1. MENORRHAGIA – AN OVERVIEW
MUKESH
Dr. MUKESH CHANDRA
M.S;FICOG;FICMU,FICMCH,Dip.Lap.Surg (Germany);Dip.Ultrasound (New Zealand)
ASSOCIATE PROFESSOR ,
Dept.of OB/GYN,S.N.MEDICAL COLLEGE,AGRA

2. Diversity of Menorrhagia
MUKESH
5% women aged consult their Gynaecologists annually with menorrhagia.
Only 58% of women receive medical therapy for menorrhagia before referral to a specialist.
60% of women with menorrhagia will have a hysterectomy within five years.
One in five women will have a hysterectomy before the age of sixty.
In 50% who undergo hysterectomies menorrhagia is the main presenting problem.
Upto 50% of women who present with menorrhagia have blood losses within a normal range
30% of all women undergoing hysterectomy for menorrhagia have a normal uterus removed.
Such variation in the management of a common complaint is an indication for guideline development
Menorrhagia has an impact on many women’s lives. Complaints of excessive menstrual bleeding, have a substantial impact on gynaecological practice and in most cases no organic pathology is identifiable.
There are wide variations both in the drugs prescribed in general practice for the management of menorrhagia, and in population-based rates of hysterectomy.
The diversity is depicted in the shown statistics

3. How do we define menorrhagia ?
MUKESH
Menorrhagia can be defined objectively or subjectively
Subjectively, menorrhagia is defined as a complaint of excessive menstrual blood loss occurring over several consecutive cycles in a woman of reproductive years
Objectively, menorrhagia is taken to be a total menstrual blood loss –80 ml per menstruation
This presentation reviews both objective and subjective menorrhagia. The management of any other abnormalities of the menstrual cycle, e.g. irregular bleeding, is beyond the scope of this talk.

4. Complexity of menorrhagia?
MUKESH
Menorrhagia— is the medical term for excessive or prolonged menstrual bleeding or both
The condition also is known as hypermenorrhea
The menstrual cycle isn't the same for every woman
Normal menstrual flow occurs about every 28 days, lasts about 5 days and produces a total blood loss of 30 to 40 milliliters
Some women have frequent menstrual spotting, while others find that heavy bleeding is normal
Between 15 and 20 percent of healthy women experience debilitating menorrhagia that interferes with their normal activities
Bleeding heavily and/or if periods last more than seven days is considered excessively heavy menstruation
Different women experience different effects before and during their periods.

5. DUB
MUKESH
Doctors generally define menorrhagia as menstrual bleeding that lasts more than eight to ten days or a blood loss of over 80 milliliters (about 1/3 cup). This would be considered dysfunctional uterine bleeding (DUB), and could lead to an iron deficiency or anemia if not attended to promptly
DUB Variations
Other types of dysfunctional uterine bleeding include metorrhagia (bleeding in between periods or menstrual spotting) and polymenorrhea (having a period more often than every 21 days)
Although 30 percent of premenopausal women complain of heavy menstrual bleeding, only 10 percent experience blood loss severe enough to be defined as menorrhagia.

6. Assessment of blood loss
MUKESH
How does one measure the amount of bleeding?
A little blood can seem like much more than it actually is. One way to gauge the bleeding is to see if she is soaking through enough sanitary protection products to require changing more than every one to two hours
Blood clots are normal during menstruation. One must remember that in addition to blood loss, the endometrium is also being shed
26% of women with normal menstrual loss ( < 60 mL) considered their periods heavy, while 40% of those with heavy losses ( > 80 mL) considered their periods to be moderate or light

7. Subjective Assessment
MUKESH
Menstrual flow that soaks through one or more sanitary pads or tampons every hour for several consecutive hours
The need to use double sanitary protection to control your menstrual flow
The need to change sanitary protection during the night
Menstrual period that lasts longer than 7 days
Menstrual flow that includes large blood clots
Heavy menstrual flow that interferes with your regular lifestyle
Constant pain in the lower abdomen during menstrual period
Irregular menstrual periods
Tiredness, fatigue or shortness of breath (symptoms of anemia)

8. MUKESH
Pathogenesis
The volume of blood lost at menstruation is controlled by local uterine vascular tone, haemostasis, and regeneration of endometrium
Patients with menorrhagia have shown a greater endometrial concentration of the vasodilator prostaglandin E (PGE),
and a relationship between total prostaglandin (PGE, PGI 2 and PGF F2 a ) concentration and average blood loss
Increased endometrial fibrinolysis may be of importance
Increased endometrial fibrinolysis may be of importance, as suggested by reduction in mean menstrual blood loss in women taking fibrinolytic inhibitors (e.g., tranexamic acid).
The frequency of the organic causes in a normal population is not known.
Anovulation may be associated with menorrhagia close to menarche and to menopause. It may be particularly important when prolonged menstrual cycles occur, as oestrogen in the absence of progesterone may cause endometrial hyperplasia, atypical hyperplasia and eventually carcinoma. Progesterone alone or progesterone associated with the oral contraceptive pill prevents such changes.
Management of women with menorrhagia may be more effective if psychosocial factors (depression, work difficulties, heavy smoking [> 20 per day], excessive alcohol intake, and sexual problems) are taken into consideration

9. Causes of Menorrhagia Hormonal imbalance Uterine fibroids Polyps
MUKESH
Hormonal imbalance
Uterine fibroids
Polyps
Ovarian cysts
Dysfunction of the ovaries
Adenomyosis
Pelvic Inflammatory Disease.
Intrauterine device (IUD
Other medical conditions
Cancer
Pregnancy complications
Medications
In some cases the cause of heavy menstrual bleeding is unknown, but a number of conditions may cause or increase your risk of menorrhagia.
Hormonal imbalance. Normally a balance between the hormones estrogen and progesterone regulates the buildup of the endometrium, which is shed during menstruation. If a hormonal imbalance occurs, the endometrium proliferates in excess and eventually sheds by way of heavy menstrual bleeding.
Uterine fibroids. Together, uterine fibroids and hormonal imbalance account for about 80 percent of all cases of menorrhagia.
Polyps. The development of small benign growths on the uterine wall (uterine polyps) or cervix may cause heavy or prolonged menstrual bleeding. Polyps of the uterus most commonly occur in women of reproductive age as the result of excessive hormone production or consumption and can lead to bleeding not associated with menstruation. Polyps are less common after menopause
Ovarian cysts. may cause menstrual irregularities, including menorrhagia due to excessive Estrogen production.
Dysfunction of the ovaries. anovulation may cause hormonal imbalance and result in menorrhagia.
Adenomyosis. Often cause heavy bleeding and pain. Adenomyosis is most likely to develop if in a middle-aged multiparous women.
Pelvic Inflammatory Disease.
Intrauterine device (IUD). Menorrhagia is a well-known side effect of using an intrauterine device. Light spotting is normal with the use of an Other medical conditionsPelvic inflammatory disease (PID), thyroid problems, endometriosis, lupus, liver or kidney disease, some uncommon blood disorders and certain cancers and chemotherapies may cause menorrhagia.
Cancer. Although rare, certain female reproductive cancers may cause menorrhagia. Uterine cancer, ovarian cancer and cervical cancer can cause excessive vaginal bleeding.
Pregnancy complications. An ectopic pregnancymay cause menorrhagia.
Medications. Certain drugs, including those that prevent the clotting of blood (anticoagulants) and anti-inflammatory medications, can cause heavy or prolonged menstrual bleeding.

10. Protocol for Clinical Evaluation
MUKESH
When to seek medical advice
If one experiences irregular vaginal bleeding, schedule an appointment with the doctor and be certain to record when the bleeding occurs during the month. If she is having heavy vaginal bleeding — soaking at least one pad or tampon an hour for more than a few hours — seek medical help. Call your doctor if you have severe menstrual pain that does not respond to at-home treatment or if you have vaginal bleeding after menopause.
Genetic tendency of heavy menstrual flow
Screening and diagnosis
. If a woman continues to complain of heavy menstrual bleeding, despite having used a drug treatment, her menstrual history should be re-evaluated and an abdominal, bimanual and speculum examination performed

11. Investigations Blood tests Pap test
MUKESH
Blood tests
Pap test
Endometrial sampling and hysteroscopy
Vaginal ultrasound
Sonohysterogram
Endometrial biopsy
Dilatation and curettage (D&C)
Blood tests: A full blood count should be performed. Tests for thyroid function and bleeding disorders should only be performed if there are suggestive features present in the history or on examination. No other endocrine investigations are necessary in the investigation of menorrhagia
Pap test. to show conditions such as infection or inflammation or to detect changes that may be cancerous or may lead to cancer.
Endometrial sampling and hysteroscopy: ,it allows direct visualisation of the uterine cavity and the opportunity for an endometrial biopsy, hysteroscopy (which enables targeted biopsy of abnormal endometrium) and are as accurate and cost effective as D&C.
Vaginal ultrasound: . The uterine cavity should initially be investigated using transvaginal ultrasound. Ultrasound diagnosis markedly increases the accuracy of clinical diagnosis and assists in treatment choice (including avoidance of surgery) and selection of patients most suited to endometrial resection, intrauterine resection of polyps and fibromyomas, open, vaginal or laparoscopic myomectomy, adenomyomectomy and hysterectomy.
Sonohysterogram. This ultrasound scan is done after fluid is injected through a tube into the uterus by way of your vagina and cervix. This allows a better look into endometrial lining.
Endometrial biopsy. should be considered for all women with persistent menorrhagia.
Dilatation and curettage (D&C) involves a general anaesthetic and a one-day stay in hospital; it is not cost effective for diagnosing endometrial malignancy in women under 40 years (who have a low prevalence of serious uterine conditions and endometrial cancer).The potential benefits need to be weighed up against the risks (general anaesthesia and possible uterine perforation and laceration of the cervix).Moreover, a significant proportion of endometrial lesions are not detected by D&C, and its usefulness as a diagnostic tool has been repeatedly questioned. It does not give additional diagnostic information over and above a hysteroscopy with endometrial biopsy (
Doctors can be certain of a diagnosis of menorrhagia only when other menstrual disorders, medical conditions or medications are ruled out as possible causes or aggravations of the condition.

12. Complications Severe pain Infertility Toxic shock syndrome Anemia
MUKESH
Excessive or prolonged menstrual bleeding can lead to other medical conditions, including:
Severe pain
Infertility
Toxic shock syndrome
Anemia
Anemia. Menorrhagia is the most common cause of anemia in premenopausal women. An estimated 10 percent of women in their reproductive years have iron deficiencies, with between 2 percent and 5 percent having iron levels low enough to cause anemia.
Severe pain. Heavy menstrual bleeding often is accompanied by menstrual cramps (dysmenorrhea). Although most women choose at-home treatment for the menstrual pain that menorrhagia can bring, others may have more severe pain and need to seek medical relief through prescription medication or a surgical procedure.
Infertility. Many conditions associated with menstrual irregularities, including heavy bleeding, ovulation abnormalities, uterine fibroids and endometriosis, are major contributors to female infertility. Irregular periods from any cause may make it more difficult to conceive.
Toxic shock syndrome. Keeping tampons in place for more that 8 hours increases the risk of infection and toxic shock syndrome, a rare but potentially life-threatening condition caused by bacteria that adhere to tampons and produce toxins

13. Treatment
MUKESH
Specific treatment for menorrhagia is based on a number of factors including:
Overall health and medical history
Extent of the condition
Cause of the condition
Tolerance for specific medications, procedures or therapies
Expectations for how the condition will progress
Effects of the condition on the lifestyle
Personal preference

14. Drug therapy Drug therapy for menorrhagia may include:
MUKESH
Drug therapy for menorrhagia may include:
Recent studies have shown tranexamic acid to be more effective (54% reduction in blood loss) than mefenamic acid (20% reduction), whereas ethamsylate (a clotting agent) was ineffective.
Second line drugs such as danazol, gestrinone, and gonadotrophin releasing hormone analogues are effective in reducing heavy menstrual blood loss but side effects limit their long-term use.
Others include:
Iron supplements
Prostaglandin inhibitors
Oral contraceptives
Progesterone
Over the last decade, a wide variety of drugs have been used for the treatment of menorrhagia. Medical treatment avoids major surgery, but has associated side effects and is generally only effective for the duration of treatment.
women with a pretreatment blood loss of mL per cycle, 92% had their blood loss reduced to less than 80 mL per cycle with tranexamic acid. Those with a menstrual blood loss of more than 250 mL per cycle did not achieve a normal blood loss and required surgery.
Danazol's serious side effects (menopausal symptoms and mild androgenic effects) make it unacceptable for long term use and it is also relatively expensive. Tranexamic acid has few side effects and offers the advantage of alleviating menstrual pain.
Iron supplements. If the condition is accompanied by anemia, iron supplementation is recommended. If your iron levels are low but you are not yet anemic, you may be started on iron supplements rather than waiting until you become anemic.
Prostaglandin inhibitors. These include nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin) to help reduce cramping and blood flow.
Oral contraceptives. Aside from providing effective birth control, oral contraceptives can be taken to help regulate ovulation and reduce episodes of excessive or prolonged menstrual bleeding.
Progesterone. Whilst oral Luteal phase progestogens are ineffective in reducing menstrual blood loss, intrauterine progestogens are effective. A progestogen releasing IUD is an effective treatment for reducing heavy menstrual blood loss and should be considered as an alternative to surgical treatment.

15. Protocol for Management
MUKESH
Surgical treatment for menorrhagia may be required if drug therapy is unsuccessful. Consideration should be given to performing an objective or semi-objective measurement of menstrual blood loss before deciding upon definitive surgical treatment

16. Surgical Options Dilation and curettage (D and C)
MUKESH
Dilation and curettage (D and C)
Operative hysteroscopy
Endometrial ablation
Endometrial resection
Hysterectomy
Except for hysterectomy, these surgical procedures are usually done on an outpatient basis. Although you'll usually need a general anesthetic, it's likely that one can go home the same day.
Dilation and curettage (D and C). A D&C is not therapeutic in cases of heavy menstrual bleeding
Operative hysteroscopy. This diagnostic procedure uses a hysteroscope to view your uterine cavity. It's often used to aid in the surgical removal of a polyp that may be causing increased menstrual bleeding.
Endometrial ablation. With the use of a laser, electrocautery instrument or thermal balloon, the entire lining of your uterus is permanently removed or destroyed. About 75 percent of women who've had this procedure are satisfied with the treatment. After endometrial ablation, you should have little or no menstrual flow, although some women resume menstrual flow after considerable time has passed since the procedure.
Endometrial resection. This surgical procedure is performed with an electrosurgical wire loop to remove the lining of the uterus. Resection has a higher success rate in reducing bleeding and relieving pain in older women than in younger women. Both endometrial ablation and endometrial resection benefit women who have very heavy menstrual bleeding but do not have other underlying uterine problems such as large fibroids, polyps or cancer.
Hysterectomy. This is the surgical removal of the uterus itself. It is a permanent procedure that will cause you to be sterile and no longer have menstrual periods. General anesthesia and hospitalization is required. Because this procedure is permanent and can lead to premature menopause in younger women, you should be sure of this treatment before going ahead with surgery.

17. Abdominal Hysterectomy Vs Endometrial Resection
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Abdominal hysterectomy vs. endometrial resection
.Abdominal hysterectomy requires longer theatre times and hospital stay, whereas resection (ablation) is a day-stay or overnight procedure.
Abdominal hysterectomy has a higher complication rate (45%) compared with transcervical endometrial resection (0-15%)
Reported mortality rates for abdominal hysterectomy are two to five times higher than those for endometrial resection, and major complication rates are five to twelve times .
Resumption of normal activities after abdominal hysterectomy takes two to three months versus two to three weeks for resection.
The probability of requiring a hysterectomy four years after endometrial resection has been estimated to be 12%.
Hysterectomy is preferable if the patient has a large uterus, severe endometriosis
Endometrial resection/ablation avoids possible ovarian dysfunction and the psychological effects of hysterectomy.
Endometrial resection has a 47% cost advantage over hysterectomy because of shorter theatre time and hospital stay, but the cost advantage diminishes with time to 29% because of the need for repeat surgery.
Hysterectomy
Compared with abdominal hysterectomy, vaginal hysterectomy is associated with less pain and morbidity, shorter hospital stays and faster recovery periods.
Laparoscopic hysterectomy results compared with abdominal hysterectomy, postoperative pain is reduced and hospital stays (one to four days) and recovery periods (one to four weeks) are shorter
Endometrial resection results in 13%-64% of women having no menstrual bleeding and 62%-77% having reduced menstrual loss.
After endometrial resection 6%-23% of women require reoperation for continued bleeding, with the higher rates being reported in studies with a longer follow-up.
Some form of sterilisation or contraception is needed after endometrial resection. Pregnancy is unlikely, but if it occurs the risk of complications is higher.

18. Conclusion
MUKESH
The diversity of possible surgical treatments indicates the need for flexibility in choosing techniques to resolve an individual patient's problem, and the possible advantage for gynaecologists to learn the new minimal invasive techniques for removal of the endometrium or the uterus