Bleeding/Menorraghia

Menorraghia: excessive bleeding during menses, regular heavy bleeding

Menmetorraghia: heavy bleeding that occurs irregularly

Polymenorrhea: bleeding less than every 21 days

Oligomenorrhea: scanty bleeding

Amenorrhea: no bleeding

- bleeding problems can have to do with frequency, flow, amount

DUB- “dysfunctional uterine bleeding”

-colloquially refers to heavy bleeding (but officially includes all of the previous definitions)

- can be ovulatory or non ovulatory

-the problem with DUB is that we don’t know if a woman with DUB is at increased risk for endometrial cancer or other endometrial pathology --- need to figure it out!

Tests to Check Endometrium Pathology

1) D/C – dilatation and curettage

-dilate cervix and take curettage and scrape the lining of the uterus

-used to think that it could be diagnostic and therapeutic because getting a sample and scraping the endometrium away

-not done very often now because it is a blind procedure

- ex: if there was a fibroid in the uterus, you could scrape the wrong side of the uterus and miss the fibroid diagnosis completely

2) Endoscopic examination – hystroscopy (look inside the uterus)

- this is the primary test

3) Transvaginal Scan (TVS) – ultrasound

-looking at the thickness of the endometrium

-insert a probe into the vagina to examine the thickness

-looking for an endometrium that is less than 0.5mm in thickness (indicates no build up, it is a thin endometrium)

Treatment

-if woman is less than 40 years old treat with medication

-if woman is greater than 40 years old or has a risk factor for endometrial cancer:

hystroscopy or TVS
if normal – treat with medication
if abnormal – surgical intervention (D/C, endometrial ablation, hysterectomy)

Medication Options:

1)Oral Contraceptives – choose one with high progesterone content

2)Marena – progesterone only IUD (blocks the estrogen and therefore the bleeding)

(don’t use depo provera because it has irregular bleeding associated with it)

But if patient does not need contraceptive therapy …

1)NSAIDS – treats dysmenorrhea and DUB

blocks some of the pain and also has been shown to help with DUB
not the greatest but if patient has dysmenorrhea and DUB – we try it first

But if patient does not have dysmenorrhea there are better options …

1) Danazol – talked about it in endometriosis, see those notes and learn it

2) Tranexamic Acid (Cyklokaperon)

in ovulatory cycles there is a lot of plasminogen activator (which helps someone have their period)
tranexamic acid blocks plasminogen activator and therefore stops bleeding
Dose: 1g every 6 hours for 4 days
start using it when the heavy bleeding begins – decreases amount of bleeding by 40%
works pretty fast
Primarily used in ovulatory cycles
Not solely used for menorrhagia (has other indications)

Side effects: N/V/D

hypotension

dizziness

retinal damage – changes in vision:

(colour changes, changes in visual acuity etc., if this happens discontinue the drug)

3) Provera

-traditionally use 10 mg daily for 10 days

-MOA:

-sometimes in DUB you don’t get a full secretory change, some of the endometrium might be secretory, some proliferative and some mixed

-if that happens the menstrual bleed is not short, and the uterus will continue to bleed and bleed and bleed

-if people are having long periods give provera for 10 days and it will change the entire endometrium into a secretory endometrium and then the bleeding will stop (because the secretory endometrium will be shed and then there is no lining left)

-used in anovulatory bleeding because if you are not ovulating, you are not producing progesterone so we will give you some

-converts the entire endometrium to a full secretory endometrium so that all of the cells can be shed

-provera is also used in women who have not had a period in a long time (amenorrhea), ie. Provera starts bleeding in this case rather than stops it

-MOA in this case:

creates a full secretory endometrium and when the drug is stopped the progesterone levels fall and this causes a period

-the main difference in the 2 provera scenarios is that when it is taken in the first case menstruation has already started and in the second case menstruation has not begun and will not begin on its own

4) GnRH analogue – wipes out all function and puts someone into menopause

- not first choice

Cases

1)so, if a premenopausal woman goes to a doc and presents with amenorrhea, give provera 10mg for 10 days every 30 days unless the woman has her own period (because if she has her own period we don’t need to induce a second one)

-this regimen would give her a monthly period and there will be no endometrial build up

2) a woman goes to the doctor’s office and she has been bleeding for quite a while … give 10 mg of provera for 10 days to stop the period (this woman has an anovulatory cycle)