Menorrhagia (heavy menstrual

bleeding)
 DEFINITION
TERMS DEFINITION
Menorrhagia a complaint of heavy cyclical menstrual blood loss over several
consecutive menstrual cycles in a woman of reproductive years, or
more objectively, a total menstrual blood loss of more than 80 ml
per menstruation. (MOH,2004)

Clinically, menorrhagia is defined as total blood loss exceeding 80 ml

per cycle or menses lasting longer than 7 days

Menorrhagia is excessive menstrual blood loss over several

consecutive cycles which interferes with the woman's physical,
emotional, social, and material quality of life. (Nice 2007)
 OTHER IMPORTANT DEFINITION…
TERMS DEFINITION

metrorrhagia Menstrual flow at irregular intervals

Menometrorrhagia irregular and excessive flow

Polymenorrhoea bleeding at intervals of less than 21 days

Postcoital bleeding is non-menstrual bleeding that occurs

immediately after sexual intercourse
 Classification

Primary Secondary

Idiopathic / DUB -Uterine and ovarian

pathologies

-Systemic diseases

ovulatory Non-ovulatory -Iatrogenic causes

PRIMARY
 Anovulatory Unopposed
90% estrogen Mx:
DUB 1. Medical
Associated with
Ovulatory increased
10% prostaglandin 2. Surgical
release -hysterectomy
•heavy or irregular menstrual
bleeding that is not caused by (hemostatic -endometrial
an underlying anatomical deficiency) ablation
abnormality, such as a fibroid,
or tumor (abnormal uterine
bleeding without any obvious
structural or systemic •Ovulatory cycles luteinizing-hormone predictor kit
pathology Regular cycle length
•Anovulatory cycles
•Usually is a diagnosis of Presence of premenstrual Unpredictable cycle length
exclusion symptoms Unpredictable bleeding pattern
•Hormonal imbalance,
-Dysmenorrhea Frequent spotting
hypothalamus-pituitary-ovary -Breast tenderness Infrequent heavy bleeding
axis -Change in cervical mucus Monophasic temperature curve
-Mittleschmertz
• normally in women just
started Biphasic temperature curve
menstruation/perimenopaus
al
Positive result from use of
SECONDARY CAUSES
Uterine and ovarian
endometriosis
pathologies

PCOS
CONDITION HISTORY PHYSICAL inv
EXAMINATION
(General,
abdominal, pelvic)

Uterine fibroids •Age: reproductive age •enlarged uterus •Inv: TAS/TVUS

(>8 weeks) Transvaginal sono
•Bleeding pattern: •tenderness/palpabl hysterography/dx
menorrhagia, metrorrhagia e on vaginal exam hysteroscopy/dx
laparoscopy, +/-
•Ass. Symp. dysmenorrhoea, endometrial biopsy,
dyspareunia, MRI
urinary/defecation problem
Endometriosis Age: reproductive age wide spectrum, Inv: laparoscopic,
depends TVUS,
Bleeding pattern: menstruating/not
menorrhagia, usually abdominal tenderness,
lasts more than 7 days mass
short interval
Speculum:
Ass.symp: red, hypertrophic
dysmenorrhoea/ lesions , bleeding on
chronic pelvic pain, contact seen at
dyspareunia, difficulty post.fornix
conceiving
adenomyosis •Age: 40 and 50 years •The uterus is Inv :
old,parous/prior uterine surgery enlarged and boggy TAS/TVS(diffuse
thickening within
•bleeding pattern: menorrhagia •Tenderness wall), MRI,
,postccoital, Intermenstrual hysteroscopic/lapar
•mass oscopic biopsy
•ass, Symp.: dysmenorrhea, (adenomyoma)
dyspareunia

Pelvic •Age: any age • febrile, rigor Inv: FBC,ESR gram

inflammatory stain, cultures from
disease •BleedIng pattern: excessive, • abd tenderness cervix, endometrial
(endometritis) Intermenstrual and postcoital biopsy
bleeding Ct scan if do not
respond to AB
•Ass. Symp: foul smelling vaginal therapy for 48-72
discharge, pelvic pain and fever, hours

Endometrial •Age: rare <20, peaks at 5th decade, • endometrial • Inv: TVUS
polyps decrease post menopausal polyps that /Transvaginal sono
protrude through hysterography/
•Bleeding patern: excessive, the cervix on VE hysteroscopy
metrorrhagia,post coital,post- •Biopsy+/- D&C
menopausal • enlarged uterus
Endometrial •Age: >40/post •uterus will be enlarged or softened and ONLY IF GOT RISK
carcinoma menopausal masses may be detected FACTORS!!!
•Pelvic examination: cervix may be •TVS/TAS
•If ET >12
10% of women with involved with cancer (Stage II), and the Endometrial biopsy/
postmenopausal vagina (Stage III) D&C
bleeding will be • rectal examination
diagnosed with •Enlarged lymph nodes in the neck and RF:
•Age >40
endometrial cancer and groin.
•Obese
an equal number with •Enlarged liver, abdominal mass or •Nulliparous
hyperplasia excessive abdominal fluid (ascites). •Hormone
•Vaginal discharge (thin/clear) therapy (HRT)
•Bleeding pattern: •Diabetes
excessive, postcoital, •stigmata of chronic •Family history
Intermenstrual bleed anovulation(hirsutism,acne,
acanthosis,obesity,wt>90kg)
•Ass. Symp :pelvic pain
Endometrial Age: stigmata of chronic anovulation ONLY IF GOT RISK
hyperplasia post/perimenopausal> (hirsutism,acne,acanthosis,obesity,wt>90 FACTORS!!!
Rf:unopposed estrogen kg) •TVS/TAS
•If ET >12
Endometrial biopsy/
Bleeding pattern: D&C
menometrorrhagia,
Ass.symptoms:
-symptomatic anemia
-Infertilitymood swings,
Hot flushes,dyspareunia
 • Systemic diseases and disorders:
CONDITION ASSESTMENT TESTS
Hx: Menorrhagia since menarche •Routine screening for coagulation
Coagulation Family history of bleeding disorders defects should be reserved for young
disorders patient who has heavy flow with the
onset of menstruation
Personal history of 1 or more of the following:
•Coagulation screen
-Notable bruising without known injury
-Bleeding of oral cavity or gastrointestinal tract •rule out von Willebrand disease; ITP;
without obvious lesion and factor II, V, VII, or IX deficiency.
-Epistaxis greater than 10 minutes duration
(possibly necessitating packing or cautery)

In a 9 year review of 59 cases of acute

menorrhagia in adolescents it was discovered that
20% had a primary coagulation disorder

Hypothyroidism Ass. Symp: Hypothyroid symptoms fatigue, TFT

constipation, intolerance of cold, and hair and skin
changes
Liver or renal Ass. Symp: liver/renal failure symptoms RP/LFT/COAG screen
disease (Dysfunction of either organ can alter coagulation factors
and/or the metabolism of hormones)
• Iatrogenic causes:
symptoms start after medication/therapy started
CONDITION

Anticoagulant treatment

Chemotherapy
disrupt the normal menstrual cycle, which is
restored easily upon cessation of the products

Intrauterine contraceptive device (Conventional

types can cause excessive bleeding)
OCP’s (inadequate dose/compliance)
Management
Acute bleeding
 Acute bleeding

Orthostatic hypotension/ hb<10 gm/dl

•Premarin 2.5 mg PO qid plus

promethazine 25 mg PO or IM or PR •Premarin 25 mg IV q4h x 24h +
q4-6h as needed (nausea) promethazine 25mg PO or IM or PR
NO Yes hosp
q4-6h as needed for nausea
outpatient mx admission
•No improvement in 2-4 doses of
premarin/bleeding soaking 1 •Transfuse 2 pint packed rbc if Hb<
pad/hour or more after 7.5mg/dl
treatment D&C
•1-2 doses no response D &C
•Bleeding stopsswitch to
OCP/cycle provera •Simultnoeus with premarin start
OCP/cycle provera
•Oral iron
•Oral ion
MEDICAL
Surgical
PRIMARY DYSMENORRHEA
Indications
•Failed medical treatment
(minimum 3-6 months)
•Intolerable side effects of
medical treatment
• Organic causes warranting
surgery (e.g. fibroid, cancer)
•Patient's preference
•Co-existing conditions (e.g.
adenomyosis with
dysmenorrhoea)
Secondary menorrhagia
CONDITION TREATMENT

Uterine fibroids
Tx:
Asymptomatic(- tx)
•medical hormonal/non-hormonal
-non-hormonal: transnemic acid/NSAID (during menstruation)
-hormonal : OCP, progestogens, androgens, levonogestral releasing IUD,
GnRH,GnRH and hormonal add-back
•Surgical: myomectomy (hysteroscopic ,laparoscopic, tans abd
resection,)hysterectomy, uterine artery embolization, MRI-guided focused US

endometriosis Tx:
Medical: hormonal
Surgical: Excision, endometrial ablation ,TAHBSO
adenomyosis •tx:
-medical
-surgical
hysterectomy(without oophorectomy),UAE ,endometrial ablation,

Pelvic
inflammatory tx:
disease -medical: broad spectrum AB, clindamycin and gentamicin administered
intravenously every 8 hours

Uterine polyps •tx: hysteroscopy + polypectomy

Endometrial •Total abdominal hysterectomy with bilateral salpingo-oophorectomy is

carcinoma required both as a primary treatment and for the purpose of staging

Endometrial Medical
hyperplasia Simple endometrial hyperplasia without atypia responds to high-dose
progestogens, with repeat histology after three months (IUD)
Surgical
Endometrial ablation or transcervical resection of the endometrium
Hysterectomy - usually advised for atypical endometrial hyperplasia
Coagulation Vitamin k/FFP/coagulation factors/desmopressin
disorders

Hypothyroid Thyroid hormone replacement therapy

Anticoagulant’s levonorgestrel releasing intrauterine device (Mirena coil)

hysterectomy
IUCD (mx chart)

OCP’s (mx chart)

MANAGEMENT FLOW
 Hx and pe
B-HCG
Correct anemia
+/- acute Menarche
FBC bleeding mx onset screen
for coagulation
disorders

Pregnancy
exclude

Non uterine source (cervical ca,

lacerations, anus, rectal,
Miscarriage urethral)
Ectopic preg.
Antepartum Mx accordingly
haemorrhage(pp,
Abruptio placenta,
vasa previa)
Etc.

pap smear (esp if +

postcoital bleed)
Mx accordingly FOBT
UFEME
 Symptoms suggests •TVS
MENORRHAGIA +
underlying pathology
•Endometrial
•Hysteroscop hyperplasia/
y/transvaginal carcinoma
- sonohysterog •Submucosal
Uterus>10 raphy/ Fibroid
weeks in size, 1st line Abd - •endometrial
pelvic mass, USS •Biopsy polyps
Normal/bulky tenderness
uterus 8-10
•d & c
weeks

Mx
accordingly
iatrogenic Normal
Symptoms/signs of Low risk
hypothyroid group (most
likely DUB)
Mx
accordingly
treat
TFT hypothyroidism

hormonal
therapy
HIGH RISK GROUP Pelvic pain
Secondary dysmenorrhea
Symptoms suggests
underlying pathology Risk factors
Age > 40 Tamoxifen
Irregular/intermenstrual/ Unopped estrogen
postcoital bleeding PCOS ( Hirsutism)
Sudden change in bleeding obesity
pattern
Dyspareunia
 -Levonogestrel
Evaluate intrauterine hormonal therapy
in 6 device
months
-Norethisterone

no ovulatory
Evaluate Oral
in 3 contraceptive yes Need contraception
months pill

Yes/does not want

No improvement add no hormone therapy
mefenemic
acid(NSAIDS) and
evaluate in 3 months Tranexamic acid
NSAID
Cyclic oral progestin (ist 5 days of
(luteal phase) menstruation)

No
improvement
treatment Treatment Successful
failure
Continue
improve
management

Further assestment
Continue medical
hysteroscopy and
therapy
biopsy
 CASE STUDY
• A 14-year-old girl was referred for assessment
of heavy menses. Menses commenced at the
age of 12 years and were unremarkable until
the past six months when she noticed an
increased amount and duration of bleeding.
The menses were regular but had increased
from four to seven days of bleeding and she
was now using up to 10 pads/day for the first
three days. She denied any sexual activity.
• Review of systems was positive for fatigue but negative
for change in weight, cold intolerance, shortness of
breath, easy bruising or prolonged bleeding

• Past medical history was unremarkable other than for

asthma, and a family history could not be obtained
because the patient was adopted..

• On physical examination the patient was pale but in no

distress. Vital signs were normal. General physical and
external genital examination was normal, with no
evidence of bruising.
• Laboratory investigation showed hemoglobin
concentration of 74 g/L (normal 120 to 153
g/L), mean corpuscular volume and mean
corpuscular hemoglobin were both slightly
below normal, UPT (-)
• Bleeding time was slightly prolonged at 10 min
(normal 2 to 9 min).
• Factor VIII was normal, von Willebrand factor
(vWf) antigen was 0.28 IU/mL (normal 0.50 to
1.50 IU/mL).
• The ristocetin cofactor (a measure of vWf
activity) was 0.36 IU/mL (0.50 to 1.50 IU/mL).
• Based on these results a diagnosis of von
Willebrand’s disease (vWD) type I (vWf is
quantitatively reduced but not absent) was
made.
Amenorrhea
 Definition
• Amenorrhea
– Absence of menstruation
• Oligomenorrhea
– Menstrual cycles of 35 days - 6 months (and cycle
length typically irregular)
 Types of amenorrhea
• Primary
• Secondary
 Primary amenorrhea
• absence of menstrual bleeding and secondary
sexual characteristics (breast development
and pubic hair) in a girl by age 14 years
• absence of menstrual bleeding with normal
development of secondary sexual
characteristics in a girl by age 16 years
 Secondary amenorrhea
• cessation of menses after menstruation
established
– 3 months in woman with previously normal
menstruation
– 9 months in woman with previous
oligomenorrhea
 Incidence
• Secondary more common than primary
• 20% vigorously exercising women, up to 50%
elite female athletes
• Most affecting
– Competitive athletes
– Ballet dancers
– Gymnasts
 Causes for primary amenorrhea
Breast + Uterus Breast + Uterus Breast + Uterus Breast + Uterus
Gonadal failure Androgen 17,20-desmolase Hypothalamic
50% 45 X, 25% 46 X
abnormal X (deletion),
insensitivity deficiency causes
25% mosaicism, pure XY (testicular
gonadal dysgenesis, XY feminization - Pituitary causes
gonadal dysgenesis normal female
(Sawyer's Syndrome - XY
karyotype, palpable phenotype, 46 XY, Ovarian causes
Mullerian system, normal normal or slightly
female testosterone increased male Uterine causes
levels, lack of sexual
development), 17-
testosterone levels,
hydroxylase deficiency X-linked recessive)
(with 46 XX)
CNS-hypothalamic- Congenital absence Agonadism 1. Physiological
pituitary disorder - CNS delay
lesion, inadequate GnRH
of uterus (utero-
vaginal atresia) 2. Weight loss/
release, isolated
gonadotropin deficiency
anorexia
3. Imperforate
hymen
 Causes of secondary amenorrhea
• Hypothalamic-pituitary - destructive lesions, Sheehan syndrome,
hyperprolactinemia, hypothalamic-pituitary dysfunction, weight
loss
• Virilizing disorder - PCOS, hyperthecosis, ovarian tumor, congenital
adrenal hyperplasia, adrenal tumor, Cushing syndrome
• Psychogenic - anorexia nervosa, change in environment (stress),
adolescence
• End organ cause - uterine adhesions, cervical stenosis,
vesicovaginal fistula, hormone-resistant endometrium
• Ovarian - gonadal dysgenesis with limited menstrual function,
premature ovarian failure, resistant ovaries syndrome
• Thyroid disease
Management
 Treatment
• Initial mx
– Exclude pregnancy
– Perimenopausal symptoms (flushings, vaginal dryness)
– History of weight changes, drugs, medical disorders
and thyroids symptoms
– Examination assessing the height, weight, visual fields,
presence of virilisation or hirsutism, pelvic
examination
– Serum for LH, FSH, prolactin, testosterone, TFT
– TVS – polycystic ovaries
Investigations Results Treatment
Ultrasound scan PCOS – small, peripheral If pregnancy desired –
placed follicular ovarian cysts clomiphine
surrounded by thickened If not desired – COCP
echodense stroma
(supported by LH:FSH ratio >3
and testosterone >3)

Elevated PL level PL> 800 mU/L on 2 occasion – MRI pituitary and treat with
hyperprolactinemia dopamine agonist –
bromocriptine

Elevated FSH level FSH > 30 U/L, for patient HRT

above 40 is menopause and
patient less than 40 is
premature ovarian failure

Abnormal TFT Treat according to the

pathology
• If all the test is normal
– Weight loss
– Depression, emotional disturbances, extreme
exercise
– Asherman’s syndrome
– Idiopathic amenorrhea
 Reference

• Cpg menorrhagia kkm malaysia

• Acess medicine
• Ten teachers
• Dutta gynecology
• Shaw’s gynaecology