Dr Kristina Naidoo
Consultant Gynaecologist
Menstrual Disorders
 Defining normality
 Defining problem
 Investigations
 Treatment
Normal menstruation
 Most menstrual cycles 22 to 35 days
 Normal menstrual flow 3 to 7 days
 Most blood loss occurs within first
3 days
 Menstrual flow amounts to 35ml*
 In general, most normal
menstruating women use five or six
pads or tampons per day.
Menarche/Menopause
 Menarche average age 12.9

Anovulatory cycles 80% in first year, 10% in 6th year
 Menopause 42-58 (average 51)
 Postmenopausal bleeding > 1 year after the last menses
Symptoms of AUB
 Heavy menstrual bleeding
 Intermenstrual bleeding (IMB)
 Postcoital bleeding (PCB)
 Irregular menstrual cycle
 Postmenopausal bleeding
 +/-pain
FIGO classification of Causes of
AUB (non-pregnancy)
PALM-COEIN
P
A
L
M
C
O
E
I
N
polyps
adenomyosis
leiomyoma
malignancy & hyperplasia
coagulopathy
ovulatory disorders
endometrial causes
iatrogenic
not classified
When to refer
Suspected cancer- symptoms
 PCB lasting more than 4 weeks over 35 years
 IMB persistent and unexplained
 1 or more episodes of PMB and NOT on HRT
 Persistent or unexplained PMB 6/52 after cessation of
HRT
 Any unscheduled bleeding on Tamoxifen
 NOT Repeated, unexplained PCB
When to refer
Suspected cancer- signs
 Palpable abdominal/pelvic mass not obviously
fibroids/urinary or GI
 Lesion on cervix suspicious of cancer
 Unexplained vulval lump
 Vulval bleeding due to ulceration
Heavy Menstrual Bleeding
(HMB)
 Excessive menstrual blood loss which interferes with a
woman's physical, social, emotional and/or material
quality of life
 It can occur alone or in combination with other
symptoms
HMB
 Blood loss is subjective
 30% women consider their bleeding to be excessive
 Half of these have a normal blood loss (<80ml)
 Women aged 30-49, 1:20 consults GP re HMB each
year
 HMB accounts for 12% of Gynae referrals
 £7 million a year spent on prescriptions in primary care
(2007)
Mirena LNG-IUS
 Provided long-term use (at least 12 months anticipated)
 Prevents endometrial proliferation.
 Contraceptive.
 Doesn't impact future fertility.
 Unwanted outcomes: irregular bleeding that can last for six
months; amenorrhoea; progestogen-related problems such
as breast tenderness, acne and headaches; uterine
perforation at insertion (1 in 100,000 chance).
 As equally effective in improving quality of life and
psychological well-being as hysterectomy.
Submucous fibroid and Mirena IUS
Tranexamic acid
 Oral antifibrinolytic .
 If no improvement, stop after three cycles.
 Unwanted outcomes: indigestion; diarrhoea;
headache.
 No increased risk of thrombosis. Cochrane review.
 Dose: 500 mg tablets. 2 to 3 tablets (1-1.5g three to
four times daily for three to four days. From onset of
heavy bleeding.
NSAIDs
 Commonly used: mefenamic acid
 Reduce production of prostaglandin.
 If no improvement, stop after three cycles.
 Preferred over tranexamic acid in dysmenorrhoea.
 Unwanted outcomes: indigestion; diarrhoea;
worsening of asthma
 Dose: mefenamic acid 500 mg tablets. 1 tablet three
times daily during heavy bleeding.
COCPs
 Prevent proliferation of the endometrium.
 Also act as a contraceptive.
 Do not impact future fertility.
 Unwanted outcomes: mood change; headache;
nausea; fluid retention; breast tenderness; DVT; MI;
CVA.
Oral progestogen
 Commonly used: Norethisterone
 Prevents proliferation of the endometrium.
 Does not impact future fertility.
 Dose: 15 mg daily on days 5-26 of the cycle.
 Unwanted outcomes: weight gain; bloating; breast
tenderness; headaches; acne; depression.
 A recent Cochrane Review showed that this regime of
progestogen results in a significant reduction in menstrual
blood loss but that women find the treatment less
acceptable than intrauterine levonorgestrel.
Injected progestogen





Depot-medroxyprogesterone acetate
Prevents proliferation of the endometrium.
Contraceptive.
Does not impact on future fertility.
Unwanted outcomes: as for oral progs; weight gain;
irregular bleeding; amenorrhoea; bone density loss.
 Current guidance:
 Use in adolescents as last resort.
 Other women re-evaluate after 2 years, if significant
risk factors for osteoporosis consider alternative.
When to refer
 Suspicion from history of increased risk of pathology:
 E.g. family history of endometrial or colonic cancer
 Infertility/nulliparity
 Obesity/diabetes
 Unopposed oestrogen therapy
 PCOS
‘One stop’ Menstrual Dysfunction
Clinic
Conventional pathway
‘One stop’ pathway
General Gynaecology Clinic ?biopsy
‘One stop’ menstrual dysfunction clinic
Pelvic scan
Review, list for Day Case Hysteroscopy
Pre-operative assessment clinic
Hysteroscopy under GA
Follow-up to plan management
Outpatient Hysteroscopy
 RCOG recommendation
 2012 favourable tariff
 Diagnosis of benign
intrauterine pathology
 Treatment
 Resection polyps, small
fibroids, RPOCs
 IUD retrieval
Conclusions
 Reassurance re normal patterns of bleeding
 Full blood count -first line investigation
 Low threshold for pelvic scanning (TVS)
 Hormonal contraception for HMB
 Red flag symptoms-> HSC205 pathway
 Risk factors for endometrial pathology-> refer early
 ‘One stop’ clinics advantageous