Men No Rag Hi A

8/9/2019 Men No Rag Hi A

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MANAGEMENT OFTHE PATIENT WITHMENORRHAGIA


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Menorrhagia

Definition:

Abnormally heavy and prolonged

intervals (Cytyc, 2004).


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I've been bleeding for 7 days

now, changing tampons every1-2 hours...


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Causes

Abnormal blood clotting

regulation

Disorders of endometrial lining


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Effects

Physical

SocialEmotional


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Physical:

clots

dysmenorrhea

anemiafatigue

headaches

nausea

(Hologic, 2008).


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Social:

60% of w omen m iss soc ia levents33% m iss w ork 33% m iss w ork (Hologic , 2008)


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Emotional:

66% feel depression

75% feel anxious

(Hologic 2008)


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Other possible causes of

heavy bleeding

Can occ ur at any t im e dur ing the

menst rua l cyc le

Can be caused by a w ide var ie ty o f c on ons e.g. ro s, po yps,

hormones) Menstr ua l b leed ing c an be:

m ore f requent t han norm al(met ro r rhag ia )exc ess ive and f requent

(menomet ro r rhag ia )


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RECOMMENDATIONS

Cochrane Database


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Grade of recommendationGrade A - based on randomizedcontrolled trials*

Grade B - based on robust experimental

Grade C - based on more limitedevidence but the advice relies on expert

opinion


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Educ at ion for w om en beforeappo in tmen t :


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Nurs ing Adv ice t ohe lp p t p repare for

app t :Regular i t y o f B leed ing:Keep t rack on ca lendar and bring t o

appoin t m ent (Grade B). oo oss: c ount ampons and padsused , & char t t heamount o f sat u rat ion(l ight , m oderate ,sat urat ed) (Grade B).


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Is this type of bleeding normal?

Perimenopausal women with irregularcycles but normal blood loss may not requirework-up (Grade C).

An abdominal and pelvic examinations ou e per orme n women presen ngwith heavy menstrual bleeding with thepossible exception of women under the age

of 20 as the likelihood of pathology is small(Grade C).


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Erratic Bleeding

Women with erratic bleeding

should be evaluated by a providerto determine presence of a fibroid/

polyp, infection etc.


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What will they do at my

appointment?review bleeding

pattern and history

pelvic exam

possible US

possibly offer meds.


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Diagnostic tools

US:

Women with

an abnormal

pelvic

examination

should have an

ultrasound to

confirm the

findings

(Grade C).


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Assessment via US

The following women with heavy menstrual bleedingare recommended to have a transvaginal ultrasound ofthe endometrium

- weight 200 lbs- age years o

- other risk factors for endometrial hyperplasia orcarcinoma such as infertility or nullipairty, family

history of colon or endometrial cancer, exposure tounopposed estrogens (Grade B).


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Diagnostic tools

Lab

Thyroid function tests may be performed

in women with heavy menstrual bleedingespec a y e woman as symp oms or

signs of hypothyroidism (Grade C).

A CBC should be offered to all womenpresenting with heavy menstrual bleeding

(Grade B)


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AssessmentLab

Test s fo r c oagu lopathyare on ly ind ic at ed inw omen w ho haveomen w ho havesusp ic ious feat ures in t he

h ist o ry o r ex am inat ion(Grade C).


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Diagnostic tools:

EndometrialBiopsy

If transvaginal ultrasound is not available then an

endometrial sample should be taken (Grade C).

If the endometrial thickness on US is 12 mm an

endometrial sample should be taken to exclude

endometrial hyperplasia (Grade A).


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Followup on Endometrial Biopsyresults

Failure to obtain sufficient material for

histological diagnosis does not requirefurther investigation unless the endometrialthickness is 12 mm (Grade B).


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Medical Management

The following treatments are effective in reducing

re ular heav menstrual bleedin :

Levonorgestrel intrauterine system (MIRENA)

Birth control Pill/ nuva ring

NSAIDS (menstruating days only) 600 mgIbuprofen TID


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Br J Obstet Gynaecol.1986 Sep;93(9):974-8.Primary and myoma-associated menorrhagia: role of prostaglandins and effects ofibuprofen.

Mkrinen L, Ylikorkala O.

The release of 6-keto-prostaglandin F1 alpha(6-keto-PGF1 alpha), a metabolite ofprostacyclin (PGI2) and thromboxane B2 (TxB2), a metabolite of thromboxane A2(TxA2), was estimated in endometrial biopsies taken from 12 menorrhagic and 12healthy women during the luteal phase of the cycle. The releases of 6-keto-PGF1alpha and TxB2 were normal, but the ratio TxB2/6-keto-PGF1 alpha was inversely

related to menstrual blood loss in women with measured menstrual blood loss. ,

bleeding (13 with primary menorrhagia, 10 with uterine fibromyomas, one withhaemostatic factor VIII deficiency) were treated at random with ibuprofen (600 mg/dayand 1200 mg/day) and with a placebo. Ibuprofen 1200 mg/day reduced (P less than0.01) median blood loss from 146 ml (range 71-374 ml) to 110 ml (30-288 ml) inprimary menorrhagia but had no effect on blood loss in women with uterine fibroids

and factor VIII deficiency. Blood loss was normal in six women and was not affectedby ibuprofen. Thus, ourdata suggest that there is a PGI2 dominance in theendometrium of patients with menorrhagia. In addition, primary, but neitherfibromyoma nor coagulation defect-associated menorrhagia, can be treated byibuprofen.


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Medical Management

Progestogens (medroxyprogesterone

acetate) given in the luteal phase (Day 12-

26 are not effective in reducin re ular

heavy menstrual bleeding (Grade A).


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REFERRAL TO MD

Hysteroscopy and biopsy isindicated for :-women with erratic menstrualbleeding.

- failed medical therapy.-suggestive of intrauterinepathology such as polyps or

submucous fibroids (Grade B).


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Surg ica lu rg i ca lManagementanagement


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Surgical Management

Dilatation and curettage is not effective fortherapy in women with heavy menstrual

bleeding (Grade B).

variety of techniques but there may be a 40%

reoperation rate after 5 years (Grade A).


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Surgical Management

Women are more likely to be satisfied with

endometrial ablation than oral medical

.

There is a similar satisfaction rate and

efficacy with endometrial ablation and

MIRENA (levonorgestrel intrauterinesystem) (Grade A).


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Surgical Management

Endometrial destruction techniques

and vaginal hysterectomy arepre era e to a om na

hysterectomy (Grade B).


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Thank You!

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