History

Fact Explanation
Excessive blood loss/ passage of large blood clots during the regular monthly menstrual cycle [1] >80 ml of blood loss is considered as menorrhagia; This may occur as a prolonged menstrual period which is menstruation lasting more than 7 days [1] Number of sanitary pads/ tampons used maybe used as a rough guide.
Fatigue, shortness of breath on exertion Anaemia [1] results due to excessive menstrual blood loss
History of currently inserted intrauterine contraceptive device [2] Foreign body within uterine cavity is a known cause of mennorhagia [2]
Features of hypothyroidism: cold intolerence, constipation, coarse dry hair [3] Hypothyroidism causes a reduction in the basal metabolic rate of the body, which increases the time needed for endometrial regeneration, causing increased and prolonged menstrual flow.
Bleeding manifestation: Bruises found in skin surface [4] Patients with inherited coagulopathies may present in their adolescent period with menorrhagia. [4]
History of bleeding disorders [2] Poor control of existing bleeding disorders may result in menorrahgia. [2]
History of anticoagulant use. [5] Anticoagulant such as warfarin usage is known to cause mennorhagia [5]
Associated dysmenorrhoea [6] Endometriosis and adenomyosis are known to cause both dysmenorrhoea and menorrhagia. [6][7][8]
Associated dyspariunea [8] Endometriosis causes both dyspareunia and menorrhagia. [8]
References
  1. APGAR Barbara, KAUFMAN H Amanda, GEORGE-NWOGU Uche, KITTENDORF Anne. Treatment of Menorrhagia [online], Am Fam Physician. 2007 Jun 15;75(12):1813-1819. Viewed: August 18, 2014. Available at: http://www.aafp.org/afp/2007/0615/p1813.html
  2. REES M, Menorrhagia [online] Br Med J (Clin Res Ed). Mar 21, 1987; 294(6574): 759–762. Viewed: August 18, 2014. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1245808/?page=1
  3. SHUTE Evan, Menorrhagia and its Modern Treatment. Can Med Assoc J. Dec 1936; 35(6): 622–627. Viewed: August 18, 2014. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1561941/?page=3
  4. ALBERS R Janet, HULL K Sharon, WESLEY M. Robert Abnormal Uterine Bleeding [online] Am Fam Physician. 2004 Apr 15;69(8):1915-1926. Viewed: August 18, 2014. Available at: http://www.aafp.org/afp/2004/0415/p1915.html
  5. PEZZOTTI William, FREULER Melissa. Using anticoagulants to steer clear of clots [online] Nursing: February 2012 - Volume 42 - Issue 2 - p 26–34 doi: 10.1097/01.NURSE.0000410303.18542.9e Viewed: August 18, 2014. Available at: http://journals.lww.com/nursing/Fulltext/2012/02000/Using_anticoagulants_to_steer_clear_of_clots.10.aspx
  6. THOMPSON J. Robert, DAVION J Raoul Adenomyosis of the Uterus: An Enigma [online] J Natl Med Assoc. Apr 1986; 78(4): 305–307. Viewed: August 18, 2014. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2571280/?page=3
  7. RINGROSE CA Douglas An Appraisal of Adenomyosis (Internal Endometriosis) A Century After its First Description [online] Can Med Assoc J. Jul 21, 1962; 87(3): 121–123. Viewed: August 18, 2014. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1849435/?page=3
  8. HAYDEN T Charles ENDOMETRIOSIS—A Review [online] Calif Med. Sep 1956; 85(3): 157–162. Viewed: August 18, 2014. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1531933/?page=1

Examination

Fact Explanation
Pallor Anaemia caused by excessive blood loss [2]
Coarse facies/ lateral eyebrow thinning/ macroglossia/ goiter/ delayed deep tendon reflexes/ bradycardia [3] Features of hypothyroidism [3]
Any bruises on general examination [4] Indicative of bleeding disorders. [4]
Abdominal examination A large fibroid maybe able to be palpated abdominally.
Bimanual pelvic examination [1] Polyps protruding through cervical os maybe visualised or felt. A fibroid maybe felt as a confined enlarged mass in the uterus Tender uterus/ adenexae indicates endometriosis [1]
Speculum examination [1] Abnormal cervix may indicate cervical cancer. Polyps maybe visualised.
References
  1. REES M, Menorrhagia [online] Br Med J (Clin Res Ed). Mar 21, 1987; 294(6574): 759–762.Viewed: August 18, 2014. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1245808/?page=1
  2. APGAR Barbara, KAUFMAN H Amanda, GEORGE-NWOGU Uche, KITTENDORF Anne. Treatment of Menorrhagia [online], Am Fam Physician. 2007 Jun 15;75(12):1813-1819. Viewed: August 18, 2014. Available at: http://www.aafp.org/afp/2007/0615/p1813.html
  3. GAITONDE Y David, ROWLEY D Kevin, SWEENEY B Lori Hypothyroidism: An Update [online] Am Fam Physician. 2012 Aug 1;86(3):244-251. Viewed: August 18, 2014. Available at: http://www.aafp.org/afp/2012/0801/p244.html
  4. ALBERS R Janet, HULL K Sharon, WESLEY M. Robert Abnormal Uterine Bleeding [online] Am Fam Physician. 2004 Apr 15;69(8):1915-1926. Viewed: August 18, 2014. Available at: http://www.aafp.org/afp/2004/0415/p1915.html

Differential Diagnoses

Fact Explanation
Local causes: anovulatory cycles, endometrial hyperplasia, endometriosis, pelvic inflammatory disease, benign tumors such as leiomyoma/ polyps, malignant tumors such as endometrial/ cervical cancer [1] Submucosal fibroid is associated with menorrhagia and removal of the fibroid relieves symptoms [2]
Systemic causes: hypothyroidism, bleeding disorders [1] Hypothyroidism reduces von Willebrand factor resulting in acquired vWB disease resulting in excessive menstrual blood loss [3]
Drugs [4] Anticoagulants can cause menorrhagia. [4]
Foreign body [1] Intrauterine contraceptive device itself may result in excessive bleeding. [1]
References
  1. REES M, Menorrhagia [online] Br Med J (Clin Res Ed). Mar 21, 1987; 294(6574): 759–762.Viewed: August 18, 2014. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1245808/?page=1
  2. KHAN T Aamir, SHEHMAR Manjeet, GUPTA K Janesh, Uterine fibroids: current perspectives [online] Int J Womens Health. 2014; 6: 95–114. Published online Jan 29, 2014. doi: 10.2147/IJWH.S51083 Viewed: August 18, 2014. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3914832/
  3. BLESING N E, HAMBLEY H, McDONALD G A, Acquired von Willebrand's disease and hypothyroidism: report of a case presenting with menorrhagia [online] Postgrad Med J. Jun 1990; 66(776): 474–476. Viewed: August 18, 2014. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2429601/?page=2
  4. PEZZOTTI William, FREULER Melissa. Using anticoagulants to steer clear of clots [online] Nursing: February 2012 - Volume 42 - Issue 2 - p 26–34 doi: 10.1097/01.NURSE.0000410303.18542.9e Viewed: August 18, 2014. Available at: http://journals.lww.com/nursing/Fulltext/2012/02000/Using_anticoagulants_to_steer_clear_of_clots.10.aspx

Investigations - for Diagnosis

Fact Explanation
Transvaginal ultrasonography (TVS) [1] Uterine abnormalities such as fibroids can be diagnosed but has low sensitivity than saline infusion sonohysteroscopy [1]
Saline infusion sonohysteroscopy [1] Infusion of sterile saline/ isotonic solution allows easy visualisation with transvaginal ultrasound scan. Fibroids, intra uterine polyps can be visualized with high sensitivity than in plain TVS. [1]
Endometrial biopsy [1] Used to exclude cancer in adult women. Can be done even as outpatient procedure since anaesthesia, cervical dilatation is not required. [1] Higher sensitivity and negative predictive value is yield when used in combination with saline infusion sonohysteroscopy. [1]
Hysteroscopy [1] This is the preferred method as intracavitatary anatomy can be directly viewed; but is of high cost. This is usually done when menorrhagia persists despite normal endometrial biopsy and saline infusion sonohysteroscopy. [1]
Thyroid function test [1] Should be done if other features of thyroid disease is observed in the patient [1]
Coagulation profile/ test for von Willebrand's disease [1][2] Patients with inherited coagulopathies may present in adolescent period with menorrhagia. [2] Recommended in adolescent and adult women with severe menorrhagia. [1]
References
  1. APGAR Barbara, KAUFMAN H Amanda, GEORGE-NWOGU Uche, KITTENDORF Anne. Treatment of Menorrhagia [online], Am Fam Physician. 2007 Jun 15;75(12):1813-1819. Viewed: August 18, 2014. Available at: http://www.aafp.org/afp/2007/0615/p1813.html
  2. ALBERS R Janet, HULL K Sharon, WESLEY M. Robert Abnormal Uterine Bleeding [online] Am Fam Physician. 2004 Apr 15;69(8):1915-1926. Viewed: August 18, 2014. Available at: http://www.aafp.org/afp/2004/0415/p1915.html

Investigations - Fitness for Management

Fact Explanation
Full blood count [1] Haemoglobin maybe low due to menorrhagia and the woman should be optimised, if necessary, with iron supplement/ blood transfusion prior to surgery.
Chest x-ray, renal function tests, blood gases, lung function [2] These should be done according to patient's symptoms and according to the ASA (American society of anesthesiologists) category patient falls in; this should be performed in preparation for any operative intervention.
References
  1. APGAR Barbara, KAUFMAN H Amanda, GEORGE-NWOGU Uche, KITTENDORF Anne. Treatment of Menorrhagia [online], Am Fam Physician. 2007 Jun 15;75(12):1813-1819. Viewed: August 18, 2014. Available at: http://www.aafp.org/afp/2007/0615/p1813.html
  2. Preoperative Tests: The Use of Routine Preoperative Tests for Elective Surgery. NICE Clinical Guidelines, No. 3. [online] London: National Collaborating Centre for Acute Care (UK); 2003 Jun Viewed: August 18, 2014. Available from: http://www.ncbi.nlm.nih.gov/books/NBK48482/

Management - General Measures

Fact Explanation
Iron supplements/ Blood transfusion [1] To treat anaemia which is usually present. [1]
References
  1. APGAR Barbara, KAUFMAN H Amanda, GEORGE-NWOGU Uche, KITTENDORF Anne. Treatment of Menorrhagia [online], Am Fam Physician. 2007 Jun 15;75(12):1813-1819. Viewed: August 18, 2014. Available at: http://www.aafp.org/afp/2007/0615/p1813.html

Management - Specific Treatments

Fact Explanation
Combined oral contraceptive pills [1] This is used in menorrhagia associated with anovulatory cycles, but evidence on its effect on menorrhagia is insufficient. [1]
Progestogens (Oral Norethisterone 5 mg tds from day 5 to day 26, for 21 days continuously or oral/ IM medroxyprogesterone acetate [1] Known to be the most effective medical treatment; useful in short term or bridging therapy; breast tenderness and irregular menstrual bleeding are known side effects. [1]
Levonorgestrel-releasing intrauterine device [1] Effective long term therapy; Patient satisfaction is higher than in oral progesterone use. Pregnancy can be achieved after removal of the device. [1]
First generation endometrial ablation (endometrial resection and rollerball or laser ablation) [1] Endometrial ablation is considered if childbearing is completed and if patient is not willing to undergo major surgery such as hysterectomy. Higher rates of amenorrhoea is achieved when compared to levonorgestrel-releasing intrauterine device. Preoperative gonadotropin-releasing hormone analogues or danazol thins the endometrium resulting in better outcome.[1] First generation ablation is done under direct vision with hysteroscope and a distension medium is used to enhance the visualization. Thus there is a high risk of fluid overload, therefore this method is not used in patients with renal/ heart failure. General or regional anesthesia is needed and longer time is needed than in second generation ablation methods. [1]
Second generation endometrial ablation (cryo/ thermal balloon/ radiofrequency/ microwave ablation or diode laser thermotherapy) [1] This is done "blindly" without the use of hysteroscope to visualise the procedure. Thus, cervical dilation is not necessary. Therefore can be done as an outpatient procedure with local anesthesia and minimum cervical dilatation. [1]
Hysterectomy [1] This is the definitive treatment for menorrhagia, however the cost is higher and is used if childbearing is completed. [1]
Nonsteroidal anti-inflammatory drugs (NSAIDs)[1][2] Mefenamic acid is the most commonly used NSAIDs, but the evidence in relation to the efficacy is insufficient. [1][2]
Tranexamic acid [5] This is an antifibrinolytic agent, but the evidence in relation to the efficacy is insufficient. [1][2][5]
Danazol [6] Danazol acts on oestrogen and progesterone receptors in endometrium inhibiting its action, resulting in thinning of the endometrium resulting in reduced menstrual blood loss. But this is not a preferred agent since evidence regarding its efficacy is insufficient. [6]
Novel oral contraceptive: Estradiol valerate (E2V) and dienogest (DNG) [5] This is a new drug recommended for menorrhagia, given for 6 months it shows 65% reduction in mean blood loss [5]
If secondary menorrhagia is suspected underlying cause should be treated. Hypothyroidism treated with thyroxine supplements. [3] Submucosal fibroids can be removed by hysteroscopic myomectomy. [4]
References
  1. APGAR Barbara, KAUFMAN H Amanda, GEORGE-NWOGU Uche, KITTENDORF Anne. Treatment of Menorrhagia [online], Am Fam Physician. 2007 Jun 15;75(12):1813-1819. Viewed: August 18, 2014. Available at: http://www.aafp.org/afp/2007/0615/p1813.html
  2. ALBERS R Janet, HULL K Sharon, WESLEY M. Robert Abnormal Uterine Bleeding [online] Am Fam Physician. 2004 Apr 15;69(8):1915-1926. Viewed: August 18, 2014. Available at: http://www.aafp.org/afp/2004/0415/p1915.html
  3. SHUTE Evan, Menorrhagia and its Modern Treatment. Can Med Assoc J. Dec 1936; 35(6): 622–627. Viewed: August 18, 2014. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1561941/?page=3
  4. KHAN T Aamir, SHEHMAR Manjeet, GUPTA K Janesh, Uterine fibroids: current perspectives [online] Int J Womens Health. 2014; 6: 95–114. Published online Jan 29, 2014. doi: 10.2147/IJWH.S51083 Viewed: August 18, 2014. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3914832/
  5. RAFIE Sally, BORGELT Laura, KOEPF R Erin, TEMPLE-COOPER E Mary, LEHMAN K Joy Novel oral contraceptive for heavy menstrual bleeding: estradiol valerate and dienogest [online] Int J Womens Health. 2013; 5: 313–321. Published online Jun 12, 2013. doi: 10.2147/IJWH.S31922 August 18, 2014. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3684222/
  6. BEAUMONT H, AUGOOD C, DUCKITT K, LETHABY A. Danazol for heavy menstrual bleeding. [online] Cochrane Database Syst Rev. 2007 Jul 18;(3):CD001017. August 18, 2014. Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001017.pub2/full