menorrhagia / PV bleeding

see also:

• gynaecology
• Emedicine
• RCH guidelines - Mx of adolescent with menorrhagia

• pregnancy-related causes - miscarriage, ectopic, late pregnancy causes such as placenta praevia and abruption, retained products
• haematologic causes such as warfarin or other anticoagulants, thrombocytopaenia, von Willebrand's disease, etc
• local causes such as trauma, vaginitis, local lesions, neoplasia / cancer / tumours, uterine fibroids (leiomyomas), uterine polyps, adenomyosis, IUD, foreign bodies, post-surgical procedures
• hormonal causes:
  • hormonal Rx or OCP-related - breakthrough or withdrawal bleeding
  • endometrial hyperplasia:
    • unopposed oestrogen build up of endometrium, often follows a period of amenorrhoea
    • prior to menopause, ovulation may not occur, although the ovaries are still producing oestrogen. This causes the endometrium to build up during a period of amenorrhoea of 2-3 months. When the oestrogen levels fluctuate downwards, there is a heavy withdrawal bleeding, which may be extremely massive, with flooding. This condition is termed metropathia haemorrhagica.
    • it may also occur in those on oestrogen only Rx
    • it must be considered in women who are obese, aged 70 or older, nulliparous, or have diabetes.
    • endometrial hyperplasia is a significant risk factor for uterine cancer
  • “dysfunctional uterine bleeding”:
    • ovulatory
    • anovulatory:
      • without ovulation, the corpus luteum fails to form, resulting in no progesterone secretion. Unopposed oestrogen allows the endometrium to proliferate and thicken. The endometrium finally outgrows its blood supply and degenerates. The end result is asynchronous breakdown of the endometrial lining at different levels resulting in bleeding heavier than normal menstrual flow.
      • the most common cause of DUB from menarche to the late-teen years, due to the immaturity of their hypothalamic-pituitary axis.
      • it is common in under-weight females (eg. <48kg) or the obese
      • patients with polycystic ovary syndrome (PCOS) / polyendocrine metabolic ovarian syndrome (PMOS)
      • non-pregnant and non-lactating patients with hyperprolactinaemia from a pituitary microadenoma
  • hypothyroidism
    • Both hypothyroidism and hyperthyroidism result in menorrhagia. Even subclinical cases of hypothyroidism produce heavy uterine bleeding in 20% of patients. Hyperthyroidism tends to cause amenorrhoea rather than menorrhagia.
  • chronic liver disease
  • steroid hormones and chemotherapy agents can disrupt the normal menstrual cycle.

• patients with heavy vaginal bleeding, especially if sanitary pads are insufficient to contain it, or large clots are repeatedly being passed, should be considered for Mx in an ED resuscitation room ASAP with following commenced:
  • large bore iv line
  • bloods for FBE, U&E, HCG (if not mid or large trimester pregnancy), Xmatch, consider clotting profile if appropriate
  • iv fluid resuscitation eg. 0.9% saline initially 1L stat, then as indicated
  • if early pregnancy, perform vaginal speculum examination ASAP to exclude products of conception (POC) retained in the cervix which may be causing cervical shock, and if present, remove these with a sponge holder forcep. This process will often need patience, preferably with a metal bivalve speculum rather than a plastic one, with a large number of attempts using gauze wrapped on a sponge holder to remove blood and clots from the vagina before the cervix can be visualised. Be prepared.
  • consider iv opiate analgesia as indicated if BP will tolerate it.
  • consider iv tranexamic acid (Cyclokapron) 1g in 100mL 0.9% saline over 15-30min if not pregnant

• if known to be pregnant and > 22 week gestation then consider placenta praevia, abruption, etc which need urgent assessment and Mx to reduce risk of stillbirth.
• if known to be pregnant and < 22 weeks gestation, then Mx as per vaginal bleeding in early pregnancy
• if recent miscarriage or delivery, consider retained products of conception and resultant endometritis as a cause - early ultrasound +/- trial of antibiotics then gynae OP r/v if stable.
  • Patients with presumed recent miscarriage may require serial HCG's to confirm this.
  • Chlamydia is now a relatively common cause of postpartum endometritis (although most are due to normal vagina flora and not STD organisms), leading to vaginal bleeding in the weeks following a delivery.
• all other patients in the potential pregnancy age group should have a serum HCG to exclude pregnancy-related causes.

• uncommonly, haematologic causes may be the main contributory factor
• haemostasis of the endometrium is directly related to the functions of platelets and fibrin.
• an FBE will exclude thrombocytopaenia as a cause
• ask the patient if they are on any anticoagulants, and if so, manage accordingly - eg. INR if on warfarin
• aspirin (acetylsalicylic acid) will increase bleeding risk for 7 days after a dose
• the patient is likely to tell you if they have known von Willebrand's disease, there is usually no need to screen for this.
  • this disorder is the most common genetic bleeding disorder, and affects 0.1-1% of the population with resultant deficiency in vWF and a secondary deficiency of factor VIII.
  • see RCH guideline on Mx of bleeding due to von Willebrand's disease
• patients with renal failure can develop uraemic coagulopathy which causes bleeding due to platelet dysfunction and abnormal factor VIII function.

• LOOK and FEEL for obvious lesions such as trauma following sexual activities, vaginitis, local tumours
• is it really vaginal bleeding - could it be from the urethra or ano-rectum?
• has the patient recently had gynae surgery such as:
  • a total abdominal hysterectomy (TAH), and now has a vault haematoma causing bleeding?
  • LLETZ procedure to cervix - if so see post-op PV bleeding after LLETZ procedure to cervix
• IUD is a common cause of increased menses and pain, but a recently inserted IUD is also at risk of causing endometritis and gynae should be consulted as to whether it should be removed, cultured and the patient started on antibiotics
• do not forget the possibility of a retained tampon, which tends to cause an offensive discharge as well as possible bleeding from local cervicitis, but is also a risk for developing potentially fatal toxic shock syndrome.

• gynaecologic cancers (eg. uterine cancer, cervical cancer, ovarian tumours) are an uncommon but obviously important cause of vaginal bleeding to exclude
• exclusion is not usually possible in the ED and patients at risk or with suspicious clinical pictures should be referred to gynae OP for pelvic US, colposcopy +/- hysteroscopy and endometrial biopsy.
• note: a normal Pap smear is not an adequate investigation to exclude cancers, it is only a screening test for asymptomatic patients.
• suspicious clinical pictures include:
  • any post-menopausal bleeding
  • clinically suggestive lesions such as cervical lesions, pelvic masses, enlarged uterus (although this may just be fibroids or adenomyosis)
  • intermenstrual bleeding
  • post-coital bleeding
  • endometrial hyperplasia - eg. the perimenopausal patient with a preceding period of amenorrhoea, or those on oestrogen only Rx.
• indications for uterine sampling¹⁾:
  • women over 45 years age
  • women with BMI > 30
  • women with FH bowel cancer
  • women with irregular bleeding
  • abnormal endometrium on US
  • NB. the chances of any endometrial pathology being present in a slim woman under age 45 years with regular menses is very small.
• indications of hysteroscopy²⁾:
  • suspected focal uterine pathology on US
  • suboptimal US visualisation of the endometrium
  • abnormal cavity seen on US
  • no endometrial sample can be obtained through pipelle biopsy

• if pregnancy, IUD and haematologic causes have been reasonably excluded and there is no evidence to indicate neoplastic cause, then a presumptive diagnosis of a hormonal cause can be made pending further OP investigation, and consideration given to a hormonal treatment +/- tranexamic acid which helps reduce uterine bleeding.
• if the patient is on hormonal therapy such as combined oral contraceptive pill (OCP) or implant, then it may be wise to discuss with gynae for a Rx option
• consider non-steroidal anti-inflammatory drugs (NSAIDs)

• primolut N
  • regime 1:
    • 10mg tds initially then reduce to bd when bleeding under control, continue for total of 10 days then stop. Advise patient they will then get a new, hopefully lighter, menses a few days after stopping it.
  • regime 2 - high dose for very heavy bleeding:
    • 20mg every 2 hours until bleeding settles to max. dose 80mg whilst in ED
    • discharge home on 20mg tds for next 6 days then 10mg tds for next 7 days, then 10mg bd for 7 days then cease for 7 days to allow a withdrawal bleed.
• tranexamic acid (Cyclokapron) if no C/I such as stroke risk, DVT risk, pregnancy, lactation, renal disease, or severe bruising
  • this is an antifibrinolytic which can decrease flow 50%
  • usual dose: ii x 500mg tablets o qid for 4 days
  • see RACGP patient information sheet (pdf)
• iv premarin
  • discuss with gynae first
  • dose: 25mg iv 4hrly

• prophylactic cyclic primolut N may reduce flow by 30% if taken from day 5 to 26 of cycle, but may give little benefit if only taken from day 19-26³⁾
• combined oral contraceptive pill (OCP) - may reduce flow by 50% in anovulatory patients
• depo provera - contraceptive and results in amenorrhoea in > 75% after 1 year of use
• Mirena IUD - useful in those he may seek pregnancy at some stage
• danazol - may be of use in those who also have endometriosis but causes menopausal effects and mild androgenic effects
• endometrial ablation
• hysterectomy

• consider sending blood for iron levels and advising patient to start supplimental oral iron Rx
• patients with severe anaemia or ongoing heavy bleeding may require admission for blood transfusion &/or therapeutic D&C

• usually this is left to gynae OP
• an overweight, hirsute, acne-prone patient would suggest the possibility of polycystic ovary syndrome (PCOS) / polyendocrine metabolic ovarian syndrome (PMOS) and thus an outpatient USS may be reasonable.
• young patients are likely to be anovulatory but an OP pelvic USS is reasonable to exclude ovarian tumours, and a prolactin level may be reasonable to exclude a pituitary microadenoma, while a TSH would be reasonable to exclude hypothyroidism.
• patients with dysmenorrhoea should also be considered for Chlamydia testing to exclude sexually transmitted infections (STDs/STIs)