Dr MUKESH CHANDRA M S FICOG FICMU FICMCH

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 MUKESH MENORRHAGIA – AN OVERVIEW

• 5% women aged 30 -49 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 MUKESH Diversity of Menorrhagia

? Menorrhagia can be defined objectively or subjectively Objectively, menorrhagia is taken to be a total menstrual blood loss – 80 ml per menstruation Subjectively, menorrhagia is defined as a complaint of excessive menstrual blood loss occurring over several consecutive cycles in a woman of reproductive years MUKESH How do we define menorrhagia

• • 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 MUKESH Complexity of menorrhagia?

• 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. MUKESH DUB

• 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 m. L) considered their periods heavy, while 40% of those with heavy losses ( > 80 m. L) considered their periods to be moderate or light MUKESH Assessment of blood loss

• • • 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) MUKESH Subjective Assessment

• 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 F 2 a ) concentration and average blood loss • Increased endometrial fibrinolysis may be of importance MUKESH Pathogenesis

• • • 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 MUKESH Causes of Menorrhagia

MUKESH Protocol for Clinical Evaluation

• Blood tests • Pap test • Endometrial sampling and hysteroscopy • Vaginal ultrasound • Sonohysterogram • Endometrial biopsy • Dilatation and curettage (D&C) MUKESH Investigations

Excessive or prolonged menstrual bleeding can lead to other medical conditions, including: • • Severe pain Infertility Toxic shock syndrome Anemia MUKESH Complications

• • 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 MUKESH Treatment

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 MUKESH Drug therapy

MUKESH Protocol for Management

MUKESH Surgical Options • Dilation and curettage (D and C) • Operative hysteroscopy • Endometrial ablation • Endometrial resection • Hysterectomy

• • • MUKESH Abdominal Hysterectomy Vs Endometrial Resection 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

MUKESH Conclusion 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