wiki:obsgynae:menorrhagia

Table of Contents

Vaginal Bleeding
- Menorrhagia
- Bleeding in early pregnancy

Vaginal Bleeding

Menorrhagia

Preferred term is Heavy Menstrual Bleeding (HMB)
Excessive flow and duration at regular intervals (vs Metrorrhagia = irregular bleeding)

1st need to establish pregnant vs non-pregnant

The goal of the work-up is to determine whether there is a uterine/endometrial abnormality, a disorder of ovulation, or a disorder of coagulation
The International Federation of Gynaecology and Obstetrics developed a mnemonic for these disorders: PALM-COEIN
- P olyp; A denomyosis; L eiomyoma; M alignancy and hyperplasia
- C oagulopathy
- O vulatory dysfunction
- E ndometrial
- I atrogenic
- N ot yet classified)

History should then be focused on:

Pelvic pain/pathology	• fibroids, malignancy • Polycystic Ovary Syndrome
Contraceptive use	•
Endocrine causes	• pituitary tumour - Galactorrhea • adrenal - Hirsutism • Thyroid disease
Systemic illnesses	• renal, hepatic
Bleeding disorders	• Duration of menses ≥7/7, impairment of daily duties • History of Rx for anaemia • FHx of bleeding disorder • Excessive bleeding with tooth extraction, other surgery etc • Family Hx
Medications	• hormones or anticoagulants
Any past procedures	• including unsuccessful hormone manipulations

Examination should focus on:

signs of volume loss is priority
signs of bleeding diathesis
signs of endocrine disorder
abdominal and pelvic masses
VE for signs of infection or mass

Acute Management

Fluid resuscitation
addressing contributing illnesses and correctable factors - bleeding disorders, anti-coag med's etc
Investigation - routine bloods, TFT, prolactin (+/- LH, FSH and adrenal test), coag's, Fe then others depending on background. USS

NSAIDs	• evidence for increased local inflammation with increased menstrual blood loss (increased TNF and COX-2) • Mefenamic acid most commonly used. Said to reduce blood loss by ~25% • Other NSAIDs also useful
Tranexamic acid (TXA)	• anti-fibrinolytic with short t_1/2 • Said to reduce blood loss by ~50% • 1g tds - qid.
Hormones	• progesterone only • although safer than combined pill, not usually recommended because of irregular and unpredictable blood loss • May be appropriate if other options not available
	• Norethisterone = most common oral progesterone used. • Said to reduce blood loss by ~80%. • 5mg - tds
	• combined pill - oestrogen risk of VTE, CVS disease, stroke and breast CA

Bleeding in early pregnancy

<6/40, painless bleeding, consider expectant management
Advise pt to repeat urine pregnancy test in 7–10/7 and return if test +ve or symptoms continue or worsen
should be referred if +ve urine pregnancy test, or continuing or worsening symptoms to EPAU

Progesterone levels in pregnancy: Prog levels

Pregnancy 1st trimester: 11.2 to 90.0 ng/mL or 35.62 to 286.20 nmol/L
Pregnancy 2nd trimester: 25.6 to 89.4 ng/mL or 81.41 to 284.29 nmol/L
Pregnancy 3rd trimester: 48 to 150 to 300 or more ng/mL or 152.64 to 477 to 954 or more nmol/L

References include:

https://www.nice.org.uk/guidance/ng88
https://emedicine.medscape.com/article/255540-overview
Medical Mx heavy menstrual bleeding
Workup and Mx
https://cks.nice.org.uk/miscarriage#!scenario