Heavy Menstrual Bleeding for Undergraduates Max Brinsmead MB BS PhD May 2015.

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Heavy Menstrual Bleeding for Undergraduates Max Brinsmead MB BS PhD May 2015

Transcript of Heavy Menstrual Bleeding for Undergraduates Max Brinsmead MB BS PhD May 2015.

Page 1: Heavy Menstrual Bleeding for Undergraduates Max Brinsmead MB BS PhD May 2015.

Heavy Menstrual Bleeding for Undergraduates

Max Brinsmead MB BS PhD

May 2015

Page 2: 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)

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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

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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)

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Information for Patients that compares Endometrial Ablation & Hysterectomy

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