Abnormal Menstruation

To realise what is abnormal, an understanding of normal menstruation is required.

Abnormalities in menstruation may include:

• Quantity; usually perceived as too great a loss - menorrhagia. This is clinically defined as a total menstrual blood loss of more than 80mls per menstruation. May be quantifiable, if anaemic.
• Timing; too frequent (polymenorrhoea - more than one period per calendar month) or infrequent (oligo-amenorrhoea)
• Duration of bleeding; normal range is 3-7 days
• Time of onset; precocious puberty (before 10 years) or delayed (after 16 years)

Non-reproductive causes

• Systemic disease disorders of blood coagulation – e.g. von Willebrand disease or prothrombin deficiency, leukaemia, idiopathic thrombocytopaenic purpura and hypersplenism. Consider screening for in adolescents who have had heavy menses since menarche, or if other signs present.
• Hypothyroidism – often associated with menorrhagia or intermenstrual bleeding. Measure TSH and treat with thyroxine.
• Cirrhosis – associated with reduced ability of liver to metabolise oestrogens and hypoprothrombinaemia.

Diseases of the reproductive tract

• Commonest causes during fertile age are those related to pregnancy, e.g. threatened, incomplete or missed abortion, ectopic pregnancy. Trophoblastic disease in women with recent pregnancy.
• Malignancies – endometrial and cervical carcinoma most common, also ovarian carcinoma.
• Endometritis – usually presents as intermenstrual spotting.
• Fibroids, endometrial polyps and adenomyosis.
• Cervical lesions – erosions, polyps and cervicitis; presenting as post-coital spotting.
• Iatrogenic – hormones used for contraception or HRT or management of other conditions. Some psychotropic drugs.

• It usually presents as heavy menstrual bleeding (menorrhagia). The diagnosis of DUB can only be made once all other causes for abnormal, or heavy, uterine bleeding have been excluded. The pathophysiology is largely unknown.
• NICE defines heavy menstrual bleeding as "excessive menstrual blood loss which interferes with the woman's physical, emotional, social and material quality of life, and which can occur alone or in a combination with other symptoms."²

Ask women to complete menstrual calendar.

• Every woman presenting with heavy menstrual bleeding should have a full blood count taken.
• Serum ferritin, female hormone testing and thyroid testing are not routinely recommended. Only if do if there is a strong clinical suspicion of underlying pathology.²
• Coagulation studies, liver function tests or thyroid function tests only if suspected problem.
• Luteal phase serum progesterone to determine if ovulating.

Depends on diagnosis.
If ovulating with menorrhagia need to exclude presence of uterine lesion. Consider referral for hysteroscopy, or transvaginal ultrasound.

Pharmacological

In dysfunctional uterine bleeding:²

• First line: Levonorgestrel-releasing intrauterine system provided long-term use (at least 12 months) is anticipated.
• Second line: Tranexamic acid or non-steroidal anti-inflammatory drugs (NSAIDs), if non-hormonal preferred, or combined oral contraceptives (COCPs).
• Third line: Norethisterone (15mg) daily from days 5 to 26 of the menstrual cycle, or injected long-acting progestogens.

Surgical

This should only be considered if:

• Pharmacological management has failed.
• There is severe impact on quality of life.
• There is no desire to conceive.
• The uterus is normal (or there are just small fibroids <3cm).

Options include endometrial ablation and hysterectomy.

Referral to secondary care for further gynaecological assessment and examination should be made:

• In women over 45yrs with heavy menstrual bleeding.
• If there is persistent intermenstrual bleeding.
• If an abnormality is suspected on physical examination (other than fibroids < 3cm in diameter).
• If there is suspicion from the history of increased risk of pathology such as carcinoma (e.g. family history or endometrial or colonic cancer, nulliparity, obesity, tamoxifen or unopposed oestrogen therapy, abnormal smear, polycystic ovarian syndrome).
• If there is treatment failure.