NICE Pathway

Patient leaflet - Menorrhagia - patient.co.uk

Patient leaflet - Surgical options - patient.co.uk

Patient leaflet - Period blood loss chart - patient.co.uk

Summary:

  • Common

  • Probability diagnosis

    • Dysfunctional uterine bleeding

    • Fibroids

    • Complication hormone therapy

    • Adenomyosis

  • Rule out

    • Malignancy - any genital tract

    • Pregnancy

  • Investigations

    • FBC

    • USS

  • Management

    • NSAIDs

      • Naproxen 500mg stat then 250mg tds

    • TXA

      • Tranexamic acid 1g aid - d1-4 of menstruation

    • COC

      • Standard COC (150/30)

        • tricycle

    • Progestogens (anovulatory)

      • Norethisterone 5-15mg/day for 14 days

        • luteal 15-28d

    • Mirena

      • PHARMAC criteria (ALL)

        • Clinical diagnosis

        • Failed to respond/unable to tolerate pharmacological therapies

        • Serum ferritin \<16

        • Haemoglobin \<120

Introduction:

  • Common problem

  • Heavy menstural bleeding commonest cause of iron-def anaemia in western world

  • 20% women in reproductive age c/o inc. menstrual loss

  • 4% of GP consults

  • 50% of patients with perceived menorrhagia have normal blood loss when investigated

  • Possibility of pregnancy + complications kept in mind

    • ectopic

    • abortion (threatened, complete or incomplete)

    • hydatidiform mole

    • choriocarcinoma

  • Mean blood loss \<80mL (usually)

  • Menstrual record useful way to calculate blood loss

  • Common =

    • fibroids

    • adenomyosis (endometrium in uterine myometrium)

  • Consider drugs

Classification

Abnormal Rhythm

  • Irregularity of cycle

  • intermenstrual bleeding

    • metrorrhagia

  • Postcoital bleeding

  • Postmenopausal bleeding

Abnormal amount

  • Inc. amount = menorrhagia

    • '>80mL per menstruation

  • Decreased amount = hypomenorrhoea

Combination (rhythm and amount)

  • Irregular and heavy

    • metromenorrhagia

  • Irregular and light periods

    • oligomenohhoea

Defining normal and abnormal

  • Based on history, physiology and pathophys

  • Most girls reach menarche @ age 13 (10-16yo)

  • Dysfunctional bleeding common first 2-3 years

    • many anovulatory cycles -> irregular periods, heavy menses and dysmoenorrhoea (prob.)

  • Once ovulation and regular menstruation are established -> predictable pattern

    • any deviation = abN

  • Normal

    • Length = 26-28d (21-35d)

    • Menstrual flow = 3-4d (2-7d)

    • Normal blood loss = 30-40mL (20-80mL)

  • AbN is

    • cycle \<21d

    • Duration of loss >8d

    • volume of loss = pads cannot cope with flow or clots

  • Normal endometrial thickness (USS) = 6-12mm

  • Cycle ovulatory if serum progesterone (corpus luteum) >20nmol/L during mid-luteal phase (5-10d before menses)

++NORMAL PHYSIOLOGY/CYCLE++

Menorrhagia

excessive blood loss >80mL

  • caused by:

    • hormonal dysfunction (anovulation)

    • excessive local production of prostaglandins in endometrium

    • excessive local fibrinolysis of clot

    • local pathology (fibroids)

    • medical disorder

  • If dysmenorrhoea -> Endometriosis or PID

  • 60-80% accuracy can be achieved in clinical assessment

Most common cause: ovulatory dysfunctional uterine bleeding

Most common organic: fibromyomatas, endometriosis, adenomyosis, endometrial polyps, PID

Diagnostic strategy model:

Probability diagnosis

  • Dysfunctional uterine bleeding

  • Fibroids

  • Complication hormone therapy

  • Adenomyosis

Serious disorders not to be missed

  • Disorders of preg.

    • ectopic

    • abortion/miscarriage

  • Neoplasia

    • cervical Ca

    • Endometrial Ca

    • Oestrogen-Producing ovarian Ca

    • leukaemia

    • Benign tumours

  • Endometrial hyperplasia

  • PID

Pitfalls

  • Genital tract trauma

  • IUCD

  • Adenomyosis/endometriosis

  • Pelvic congestion syndrome

  • SLE

  • Rarities:

    • endocrine disorders

    • bleeding disorder

    • liver disease

7 masquerades:

  • Depression: association

  • DM: yes

  • Drugs: yes

  • Anaemia: Assoc.

  • Thyroid: yes: hypo

  • Spinal dysfunction: nil

  • UTI: nil

Is the patient trying to tell me something?
  • Exaggerated perception

History

  • smoking/psychosocial facts

    • cigarette smokers 5x more likely to have abN menstrual function

    • impact of bleeding

  • Pregnancy/pregnancy complications

  • trauma of genital tract

  • medical disorders

  • endocrine disorders

  • cancer of genital tract

  • complications of the pill

Examination

  • Anaemia r/out

  • bleeding disorder

  • Speculum: ?ulcers (cervical Ca); Polyps

  • Pap smear

  • Bimanual: ?uterine/adnexal tenderness, regularity of uterus

Investigations

  • selected carefully

  • indications:

    • older patients

    • AbN exams

    • persistent symptoms

    • suspicion of other disease

  • consider:

    • FBC - exclude anaemia/thrombocytopenia

      • NICE - should be carried out in all women

    • Iron studies (ferritin)

    • Hysteroscopy/endometrial sampling

      • NICE

        • Persistent

        • Women >45

        • Treatment failure

  • Special investigations:

    • pregnancy testing

    • laparoscopy (endometriosis, pID, other pelvic pathology)

    • serum biochemical screen

    • coagulation screen

    • TFT

    • SLE (ANA)

  • USS

    • NICE

      • Uterus is palpable

      • Vaginal examination reveals pelvic mass of uncertain origin

      • Pharmaceutical treatment fails

Dysfunctional uterine bleeding

  • Diagnosis of exclusion

excessive bleeding, whether heavy, prolonged or frequent, of uterine origin, which is not associated with recognisable pelvic disease, complications of pregnancy or systemic disease

Clinical features

  • Working diagnosis

    • initial history

    • normal PE

    • normal initial investigations

  • very common

    • 10-20% incidence of women at some stage

  • Peak incidence late 30s-40s

  • Anovulatory DUB 2 peaks

    • 12-16yo

    • 45-55yo

  • Bleeding irregular with spotting, variable monorrhagia

  • serum progesterone and pit hormone (LH+FSH) confirm anovulation

  • 40% initial diagnosis of DUB have other pathology

    • fibroids/polyps

Symptoms

  • Heavy bleeding

    • saturated pads

    • frequent changing

    • accidents

    • flooding

    • clots

  • Prolonged bleeding

    • menstruration >8d

    • heavy bleeding >4d

  • Frequent bleeding

    • more than once/21d

    • Pelvic pain and tenderness are not usually prominent

Management

  • Establish Dx - confirming symptoms and exclude other pathology

  • If no evidence of iron def/anaemia -> conservative management

  • \<35yo medical therapy

  • '>35 hysteroscopy and direct endometrial sample

Treatment

  • First line: fibrinolytic inhibitors or anti prostaglandin agents

    • given ASAP

    • throughout menses

    • 60-80% respond if compliance good

    • ideally start NSAID >4d prior to start of menses

    • should be stopped if not achieved reduced bleeding within 3 menstrual cycles

  • First line: Combined oral contraceptive

    • both ovulatory and anovulatory

    • 20% don't respond

    • use pill with a higher oestrogen dose

      • 50mcg cf. 35mcg

  • Progestogens

    • Oral - usually no benefit in ovulatory DUB

    • Adolescent w anovulatory DUB

      • cyclical oral progestogens - 6/12

      • IM medroxyprogesterone acetate - Depo-provera) will induce amenorrhoea in 50% of users in 1yr

      • Intrauterine progesterone implant (MIRENA) 0 releases 20mcg of levonorgestrel/day -> considerable effectiveness

        • most efficacious hormone treatments

        • PHARMAC

          • Clinical diagnosis

          • Failed to respond/unable to tolerate pharmacological therapies

          • Serum ferritin \<16

          • Haemoglobin \<120

    • Most effective = Tranexamic acid

      • endometrial plasminogen activation

      • 1g qid for first 4 days of the menstrual cycle commencing at the onset of visible bleeding

  • Surgery

    • If uterus is enlarged

    • 12-week gestation (grapefruit)

    • anaemic

    • options:

      • endometrial ablation/electrodiathermy excision

      • hysterectomy

Regimens:
NSAIDs:

  • Mefenamic acid 500mg tis (4 days prior menses due to end) partially funded

  • Naproxen 500mg stat then 250mg tds

  • Ibuprofen 800mg stat then 400mg q6-8h

Antifibrinolytics
  • Tranexamic acid 1g aid - d1-4 of menstruation
COC

  • 50mcg oestrogen

    • microgynon (levonorgestrel 125 + ethinylestradiol 50)

      • epileptics: on enzyme inducing

  • Standard COC (150/30)

    • tricycle
Progestogens (anovulatory)

  • Norethisterone 5-15mg/day for 14 days

    • luteal 15-28d

  • Medroxyprrogesterone - 20-30mg/day

  • Mirena

    • PHARMAC criteria (ALL)

      • Clinical diagnosis

      • Failed to respond/unable to tolerate pharmacological therapies

      • Serum ferritin \<16

      • Haemoglobin \<120

Typical treatments:
Acute Heavy

  • Curettage/hysteroscopy

  • IV oestrogen (Premarin) then oral

  • oral high dose progestogens

    • 5-10mg 2hourly until bleeding stops then 5mg bd/tds for 14d
Chronic bleeding

  • Anovulatory women:

    • cyclical oral progestogens 14d

    • txa

  • Ovulatory

    • cyclical prostaglandin inhibitor (NSAIDs)

    • ORal contraceptive

    • Antifibrinolytics

Cycle irregularity

Patients \<35yo

  • Cause usually hormonal

    • rarely organic

    • keep malignancy in mind

  • Management options:

    • explanation and reassurance

    • COC pill for better cycle control - any pill can be used

    • POP from day 5-25 cycle

Patients >35yo

  • refer for investigations for organic pathology

    • endometrial sampling and/or hysteroscopy

Intermenstrual bleeding and postcoital bleeding

  • Cervical ectropion

  • Cervical polyps

  • IUCD

  • OCP

intermenstural bleeding should always be investigated

Cervical ectropion commonly found in women on the pill and post partum can be left untreated unless intolerable bleeding discharge or moderate postcoital bleeding present

Change to higher oestrogen pill

Uterine fibroids (leiomyoma)

Benign tumours of smooth muscle of the myometrium

Classification:

  • subserosal

  • intramural

  • subendometrial

  • intra-uterine

  • Oestrogen dependent

  • shrink with oner of menopause

Clinical features:

  • Present in 30% women >35

  • 1/800 develop malignancy

  • Usually asymptomatic

Symptoms (esp. if large)

  • Menorrhagia

  • Dysmenorrhoea

  • Pelvic discomfort

  • Bladder dysfunction

  • Pain with torsion of pedunculated fibroid

  • Pain with 'red degeneration' - only in pregnancy:

    • pain, fever, local tenderness

Other features:

  • Infertility:

    • can act like iucd if submucosal

    • calcification

Examination

  • Bulky uterus

Investigations

  • USS

  • FBC - ?anaemia

  • Uterine biopsy (malignancy suspected)

Management

  • Consider COC

  • GnRH analogues

    • esp. if >42

    • can shrink fibroids (max 6/12)

  • Surgery

    • myomectomy

    • Hysteroscopic resection

    • hysterectomy

    • Emobolisation