Menorrhagia – Metrorrhagia – IMB

Uterine bleeding disorders are together with pain the most frequent complaints in gynaecology.

Menorrhagia : abundant menstuation
Metrorrhagia : irregular bleedings
IMB : intermenstrual bleeding
Spotting : slight bleedings

Basic concepts in gynedology

The menstrual cysle and the endometrium

Oestrogens make the endometrium grow. Progestagens stop the growth and transform the endometrium either for a pregnancy or a menstruation.

When a women produces only estrogens eg anovulatory cycles . This means a thicker endometrium and heavier menstruations.

Combined therapy of Oestrogens+progestagens = a thin endometrium since absence of growth and thus less heavy bleedings . This is typical for orals contraceptive pills, for a continuous combined therapy after menopause. But this therapy also has side effects , such as

- spotting in a few to 10% of women. The best explation is the growth of capillaries in the endometrium by progestagens.
- it therefore is common practice to give this therapy discontinuously.
- it therefore is not useful to increase the dose when spotting occurs.

Menorrhagia = too heavy menstruation

It can be disturbing for the woman, but it becomes a medical problem when associated with anemia and insufficient reserves of iron, ie when menstruation is more than 80 ml.

Etiology
anovulation
a local problem in the uterus such as a polyp or a myoma.
sometimes without obvious cause / somtimes attributable to adenomyosis
Diagnosis
? ovulation ? ultrasound and hysteroscopy to evaluate the uterine cavity.
Therapy
anovulation : R/ progestagens in the second half of the cysle ; eventuallyl oralecontraception
polyp = hysteroscopic polypectomy
myoma = hysteroscopice myomectomie. If larger than 5 cm experience is required and for very large myoma’s a laparosopic myomectomy should be considered.
menorrhagie without pathology : this is an indication for and ablation of the endometrium as the least invasive therapy. It should be realised that a superficial ablation -> diep ablation -> lap subtotal hysterectomy -> total lap hysterectomy are interventions which are increasingly invasive.

Spotting

Spotting should never be considered as normal and should be investigated by hysteroscopy and or ultrasound
When estrogens and progestogens are used together however spotting occurs in 2 to 10 %

When should we become worried

Menorrhagia with anemia.
Spotting after menopause
Spottting when taking oral contraception , continuous combined therapy or Orgametril or Mirena is not necessarily abnormal but shoudl anyway be investigated;

Which exams

Biochemistry to dectect anemia

Ultrasound is not invasive and can detect the larger myoma’s outside the cavity.

Hysteroscopy still is thebest exam for the cavity. I almost non invasive with the small hysteroscopes.

Which therapy

Medical

Menorrhagia : start with progestagens, eventually together with coagulation enhancement if the cavity is normal .
Spotting : change therapy

Surgery is a continuum from less to more invasive :

ablation
-> deep ablation
-> lap subtotal hysterectomy
-> lap hysterectomy.

Considerations

An ablation is the least invasive and takes 10 min only. Day surgery. Although a 20% risk of recurrent surgery is often quoted, this figure is much lower for the more experienced hysteroscopists.
Subtotal hysterectomy takes less tahn 1 hour while the pelvic support structure remains intact : thus less pain and a more rapid recovery.
Total laparoscopic hysterectomy takes 1 hour and an hospitalisation of 3 days. When there is a risk of cervical cancer this should be preferred.