Irregular Bleeding Patterns

MENORRHAGIA

Menorrhagia is defined as a complaint of heavy cyclical menstrual bleeding over several consecutive cycles. It is also worth being aware that an average menstrual cycle occurs every 21 to 35 days and last from 2 to 7 days. Normal blood flow is 30 to 80ml (RCOG, 2004). Menorrhagia can be defined objectively or subjectively. Objective menorrhagia is taken to be a total menstrual blood loss of 80 ml or more. Subjective menorrhagia is defined as a complaint of excessive menstrual blood loss over several consecutive cycles in a woman of reproductive years.

Epidemiology

Menorrhagia has an impact on many women's lives, with 1 in 20 women aged 30-49 consulting her GP each year with this complaint. On referral to a gynaecologist, surgical intervention is highly likely, with 1 in 5 women in the UK having a hysterectomy before the age of 60 years. About half of all women who have a hysterectomy for menorrhagia have a normal uterus removed (RCOG, 1999).

Pathogenesis

Menorrhagia is thought to be associated with uterine fibroids, adenomyosis, pelvic infection, endometrial polyps and the presence of a foreign body such as an intrauterine contraceptive device. Lumsden and Norman (1998) state that in women with menstrual blood loss greater than 200 ml, over half will have fibroids, although only 40 per cent of those with adenomyosis actually have menstrual blood loss in excess of 80ml. According to Hurskainen et al., (1999) approximately half of the cases who present with menorrhagia show no underlying pathology. It is thought that vascular changes may play an important role, but the condition remains poorly understood.

Diagnosis and management of menorrhagia (See Table 12)

Treatment should take into consideration patients' issues. Women should be included in the decision-making process. Surgical treatment should only be carried out with outcomes and complications explained. Quality of life issues should be addressed.

Table 12

History

(A full gynaecological history should be taken)

Examination

Heavy cyclical menstrual blood loss over several consecutative cycles without any intermenstrual or post-coital bleeding (RCOG 1998)

Investigation

Bimanual abdominal examination • Cervical smear if due • Sexual health screen if history suggests pregnancy test

Full blood count

Note: Symptoms of other pathology include: • Irregular bleeding • Sudden change in blood loss

  • Intermenstrual bleeding
  • Postcoital bleeding
  • Dyspareunia • Pelvic pain • Premenstrual pain

Risk factors for oestrogen treatments:

Polycystic Ovary SyndromeObesity (RCOG 1998)

Note: • If uterus enlarged, i.e. above 10 weeks in size, if there is pelvic masses or tenderness noted, refer appropriately.

• If pregnancy test positive, refer appropriately

Note: Treat for anaemia if anaemic

Amended from: Royal College of Obstetrics and Gunaerology, 1998.

Drug treatment

Second-line drugs include danazole and gonadotrophin-releasing hormone analogues which are shown to be effective in reducing heavy menstrual blood loss, but side-effects limit their long-term use. Progestogen-releasing intrauter-ine systems reduce heavy menstrual blood loss and are a good alternative to surgical treatment.

Surgical treatments

  • Hysteroscopic removal of submucous fibroids or polyps.
  • Endometrial ablative procedures are effective in treating menorrhagia.
  • Hysterectomy - should be balanced against its potential mortality and morbidity.
  • RCOG, 2004)
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