over 80
milliliters (about 1/3 cup). This would be
considered dysfunctional uterine bleeding
(DUB), and could lead to an iron deficiency or
anemia if not attended to promptly
DUB Variations
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Other types of dysfunctional uterine bleeding
include metorrhagia (bleeding in between
periods or menstrual spotting) and
polymenorrhea (having a period more often
than every 21 days)
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Although 30 percent of premenopausal
women complain of heavy menstrual
bleeding, only 10 percent experience blood
loss severe enough to be defined as
menorrhagia.
Assessment of blood loss
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How does one measure the amount of
bleeding?
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A little blood can seem like much
more than it actually is. One way to
gauge the bleeding is to see if she is
soaking through enough sanitary
protection products to require changing
more than every one to two hours
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Blood clots are normal during
menstruation. One must remember that
in addition to blood loss, the
endometrium is also being shed
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26% of women with normal
menstrual loss ( < 60 mL) considered
their periods heavy, while 40% of those
with heavy losses ( > 80 mL) considered
their periods to be moderate or light
Subjective Assessment
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Menstrual flow that soaks through one or
more sanitary pads or tampons every hour
for several consecutive hours
The need to use double sanitary protection
to control your menstrual flow
The need to change sanitary protection
during the night
Menstrual period that lasts longer than 7
days
Menstrual flow that includes large blood
clots
Heavy menstrual flow that interferes with
your regular lifestyle
Constant pain in the lower abdomen during
menstrual period
Irregular menstrual periods
Tiredness, fatigue or shortness of breath
(symptoms of anemia)
Pathogenesis
• The volume of blood lost at menstruation is
controlled 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 and
average blood loss
• Increased endometrial fibrinolysis may be of
importance
Causes of Menorrhagia
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Hormonal imbalance
Uterine fibroids
Polyps
Ovarian cysts
Dysfunction of the
ovaries
• Adenomyosis
• Pelvic Inflammatory
Disease.
• Intrauterine device
IUD
• medical conditions
• Cancer
• Medications
Protocol for Clinical Evaluation
Investigations
• Blood tests
• Pap test
• Endometrial sampling
and hysteroscopy
• Vaginal ultrasound
• Sonohysterogram
• Endometrial biopsy
• Dilatation and
curettage (D&C)
Complications
Excessive or prolonged menstrual bleeding can
lead to other medical conditions, including:
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Severe pain
Infertility
Toxic shock syndrome
Anemia
Treatment
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Specific treatment for menorrhagia is based on a
number 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
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.
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Second line drugs such as danazol, gestrinone, and gonadotrophin
releasing hormone analogues are effective in reducing heavy
menstrual blood loss but side effects limit their long-term use.
Others include:
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Iron supplements
Prostaglandin inhibitors
Oral contraceptives
Progesterone
Protocol for Management
Surgical Options
• Dilation and
curettage (D and C)
• Operative
hysteroscopy
• Endometrial ablation
• Endometrial
resection
• Hysterectomy
Abdominal Hysterectomy Vs Endometrial Resection
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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 with
transcervical 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 three
months versus two to three weeks for resection.
The probability of requiring a hysterectomy four years after endometrial resection has
been 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 to
29% because of the need for repeat surgery.
Hysterectomy
Compared with abdominal hysterectomy, vaginal hysterectomy is associated with
less 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 recovery
periods (one to four weeks) are shorter
Conclusion
The diversity of possible surgical
treatments indicates the need for
flexibility in choosing techniques
to resolve an individual patient's
problem, and the possible
advantage for gynaecologists to
learn the new minimal invasive
techniques for removal of the
endometrium or the uterus