heavy menstrual bleeding for undergraduates max brinsmead mb bs phd may 2015
TRANSCRIPT
Heavy Menstrual Bleeding for Undergraduates
Max Brinsmead MB BS PhD
May 2015
A Few Definitions
Menorrhagia– Excessive menstrual loss at regular intervals
Metrorrhagia– Excessive menstrual loss without evidence of any cycling– Typical of anovulatory bleeding at the extremes of reproductive life
Intermenstrual bleeding (IMB)– Episodes of bleeding between menstrual periods– Postcoital bleeding is a type of IMB
The generic modern terms are Heavy Menstrual Bleeding (HMB) & Abnormal Uterine Bleeding (AUB)
Heavy menstrual bleeding is defined as:
Excessive menstrual blood loss which interferes with a woman’s… – physical– emotional– social or– material quality of life
This implies that the woman herself is the primary judge of severityAnd there can be substantial variation in tolerance to this dis - ease
While a pathological description is impractical:
That is, the menstrual loss of an amount of blood loss that is likely to lead to health sequelaeBecause treatment options have risk & cost implications, a health provider is obliged to indicate to patients some criteria for diagnosisMy criteria:– Sufficient to cause iron deficiency (exclude other causes)– Escapes from accepted menstrual protection– Requires changes > 4 hourly– Up at night more than once– Passage of large clots– Lasts for >7 days (full flow)
Incidence of Heavy Menstrual Bleeding
The Impact on WomenCross sectional studies indicate that 5 – 50% of women will complain of “heavy periods”
Quantified studies show that ≈ 10% of women will have menstrual losses that ≥ 80 ml
Many studies indicate that the condition is associated with…– Reduced employment options– Work absences– Decreased earning capacity that for women are more important than
such psychological effects as…– Depression and anxiety– Mood changes, irritability– As well as effects on social life, hobbies etc
Can be summarised in “Quality of Life” measures
Fibroids
Adenomyosis
Endometriosis & Chronic PID
Endometrial cancer
Bleeding disorders– Idiopathic and acquired thrombocytopenia– Other known & undiagnosable disorders of coagulation
Physiological– Includes dysfunctional uterine bleeding– All studies show >50% have no identified pathology
Some Causes of Heavy Menstrual Bleeding
How many days does your period last forHow many heavy days? What do you mean by heavyWhat do you use for menstrual protectionHow often do you change? Why do you change so oftenWhat do you use at nightDo you change at night? How many nightsDo you pass clots? How big are the clots? How oftenAny accidents (escape from menstrual protection)What do you mean by floodingDo you have to modify your life when you have your periodsWhat do you do for contraception in your relationshipDo you experience any other bleeding or bruisingAre you taking iron tablets
Some History-taking Tips
Consider the cultural contextExplore parity, fertility requirements etcConsider occupation and activitiesThe extent of examination and investigations will depend on
– Age >45– Intermenstrual bleeding– Any pelvic pain or pressure symptoms
Details of any previous gynaecological interventions Other illnesses or conditions may influence treatment optionsOther symptoms may influence treatment choices
– Infertility– Prolapse– Urinary incontinence
Family History
Other History-taking Essentials
A general examination of all patients– Height & weight– Signs of anaemia– Signs of endocrinopathy
• Thyroid• Androgen excess
Abdominal examination– For significant uterine enlargement
• Only rewarding in slim patients• A palpable uterus is >12w size
A vaginal examination is not required in primary care if there is no palpable uterus & a Pap smear is not required
• Unless a Mirena is planned
And patients should not be sent for US without prior VE
Examination
A Full Blood Count (FBC) for all patients– Look for iron-deficiency anaemia– Check the platelet count
S Ferritin– Is the most sensitive indicator of Iron deficiency– But it is an acute phase reactant
Thyroid function tests– Only when clinically indicated
Female hormones– Have no role– Even when the diagnosis is dysfunctional uterine bleeding
Laboratory Tests in Primary Care
Symptoms from menarche
Positive Family History
Other personal bleeding or bruising
There is thrombocytopenia
Tests to do:– Renal and Liver Function Tests– Bleeding time and Coagulation time– Seek specialist haematological advice
The most commonly identified abnormality is von Willebrands Disease
Indications for Tests of Coagulation Disorders
Ultrasound is the imaging of choice– But is not required unless the uterus is enlarged– Required for uncertainty after pelvic examination– Required after a failure of primary medical treatment
Required information from this examination include:– Uterine size including length of the endometrial cavity– Myometrial abnormalities– Any adnexal pathology
Considerable caution is required when...– Comments about endometrial thickness are reported as abnormal– Fibroids <4 cm in size are reported– Multiple fibroids are reported but there is no clinical evidence of an
enlarged or irregular uterus– Adnexal cysts <5 cm diameter are reported
Imaging in Primary Care
What is the risk of significant pathology?
This is mostly about the risk of endometrial cancer
There are many studies…– Most do not distinguish between HMB and AUB
The risk of endometrial Ca is age dependent– For women <30 yrs age the risk is 1:10,000– For those >45 years the risk is 8:10,000– And the risk of endometrial hyperplasia is ≈ 4X higher
Who is at risk of Endometrial Cancer?– Those with intermenstrual bleeding– Those with irregular cycles – PCO disorder– Infertility– Obesity– Positive Family History
Patient is >45 years of age
There is irregular or intermenstrual bleeding
The uterus is >10 weeks size
There are symptoms or signs suggestive of such pelvic conditions as endometriosis, PID , adnexal pathology etc.
Ultrasound suggests uterine fibroids >4 cm or distortion of the uterine cavity
Failure of primary pharmaceutical treatment
Patient request
Indications for Referral
Hormonal• Levonorgestrel IUS (“Mirena”)• Combined COC• Cyclical oral Progestins• Injected Progestin (“Depo Provra”)• Danazol• GnRH analogues
Non Hormonal• NSAIDs• Tranexamic Acid (“Cyclokapron”)
Medical Options for the Treatment of Heavy Menstrual Bleeding
Endometrial Ablation• Hysteroscopic endometrial resection• 2nd generation techniques
– Thermal balloon endometrial ablation (TBEA)– Microwave endometrial ablation (MEA)
Myomectomy
Uterine Artery Embolisation
Hysterectomy• Abdominal, vaginal or laparoscopic• Subtotal or total• With or without bilateral oophorectomy
Surgical Treatment Options for Heavy Menstrual Bleeding
The Mirena IUS for HMB
Reduces mean menstrual loss by 71 – 96%
Up to 50% of patients amenorrhoeic after 6m depending on age
≈ 85% patients are satisfied (continuation rate)
≈ 1% rate of troublesome hormonal side effects
When compared to endometrial ablation (EA)– Mean reduction in blood loss is greater with EA– But overall satisfaction equal– And Mirena better in the longer term (1 small study)
When compared to hysterectomy– Overall satisfaction rates are equal– But Mirena is half the cost even when up to 40% of patients go on to
hysterectomy
Oral Hormones for HMBWhat is the Evidence?
Mean blood loss (MBL) is reduced by ≈40%
Risks in older women and smokers plus side effects limit use of COC (oestrogen)
Progestin e.g. Norethisterone 5 mg TDS from Day 5 to 27 of a cycle is effective in reducing (MBL)
Progestin not as effective as NSAIDs and Tranexamic acid
Side effects are limiting – weight gain, headaches, acne, mood changes, mastalgia
They are of most use in the short term treatment of DUB at the extremes of reproductive life
IM Depo Provera for HMB
≈10% of patients are amenorrhoic after 3m of 150 mg every 12w
≈50% amenorrhoic after 12m
Continuation rates are low, however, presumably due to side effects
And there is a small risk of bone mineral loss with long term use
GnRH analogues for HMB
Most studies have been directed at the reduction of uterine size with these agents that induce a “reversible menopause”
Reductions in uterine size up to 75% over 6m can occur
And up to 90% of patients achieve amenorrhea
This can be very useful prior to hysterectomy
Oestrogen-deficiency symptoms i.e. hot flushes, vaginal atrophy and bone loss are limiting
But these can be overcome with add-back therepy using small doses of oral oestrogen, COC, progestin or tibiloneGnRH are currently very expensive drugs
Tranexamic Acid (Cyklokapron) for HMB
Inhibits plasminogen activation but has no effect on blood clotting in healthy vessels
Reduces fibrin breakdown in spiral arterioles
Systematic reviews confirm that mean blood loss during menstruation is reduced by ≈ 50%
12% of women experience side effects• Nausea, vomiting, dyspepsia• Diarrhoea• No apparent risk of thromboembolism• Visual side effects are rare
Dose 1G every 6 – 8 hours
It is not contraceptive nor cycle regulating
NSAIDs for HMB
Systematic reviews confirm that mean menstrual blood loss during menstruation is reduced by ≈ 30%
Mefanamic acid e.g. Naprosyn better than Ibufren e.g. Indocid
Side effects are well known but risk is reduced by intermittent use
Dose 1 – 2 tablets 4 – 6 hourly
Particularly useful when dysmenorrhoea is also a problemNot recommended if there is a known bleeding disorder loss
Information for Patients that compares Endometrial Ablation & Hysterectomy
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