Question 4

Che Mah is a 45 year old Para 5 presented herself to the outpatient clinic for prolonged menses since
Jan this year. The menses was heavy for the first 7 days, later become staining only on and off till now.
a)

Discuss the management of this lady

Differential diagnosis
)

Fibroids

Endometrial polyp

Pelvic inflammatory disease

Endometrial or cervical Ca

Intrauterine contraceptive devices (IUCDs)

Coagulation disorders, e.g. von Willebrands disease

Thyroid disease

Assessment and Investigations

Assessment of menstrual blood loss

Pattern of menstrual blood loss

Pelvic examination

Full blood count

Thyroid function test

Assessment of endometrium

Ultrasound

Hysteroscopy and endometrial biopsy

Points to consider when selecting

appropriate management

Patients preference of treatment

Risks or benefits of each option

Contraceptive requirement:

Family complete?

Current contraception

Past medical history:

Any contraindication to medical therapies for heavy menstrual bleeding

Suitability for an anaesthetic (surgical history)

General Management
1)

Medical Care

a)

Mefenamic Acid and other NSAIDs

Reduction in mean menstrual blood loss of 20-25 %

Benefits:

Effective analgesia

First line treatment of choice where dysmenorrhea coexists

Disadvantages:

Contraindicated with the history of duodenal ulcer and severe asthma

Some recent concerns that long term usage of NSAIDs may cause reversible difficulties in
conceiving.

b)

Tranexamic acid

Mean reduction in menstrual blood loss of about 50%

Benefits:

Only requires to be taken on days when the bleeding is particularly heavy

Compatible with ongoing attempt at conception

Disadvantages:

c)
)

Combined OCPs
Benefits:

May be associated with an increased risk of venous thrombosis

Doubles up as a very effective contraceptive when taken properly

Disadvantages:

Contraindicated for patients who have risk factors for thromboembolism

Unsuitable for patients over 35 years old who smoke

Unsuitable if there is personal or family history of breast Ca

Unsuitable for patients who are grossly overweight

d)

Norethisterone

Cyclical progestogen

Effective taken in a cyclical pattern from day 6 to day 26 of menstrual cycle

Benefits:

Save and effective oral preparation

Can regulate bleeding pattern

Disadvantages:

Not a contraceptive

Can cause breakthrough bleeding

e)

Levonorgestrel intrauterine system (LNG-IUS)

Provide a highly effective alternative to surgical treatment

Mean reductions in menstrual blood loss of around 65% by 1 year after LNG-IUS insertion

Benefits:

Provides contraceptive cover comparable with sterilization

Effective for associated dysmenorrhea

Around 30% of women are amenorrheic by 1 year after insertion

Disadvantages:

Irregular menses and breakthrough bleeding for the first 3-9 months after insertion

f)

GnRH agonist

Act on pituitary to stop the production of oestrogen which result in amenorrhea

Used in short term due to resulting hypoestrogenic state which predisposes to osteoporosis

Benefits:

Effective for associated dysmenorrhea

Disadvantages:

Can cause irregular bleeding

Can be associated with flushing and sweating

Only suitable for short term usage unless combined with addback HRT

2)

Surgical Care

Normally restricted to women for whom medical treatment have failed

Must be certain that their family is complete

a)

Endometrial ablation

Ablation of endometrial lining of the uterus to sufficient depth prevents regeneration of endometrium

Mean reduction in blood loss is estimated at around 90%

Success rates

As a general rule, 40% will become amenorrheic, 40% will have markedly reduced menstrual loss, and
20% will have no difference in their bleeding

b)
)

Hysterectomy
Subtotal hysterectomy (STAH) removal of uterus while cervix remains

Carried out when patient states this as her preference or when adhesions prevent safe removal of cervix

Screening (cervical smears) are required as there is risk of cervical cancer

Bilateral Salpingo-oopherectomy removal both ovaries and Fallopian tubes

Result in immediate postmenopausal state

HRT may need to be considered