Management of menorrhagia

1. Management of Menorrhagia
Christine Putri, Nick Harper,
Chris Brookes

2. Menorrhagia
•NICE Definition:
“excessive menstrual blood loss which interferes
with the woman’s physical, emotional, social
and material quality of life, and which can
occur alone or in combination with other
symptoms. Any interventions should aim to
improve quality of life measures.”
>80ml per cycle

3. Epidemiology
33% of woman complain of heavy periods
Prevalence 8–27% – subjective
11-26% - objective

4. Causes
•Dysfunctional uterine
bleeding
•IUCD
•Fibroids
•Endometriosis
•Adenomyosis
•Pelvic infection
•Polyps
•Endometrial carcinoma
•Anticoagulation therapy
•Hypothyroidism
•Blood dyscrasia

5. •RCT, n=638 with undertaken in the UK on
women with menorrhagia (Critchley et al,
2001)
•<40 yr group: 11.5% endometrial/uterine
polyps, 36% uterine fibroids, 1% endometrial
cancer and 1% had hyperplasia
•>40 group: 6% endometrial/uterine polyps,
19% uterine fibroids

6. Dysfunctional Uterine Bleeding
•80% of women treated for heavy menstrual
bleeding have no anatomical pathology
(Lethaby et al, 2008)
•Absence of pelvic pathology
•menarche and perimenopause
•Ovulatory(10%) or unovulatory(90%)

7. Fibroids
•Benign smooth muscle tumour (leiomyomas)
•Common, 20% of women
•Oestrogen-dependent
•Presentation:
–menorrhagia,
–fertility problems,
–pain,
–mass

9. Endometrial Polyps
•growth of the lining of the
uterus
•Presentation:
•asymptomatic, irregular
bleeding, IMB, PMB,
menorrhagia

10. History
•Nature of bleeding
•Symptoms suggesting possible significant
pathology
•Other features that may determine treatment
or other action

11. Examination
•General observation
•Abdominal examination
•Pelvic examination (+/- swabs)

12. Investigations
•FBC, ferritinin: anemia
•TFT, coagulation: to exclude systemic cause
•TVS: To exclude local organic causes
•Endometrial biopsy (at hysteroscopy or with
a pipelle)
•Hysteroscopy: visualize uterine cavity

13. Measurement of blood loss
•Direct measurement of MBL – alkaline
haematin
•Indirect measurement of MBL – pictorial
blood loss assessment charts (PBAC)
•Surrogate and self-assessment measures of
MBL

18. Methods of Management
1

19. Pharmaceutical treatment
•Combined OCP
•Antifibrinolytics
–Tranexamic acid
•NSAIDS
–Mefenamic acid
•Oral progestogens
–Norethisterone
•821,700
prescriptions
•£7,176,595
2

20. •Progestogen - Progestin - Levonorgestrel
•Mirena (Bayer)
•Contraception
•Primary menorrhagia
•Endometrial hyperplasia
Intrauterine System (IUS)
3

21. Intrauterine System (IUS)
•Local effects
•Thickening of cervical
mucus
•Suppression of ovulation
•Prevention of endometrial
proliferation
4

22. Intrauterine System (IUS)
•Ectopic (50%)
•PID
•Irregular bleeding/spotting
•Embedment
•Perforation
•Expulsion
•Sepsis
5

23. Pharmaceutical treatment - NICE
•No structural/histological abnormality
1.Mirena
2.Tranexamic acid/NSAIDs/cOCP
3.Norethiserone (days 5-26)
•Try 2
nd
treatment if no improvement after 3
menstrual cycles
6

24. Endometrial destruction
•Endometrium + superficial
myometrium
•Infertility?
1.Direct hysteroscopic vision
2.Non hysteroscopic vision
7

25. Direct Hysteroscopic vision
Laser photovapourisation
Laser Photovapourisation
8

26. Direct Hysteroscopic vision
Laser photovapourisationRollerball ablation
Rollerball ablation9

27. Direct Hysteroscopic vision
Laser photovapourisation Endometrial excisionRollerball ablation
Endometrial excision
10

28. Direct Hysteroscopic vision
Laser photovapourisation
Bipolar
radiofrequency
Endometrial excisionRollerball ablation
Bipolar radiofrequency
11

29. Direct Hysteroscopic vision
Laser photovapourisation
Hydrothermal
ablation
Bipolar
radiofrequency
Endometrial excisionRollerball ablation
Hydrothermal
ablation
12

30. Non Hysteroscopic vision
Microwave
ablation
Microwave
ablation
13

31. CryoablationMicrowave
ablation
Non Hysteroscopic vision
Cryoablation
14

32. CryoablationMicrowave
ablation
Heated balloon
system
Non Hysteroscopic vision
Heated balloon
system
15

33. Endometrial ablation - NICE
•10,000 cases (‘93-94)
•Complication rate 4.4%
•Vaginal discharge, Cramping
•Initial treatment only after discussion
•Avoid subsequent pregnancy
•Any second generation method (cheapest)
16

34. Hysterectomy – 100% success!!!
•Abdominal
•Vaginal
•Laparoscopic
•Size
•Mobility
•Fibroids
17

35. 18

36. Hysterectomy
•60% of GP referrals for HMB – Hysterectomy
•24,355 in 1993
•10,559 in 2002
•Over 95% satisfaction rate after 3 years
•Up to 67% experience complication
–Haemorrhage, damage to abdo. organs
19

37. Hysterectomy - NICE
•Not 1
st
line treatment
•Pros/cons/risks
1.Vaginal (fewer complications)
2.Abdominal
Total or Subtotal – shared choice
20

38. Evidence Base

39. Pharmacological intervention - Oral
contraceptive pill
•Farquhar, C. and Brown, J., 2009, Oral contraceptive
pill for heavy menstrual bleeding
•Only one trial of 45 fit criteria
•No significant difference between OCP, mefenamic
acid, low dose danzol or naproxen
•Review unable to achieve objectives

40. •Lethaby, A et al, 2009, Antifibrinolytics for heavy menstrual bleeding.
•Four of fifteen trials that met criteria were used in meta-analysis
•Significant reduction compared to placebo -94.0 (95% CI: -146.5 to -73.8)
•Comparisons with mefenamic acid, norethisterone in luteal phase and
etamsylate all produced a significant reduction in blood loss.
•-73 (95% CI: -123.4 to -22.6), -111.0 (95% CI: -178.5 to – 43.5) and -100
(95% CI: -143.9 to -56.1)
Pharmacological intervention -
Antifibrinolytics

41. •Lethaby, A. et al, 2009, Nonsteroidal anti-inflammatory drugs for heavy
menstrual bleeding
•Nine of seventeen selected trials were included
•NSAIDS were more effective than placebo at reducing bleeding
•Less effective than tranexamic acid, danazol and the levonorgestrel
intrauterine system
•No significant differences between NSAIDS and other medical treatments
Pharmacological intervention -
NSAIDS

42. •Lethaby, A. Et al, 2009, Cyclical progestogens for heavy
menstrual bleeding
•Seven randomised trials that were selected included
•No comparison with placebo
•Significantly less effective than tranexamic acid, danazol and
levonorgestrel IUS
Pharmacological intervention – Oral
progestogens

43. •Lethaby et al, 2009, Progesterone or progestogen-releasing intrauterine
systems for heavy menstrual bleeding
•Nine trials were selected and incorporated
•LNG IUS significantly reduced blood loss compared with luteal
progestogens
•Endometrial ablation compared favourably with LNG IUS
•-45.2 units (95% CI: -56.9 to -33.5), but similar patient satisfaction
Pharmacological intervention –
Levonoregestrel IUS (LNG IUS)

44. •Lethaby, A. et al, 2009, Endometrial resection / ablation
techniques for heavy menstrual bleeding
•No significant difference between hysteroscopic and blind
ablation
•Significant advantage of hysterectomy when compared with
ablation
•Ablation cheaper in short term but narrows over longer term
•Hysterectomy stops all bleeding
Surgical intervention

45. •Majoribanks J, et al, 2010, Surgery versus
medical therapy for heavy menstrual bleeding
•Twelve trials met criteria and were included
•58% of those randomised to medical
treatment had received surgery by 2 years
Medical vs. surgical

46. •Compared to oral medication endometrial resection
significantly more effective NNT = 2, one study
•Conservative surgery significantly more effective than LNG-
IUS at one year
•Two small studies favoured LNG IUS or found no difference –
skewed data, loss to follow up
•No difference in satisfaction rates between LNG IUS and
surgery
Pharmacological intervention –
Medical vs. surgical

47. Summary
Treatment Reduction in
blood loss (%)
Notes
Combined oral
contraceptive pill
43 Contraceptive, little evidence base,
weight change etc.
Tranexamic acid 29–58 Well tolerated. Do not improve
dysmenorrhea
NSAIDs 20–49 Only taken during menstruation. GI side
effects
oral progestogen* 83 Weight change, nausea, headache,
bloating
Levonorgestrel IUS
(Mirena)
71–94 Contraceptive, irregular bleeding,
ectopics
Endometrial ablation10% amenorrhea
90% sig.
reduction
Infertility? All methods similar, go for
cheapest.
Hysterectomy 100 Infertility

48. References
•Farquhar, C. & Brown, J. (2009) Cochrane Review – Oral contraceptive pill for heavy
menstrual bleeding.
•Lethaby, A., Irvine, G. & Farquhar, C. (2010) Cochrane Review – Cyclical progestogens for
heavy menstrual bleeding.
•Majoribanks, J., Lethaby, A. & Farquhar. (2010) Surgery versus medical therapy for heavy
menstrual bleeding.
•Lethaby, A., Hickey, M., Garry, R. & Penninx, J. (2009) Cochrane Review – Endometrial
resection/ablation techniques for heavy menstrual bleeding
•Lethaby, A., Shepperd, S., Farquhar, C & Cooke, I. (2009) Ecochrane Review – Endometrial
resev=ction versus hysterectomy for heavy menstrual bleeding
•Lethaby, A., Farquhar, C. & Cooke, I. (2009) Cochrane Review – Antifibrinolytics for heavy
menstrual bleeding.
•Lethaby, A., Augood, C., Duckitt, K. & Farquhar, C. (2009) Cochrane Review – Nonsteroidal
anti-inflammatory drugs for heavy menstrual bleeding
•Lethaby, A., Ivanova, V. & Johnson, N. (2009) Total versus subtotal hysterectomy for benign
gynaecological conditions
•NICE – Heavy menstrual bleeding