men no rag hi a
TRANSCRIPT
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MANAGEMENT OFTHE PATIENT WITHMENORRHAGIA
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Menorrhagia
Definition:
Abnormally heavy and prolonged
intervals (Cytyc, 2004).
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I've been bleeding for 7 days
now, changing tampons every1-2 hours...
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Causes
Abnormal blood clotting
regulation
Disorders of endometrial lining
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Effects
Physical
SocialEmotional
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Physical:
clots
dysmenorrhea
anemiafatigue
headaches
nausea
(Hologic, 2008).
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Social:
60% of w omen m iss soc ia levents33% m iss w ork 33% m iss w ork (Hologic , 2008)
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Emotional:
66% feel depression
75% feel anxious
(Hologic 2008)
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Other possible causes of
heavy bleeding
Can occ ur at any t im e dur ing the
menst rua l cyc le
Can be caused by a w ide var ie ty o f c on ons e.g. ro s, po yps,
hormones) Menstr ua l b leed ing c an be:
m ore f requent t han norm al(met ro r rhag ia )exc ess ive and f requent
(menomet ro r rhag ia )
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RECOMMENDATIONS
Cochrane Database
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Grade of recommendationGrade A - based on randomizedcontrolled trials*
Grade B - based on robust experimental
Grade C - based on more limitedevidence but the advice relies on expert
opinion
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Educ at ion for w om en beforeappo in tmen t :
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Nurs ing Adv ice t ohe lp p t p repare for
app t :Regular i t y o f B leed ing:Keep t rack on ca lendar and bring t o
appoin t m ent (Grade B). oo oss: c ount ampons and padsused , & char t t heamount o f sat u rat ion(l ight , m oderate ,sat urat ed) (Grade B).
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Is this type of bleeding normal?
Perimenopausal women with irregularcycles but normal blood loss may not requirework-up (Grade C).
An abdominal and pelvic examinations ou e per orme n women presen ngwith heavy menstrual bleeding with thepossible exception of women under the age
of 20 as the likelihood of pathology is small(Grade C).
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Erratic Bleeding
Women with erratic bleeding
should be evaluated by a providerto determine presence of a fibroid/
polyp, infection etc.
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What will they do at my
appointment?review bleeding
pattern and history
pelvic exam
possible US
possibly offer meds.
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Diagnostic tools
US:
Women with
an abnormal
pelvic
examination
should have an
ultrasound to
confirm the
findings
(Grade C).
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Assessment via US
The following women with heavy menstrual bleedingare recommended to have a transvaginal ultrasound ofthe endometrium
- weight 200 lbs- age years o
- other risk factors for endometrial hyperplasia orcarcinoma such as infertility or nullipairty, family
history of colon or endometrial cancer, exposure tounopposed estrogens (Grade B).
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Diagnostic tools
Lab
Thyroid function tests may be performed
in women with heavy menstrual bleedingespec a y e woman as symp oms or
signs of hypothyroidism (Grade C).
A CBC should be offered to all womenpresenting with heavy menstrual bleeding
(Grade B)
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AssessmentLab
Test s fo r c oagu lopathyare on ly ind ic at ed inw omen w ho haveomen w ho havesusp ic ious feat ures in t he
h ist o ry o r ex am inat ion(Grade C).
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Diagnostic tools:
EndometrialBiopsy
If transvaginal ultrasound is not available then an
endometrial sample should be taken (Grade C).
If the endometrial thickness on US is 12 mm an
endometrial sample should be taken to exclude
endometrial hyperplasia (Grade A).
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Followup on Endometrial Biopsyresults
Failure to obtain sufficient material for
histological diagnosis does not requirefurther investigation unless the endometrialthickness is 12 mm (Grade B).
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Medical Management
The following treatments are effective in reducing
re ular heav menstrual bleedin :
Levonorgestrel intrauterine system (MIRENA)
Birth control Pill/ nuva ring
NSAIDS (menstruating days only) 600 mgIbuprofen TID
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Br J Obstet Gynaecol.1986 Sep;93(9):974-8.Primary and myoma-associated menorrhagia: role of prostaglandins and effects ofibuprofen.
Mkrinen L, Ylikorkala O.
The release of 6-keto-prostaglandin F1 alpha(6-keto-PGF1 alpha), a metabolite ofprostacyclin (PGI2) and thromboxane B2 (TxB2), a metabolite of thromboxane A2(TxA2), was estimated in endometrial biopsies taken from 12 menorrhagic and 12healthy women during the luteal phase of the cycle. The releases of 6-keto-PGF1alpha and TxB2 were normal, but the ratio TxB2/6-keto-PGF1 alpha was inversely
related to menstrual blood loss in women with measured menstrual blood loss. ,
bleeding (13 with primary menorrhagia, 10 with uterine fibromyomas, one withhaemostatic factor VIII deficiency) were treated at random with ibuprofen (600 mg/dayand 1200 mg/day) and with a placebo. Ibuprofen 1200 mg/day reduced (P less than0.01) median blood loss from 146 ml (range 71-374 ml) to 110 ml (30-288 ml) inprimary menorrhagia but had no effect on blood loss in women with uterine fibroids
and factor VIII deficiency. Blood loss was normal in six women and was not affectedby ibuprofen. Thus, ourdata suggest that there is a PGI2 dominance in theendometrium of patients with menorrhagia. In addition, primary, but neitherfibromyoma nor coagulation defect-associated menorrhagia, can be treated byibuprofen.
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Medical Management
Progestogens (medroxyprogesterone
acetate) given in the luteal phase (Day 12-
26 are not effective in reducin re ular
heavy menstrual bleeding (Grade A).
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REFERRAL TO MD
Hysteroscopy and biopsy isindicated for :-women with erratic menstrualbleeding.
- failed medical therapy.-suggestive of intrauterinepathology such as polyps or
submucous fibroids (Grade B).
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Surg ica lu rg i ca lManagementanagement
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Surgical Management
Dilatation and curettage is not effective fortherapy in women with heavy menstrual
bleeding (Grade B).
variety of techniques but there may be a 40%
reoperation rate after 5 years (Grade A).
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Surgical Management
Women are more likely to be satisfied with
endometrial ablation than oral medical
.
There is a similar satisfaction rate and
efficacy with endometrial ablation and
MIRENA (levonorgestrel intrauterinesystem) (Grade A).
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Surgical Management
Endometrial destruction techniques
and vaginal hysterectomy arepre era e to a om na
hysterectomy (Grade B).
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Thank You!