🔑 Key Learning

  • Menorrhagia is heavy menstrual bleeding that affects quality of life and is often idiopathic
  • It is the most common cause of iron deficiency anaemia in menstruating women
  • 1st line treatment: LNG-IUS (e.g. mirena) if no significant structural abnormality
  • Investigations are guided by symptoms and suspicion of underlying pathology
  • Refer to gynaecology if fibroids are > 3 cm or there are pressure symptoms

🧬 Pathophysiology

Menorrhagia refers to excessive blood loss during menstruation, commonly idiopathic or due to uterine pathology, clotting disorders, or hormonal imbalance.

👀 Clinical Features

  • Heavy or prolonged bleeding during periods
  • May affect physical, emotional, or social quality of life
  • May be associated with pelvic pressure or pain depending on cause

🧪 Investigations

Initial investigations

  • FBC to assess for anaemia
  • Coagulation screen to exclude clotting disorders (e.g. VWD)
  • TFTs
  • HVS/cervical swabs if signs of infection

Further investigations

  • Pelvic ultrasound for suspected fibroids, adenomyosis (bulky, tender uterus) etc. 
  • Hysteroscopy if endometrial pathology suspected

2WW referral

  • Postmenopausal bleeding in women aged > 55
  • Abnormal cervical appearance
  • Ascites or abdominal mass (not due to fibroids)
  • Pelvic mass with systemic features (e.g. weight loss)

💊 Management

No identified pathology / fibroids < 3 cm / adenomyosis

1st line: LNG-IUS
2nd line:

  • Non-hormonal: Tranexamic acid or NSAIDs
  • Hormonal: COCP or cyclical progestogen

Fibroids > 3 cm

  • Refer to gynaecology
  • Options include myomectomy, uterine artery embolisation

🧬 Uterine Fibroids

Pathophysiology

Benign smooth muscle tumours of the myometrium

👀 Clinical Features

  • Menorrhagia
  • Pressure symptoms: pelvic pain, urinary frequency/urgency or bowel symptoms
  • Subfertility
  • Enlarged, irregular, non-tender uterus

💊 Management

  • < 3 cm: treat as for general menorrhagia - 1st line LNG-IUS
  • 3 cm or symptoms/subfertility: refer to gynaecology

Complication – Red degeneration of Fibroids

  • Ischaemia and subsequent necrosis of a fibroid
  • Commonly occurs during the second or third trimester of pregnancy, due to disruption of the fibroids blood supply
  • Acute abdominal pain, low-grade fever, nausea, vomiting

📝 Exam Clues & Clinchers

  • Heavy periods with no pathology: LNG-IUS is 1st line
  • Bulky tender uterus with heavy bleeding: adenomyosis
  • Pressure symptoms and irregular uterus: fibroids
  • Red degeneration: severe abdominal pain in pregnant woman with fibroid history

🔗 Useful Links and References