Menorrhagia

DR Tey Wei Jin

• Definition:
• Bleeding that falls outside population based 5th-95th percentiles for menstrual
regularity, frequency, duration and volume
Heavy Menstrual Bleed
Lasts longer than 7 days
Menstrual blood loss of 80 mL or greater
P- Polyps
• Lifetime prevalence of endometrial polyps is 8-35%
• 95% are benign
• Incidence increase with age
• Mostly asymptomatic
• Commonest presenting symptoms- intermenstrual
bleed
• PE usually unremarkable except prolapse polyps
through cervix
• Can be visualized by transvaginal ultrasound
• May mistaken for submucosal fibroid
A- Adenomyosis
• Presence of endometrial tissue in
myometrium
• Prevalence 5-70%
• Typical symptoms:
• Dysmenorrhea
• Irregular menses
• Heavy menses
• Examination:
• Bulky tender uterus
L- Leiomyoma/uterine fibroid
• Benign tumour of smooth
muscle of myometrium
• Found in ~ 80% in woman
• Classified according to location
• Common presentation
• Heavy prolonged menses
• Pelvic pain
• Pressure symptoms
• anaemia symptoms
M- Malignancy

• Endometrial cancer is the most

common gynaecological
malignancy
• Consider as a diagnosis until
proven otherwise in
postmenopausal bleeding
• Peak incidence at 50-70 years
old
M- Malignancy
• Cervical cancer should be the diagnosis until proven otherwise for
postcoital bleeding
• Associated symptoms and signs
• Intermenstrual bleed
• Vaginal discharge- may be offensive
• Ulceration or mass in cervix
• Bleeds on contact
• Mainly diagnose in routine pap smear screening as most patient are
asymptomatic
C- Coagulopathy
• Approximately ~ 17-20% patient with HMB have bleeding disorder
• Commonest cause
• Von Willebrand disease
• Platelet dysfunction
E- Endometrium
• “dysfunctional uterine bleed”
• Diagnosis of exclusion
• Defined as ‘excessive bleeding’ whether heavy, prolonged or frequent,
of uterine origin which is not associated with recognisable pelvic
disease, complications of pregnancy or systemic disease
• Pelvic pain and tenderness are not usually the prominent features
I- Iatrogenic
• Hormonal contraception is the most common cause
(breakthrough bleeding)
• Copper IUCD may cause low grade endometritis which
contribute to abnormal uterine bleeding
• Antipsychotic treatment such as Risperidone can cause
hyperprolactinaemia that can cause amenorrhea
• others
• Anticoagulant medication
• tamoxifen
N- Not otherwise classified
• This category contain poorly understood conditions, rare
disorder and condition that do not otherwise fit into
classification system
• Examples
• Arteriovenous malformations
• Endometrial pseudoaneurysm
• Myometrial hypertrophy
• Chronic endometritis (not precipitated by IUCD)
• Caesarean scar defects
History taking • menarche
• LMP
• Menstrual history • bleeding
• Anaemia symptoms • Frequency
• Regularity
• Associated symptoms • Duration
• Screening for • Volume
• Coagulopathy • Blood clots
• Ovarian dysfunction • Intermenstrual bleeding
• Postcoital bleeding
• Drug hx
• Impact on quality of life
• Malignancy risk
• Menstrual history
• Anaemia symptoms • fatigue
• Dizziness
• Associated symptoms
• Palpitations
• Screening for • Reduce effort tolerance
• Coagulopathy • Blackout
• Ovarian dysfunction • Chest pain
• Drug hx
• Malignancy risk
• Menstrual history
• Anaemia symptoms • Pressure symptoms
• Urinary incontinence
• Associated symptoms • Urinary frequency
• Pelvic pain
• Screening for • Abdominal mass
• Coagulopathy • Dysmenorrhea
• Ovarian dysfunction • Abnormal per vaginal discharge
• Constitutional symptoms
• Drug hx
• Malignancy risk
Physical examination
1. Basic examination
2. Sign of systemic disease
3. Abdomen
4. Per-speculum and bimanual pelvic examination
Blood investigations
• Basic compulsory investigation for all woman with abnormal menses:
• FBC (anaemia/ thrombocytopenia)
• UPT (TRO pregnancy)
• Thyroid function test indicated for
• Symptoms & sign of thyroid disorder
• Initial workup doesn’t reveal a likely cause
• Coagulation profile should be taken if bleeding disorder suspected
Other investigations
• PAP smear
• Pipelle samplings
• TAS/TVS
Hysteroscopy
• Offer outpatient hysteroscopy if history suggest
submucosal fibroid, polyps or endometrial pathology

• Criteria for endometrial tissue sampling (diagnostic

hysteroscopy)
• Age > 45 years old with abnormal uterine bleeding
• Age < 45 years old with history of unopposed estrogen
exposure
• Age < 45 years old with risk of malignancy
• Failed medical therapy
• Persistent abnormal uterine bleeding
Medical treatment
• Preferred initial 1st line approach management
• 2 options
• Lenovogestrel-releasing intrauterine system (Mirena) is the most
effective to decrease HMB (71-95%)
• COCP are effective to decrease HMB (35-69% reduction) and can be
used to regulate bleeding in ovulation dysfunction patient
• POP is effective (87% reduction) but long term patient satisfaction is
low
• Oral tranexamic acid reduce HMB by 26-54% and safe for patient who
attempt to conceive
• NSAIDs reduce HMB by 10-52%
Surgical treatment
• The need of surgical treatment is based on
• Clinical stability of patient
• Severity of bleeding
• Response to medical treatment
• Underlying medical disorder
• Options
• Dilatation and curettage
• Endometrial ablation
• Uterine artery embolization
• Hysterectomy
• Myomectomy
• Polypectomy
Case vignette
 41/ female
Single, nulliparous
U/L hypertension & well controlled
bronchial asthma
Presented with:

Prolonged heavy menstrual bleeding – 1 year

 5 to 6 days menses -> 7 to 10 days
 Used 3 to 4 overnight pads with blood clots during
1st 3 days of menses
 Ass. with cramping lower abdominal pain
Otherwise,
No anaemic symptoms
No postcoital/ intermenstrual bleed
No constitutional symptoms
No abdominal bloatedness
No change in bowel habits
No fever
No increase bleeding tendency
 Menstrual history
• Menarche at the age of 13 years old
• Duration of cycle: 5 to 6 days
• Interval between period: 28 to 30 days
• Amount of flow: Heaviest on the first 2-3 days
Denies any dysmenorrhea
 PMH/PSH
1. Hypertension
o -On Tab Atacand plus 1/1 OD (candesartan cilexetil 16 mg and
hydrochlorothiazide 12.5 mg 1/1 OD)
o -Diagnosed 3 years ago, under GP follow up
2. Childhood Bronchial Asthma
o -Currently not on any inhaler
o -Last asthma exacerbation >10 years ago. No ICU
admission or intubation.

 No past surgical history

 Family History
 Both parents have diabetes mellitus,
hypertension and dyslipidaemia on treatment
 No family history of malignancy
 Have 5 siblings, patient is the youngest. No
sisters suffer from menorrhagia
 Social History
 Patient works as a clinic assistant at Klinik Idzham
 She lives in a rented apartment house at Pandan Indah.
Financially stable
 Patient does not smoke cigarettes / drink alcohol. She also
denies any high-risk behaviour and denies any previous
sexual intercourse (virgo intacta)
First seen in Gynae clinic in June 2020
- Assessment done noted a huge pedunculated
uterine fibroid size 8 x 8 cm with no compressive.

She was discharged home with:

-Tab Tranexamic acid 500mg TDS
-Tab Mefenamic Acid 500mg TDS
Subsequently under Gynae follow up 6/12
Investigation done in O&G clinic

FBC (18/11/2021)
TWC 9 / Hb 12.6 / Plt 459 / RBC 5.48/ Hct 39.2%/
MCV 71.5 / MCH 23 / MCHC 32.1
USG abdomen (15/10/2021):

-Uterus anteverted with normal uterus size of 7 cm x 4

cm. ET was 5 mm.
-Present of Pedunculated Uterine fibroid measuring
10.8 cm x 8 cm, bilateral ovaries visualised were
normal, no hydronephrosis and no free fluid seen
Hysteroscopy and DD&C
Impression: Heavy Menstrual bleed secondary to
Uterine fibroid

Findings: Uterine cavity slightly deviated to the left.

Right lateral wall slightly indented (Possibly due to
fibroid)
Endometrial line normal, no abnormal growth seen.
Both ostia of fallopian tubes seen
Good amount of tissues obtained.
Endometrial curettage
No hyperplasia or malignancy seen
Interpretation: Disordered proliferative
endometrium

Cervical pap smear

Negative for intraepithelial lesion or malignancy
(NILM)
Patient was electively admitted to ward for laparotomy
myomectomy

In ward,
O/E: Alert, conscious, pink and good hydration

BP 133/86 mmHg
PR 90 bpm
RR 20 bpm
SpO2 99% under RA
Temp 37 degree Celsius
Lungs: Clear, equal air entry, vesicular breath sound
bilaterally

CVS: Dual rhythm, no murmur heard.

P/A: Soft, non-tender, palpable abdominal mass

approximately 20 weeks size at umbilical region, firm in
consistency, mobile, non tender, unable to get below
the mass
Pelvic examination

VE: Os parous, cervix was thick and tubular

Fullness over right adnexal mass
Mass moving together with uterus
 Intraoperative
• Operation: Laparotomy Myomectomy
• Preoperative diagnosis: Pedunculated Uterine Fibroid
• Postoperative diagnosis: Pedunculated Uterine Fibroid
• Operative Findings:
• Pedunculated fibroid size 10 cm x 9 cm, multilobulated arising from superior part of left
cornu with thick stalk, consist of big vessels.
• Uterus was in normal size
• Bilateral ovaries and fallopian tubes were normal
• Bowel and Omentum were also normal, no ascites seen.
• EBL: Minimal
• Myometrium Myomectomy HPE: Leiomyoma with degenerative
change
References

• http://www.nice.org.uk/guidance/ng88

• John M, Jill R, Justin C, Clare M:Murtagh’s general practice 7th edition

• JANET R. ALBERS, M.D., SHARON K. HULL, M.D., and ROBERT M.

WESLEY, M.A.Abnormal uterine bleeding. Am Fam Physician. 2004 Apr
15;69(8):1915-1926.