​​Kembara Xtra - Medicine - Menorrhagia

​​Kembara Xtra - Medicine - Menorrhagia  
Menorrhagia is no longer a popular name; instead, "abnormal uterine bleeding" (AUB) is favored.
severe menstrual bleeding (HMB), intermenstrual bleeding (IMB), and a mix of both severe and protracted menstrual bleeding are only a few of the symptoms that are described as part of AUB.
● The International Federation of Gynecology and Obstetrics (FIGO) has created two systems to help with the difficult task of helping clinicians identify the etiology of AUB due to the inconsistent usage of terminology and definitions to describe AUB. These consist of: FIGO AUB system 2 concentrated on categorizing AUB etiology into structural and nonstructural causes using the PALM-COEIN classification system. FIGO AUB system 1 standardized terminology and established the criteria of normal and abnormal menstrual bleeding.

Epidemiology One of the main reasons for outpatient gynecologic consultations, AUB affects 20–30% of patients on a yearly basis and is a frequent condition that raises medical expenses and lowers quality of life.
AUB has a prevalence of 3-30% and affects women most severely during their reproductive years; the prevalence rises with age and is highest in adolescence and the fifth decade.

Pathophysiology and Etiology 
The pathogenesis of AUB is as varied as the categories used to describe the illness.
The following structural factors are mentioned: Polyp (AUB-P), P
(AUB-A) - Adenomyosis
Leiomyoma (AUB-L), -
Leiomyoma submucosa (AUB-LSM)
Additional Myoma (AUB-LO)
- M (AUB-M): malignancy/hyperplasia
Among the nonstructural reasons are: - C— coagulopathy (AUB-C)
Ovulation (AUB-O),
Endometrial (AUB-E), symbol:
Iatrogenic injury (AUB-I)
(AUB-N) - N - Not yet categorized

Child Safety Considerations
Due to the immaturity of the hypothalamic-pituitary-ovarian axis, adolescents are at risk of irregular bleeding and HMB. Adolescents with HMB should be evaluated for possible bleeding disorders, especially von Willebrand disease and qualitative platelet dysfunction. Genital bleeding before puberty is, by definition, not menstrual bleeding and requires further evaluation.
pregnant women's issues
Pregnancy-related bleeding is by definition different from monthly bleeding and needs to be assessed further. AUB assessment should include obtaining a pregnancy test.

Prevention 

Combination oral contraceptives, especially when progesterone predominates, may prevent HMB. Less menstrual bleeding is the effect of lower estrogen levels.
Contraceptives that simply contain progesterone may lessen overall blood loss, but they frequently cause irregular bleeding.


In order to diagnose the patient's abnormal bleeding, it's critical to fully comprehend the patient's bleeding episode and ask questions centered on PALM-COEIN etiologies.
Menstrual cycle length, duration, variability, and amount of blood loss should all be mentioned in the menstrual history. Ask about how often pads are changed or if pads need to be replaced overnight to estimate the amount of blood loss. Women who switch sanitary products every two to three hours would have lost at least 80 mL each cycle. Additionally, one can inquire about the existence and size of clots as well as the feeling of "flooding."
The doctor should ask the patient about their gynecologic, obstetric, sexual, medical, surgical, family, and drug histories.
● For women with HMB, the following screening technique can be used to look for potential coagulopathy: plus one of the following conditions: - HMB since menarche
Postpartum bleeding
 Post-operative bleeding
Dental work-related bleeding Two or more of the following:
Two monthly bruises, one to two monthly epistaxises, frequent gum bleeding, and a family history of bleeding symptoms
If the patient responded "yes" to any of the questions above, the screen is positive and calls for more testing and a referral to a hematologist.
Regular menstrual cycles, midcycle pain, and premenstrual symptoms are signs that bleeding is ovulatory.
- Structural factors may be the source of abdominal pain or cramps experienced at different times of the cycle.
- Determine the effects of bleeding on the patient's health and anemia symptoms.

clinical assessment 

When a patient is bleeding suddenly, the evaluation should start by looking for potentially fatal hemodynamic instability symptoms. It is important to acquire orthostatic vital signs, which can reveal hypovolemia.
By observing obesity, evaluating the thyroid, and checking the skin for ecchymoses and petechiae, as well as indicators of hyperandrogenism like hirsutism and acne, one might search for further potential causes of AUB. Examine the vulva, urethra, vagina, anus, and perineum extensively with a speculum to look for more bleeding spots. Keep an eye out for injuries, such as lacerations. Additionally, it is advisable to take notice of any hemorrhoids as a potential source of bleeding. To detect uterine or cervical anomalies or enlargement, a bimanual exam is performed. During this examination, pelvic and adnexal masses would also be palpated.

Differential diagnoses include normal menstrual cycles, pregnancy complications, and other types of bleeding (such as gastrointestinal, vaginal, or cervical). 

Laboratory Results 

Initial examinations (lab, imaging)

Pregnancy tests and CBCs should be performed on all new patients.
If the patient is bleeding severely, type and crossmatch are required.
Other testing might consist of: - TSH with reflex T4 - PT/INR, PTT - CMP
study on iron and a STI panel
 Labs to think about in certain situations: - Plasma vWF antigen, plasma vWF activity (ristocetin cofactor activity, vWF:RCo activity, and vWF collagen binding), factor VIII, and other factor tests are performed in cases of suspected coagulopathy (2). - Tests for thyroid function, human chorionic gonadotropin, prolactin, and follicle-stimulating hormone are used to diagnose ovulatory dysfunction. - Cultures of the endocervix to rule out infections
- Pap smear Transvaginal ultrasound should be the first imaging test performed, according to the clinician's discretion.
Tests in the Future & Special Considerations
Endometrial polyps and submucosal leiomyoma can be diagnosed by diagnostic hysterography, saline infusion sonohysterography, and hysterosalpingography.
- Endometrial sampling and polyp removal can both be done during hysteroscopy.
MRI can be used to better visualize adenomyosis alterations and establish whether uterine-sparing treatment is an option for leiomyoma patients. Leiomyosarcoma can also be found using MRI.
Other/Diagnostic Procedures
Endometrial biopsy with or without hysteroscopy is conducted for potential endometrial hyperplasia or cancer in patients who are >40 years old or 40 years old with high-risk characteristics.

First Line of Medicine
Hormonal - OCP is typically used to control and reduce bleeding.
Estrogen and progesterone are non-hormonal. Women who want to get pregnant and lessen the negative effects of hormones typically choose these.
- Antifibrinolytics - NSAIDS
Acute severe bleeding: Conjugated equine estrogen 25 mg IV every 4 to 6 hours for 24 hours together with IV antiemetic medications; monophasic 35-mg estrogen-containing OCP taken three times per day for seven days; and then once per day; and medroxyprogesterone 20 mg or norethindrone 20 mg taken three times per day for seven days. - Tranexamic acid 1.5 g or 10 mg/kg IV every eight hours for five days, with a maximum dose of 600 mg. Chronic bleeding can be treated with Ibuprofen 600 mg every 6 hours or 800 mg every 8 hours, naproxen 500 mg at first, followed by 250 to 500 mg twice daily, and mefenamic acid 500 mg three times per day (with food). - Monophasic OCP with 30 to 35 mg of estrogen taken daily, either with or without inert tablets. - Depot medroxyprogesterone 150 mg subcutaneously every three months. - Medroxyprogesterone 5–10 mg or norethindrone 5–10 mg daily. Levonorgestrel intrauterine devices ranging from 19.5 to 52 mg for 5 years (19.5 mg LNG-IUS is a little smaller device); etonogestrel subdermal implant for 3 years Next Line
In the care of HMB brought on by leiomyoma and adenomyosis, second-line medications include danazol, GnRH agonists, aromatase inhibitors, selective estrogen receptor modulators (SERMs), and selective progesterone receptor modulators (SPRMs). It should be noted that SPRMs are not yet accessible in the United States.

Referral 

Patients with suspected or confirmed coagulopathy should be referred to hematology.
 Mention gynecology If a primary care provider is uncomfortable inserting an intrauterine device, taking an endometrial sample, treating chronic bleeding, or there is a suspicion of cancer.

Additional Therapies: The FDA had approved MRI-guided focused ultrasound (MgFUS) for the treatment of uterine fibroids, and it has been successfully used to reduce bleeding in patients with adenomyosis. Iron replacement medication, both oral and intravenously, for anemia.


Dilation and curettage are surgical options that may be explored in cases of significant acute bleeding.
 Surgical techniques are targeted at the particular pathology that has been detected.
- Endometrial polypectomy and cervical polypectomy
- Hysterectomy for adenomyosis
- Leiomyoma—for females who do not want children
Hysterectomy, uterine artery embolization, and radiofrequency ablation can all be done laparoscopically. Myomectomy is preferred for ladies who want to become pregnant.
Hysterectomy with or without adjuvant therapy and radiotherapy for malignancy At 1 and 2 years, conservative surgery (i.e., myomectomy, endometrial ablation, or uterine artery embolization) is superior to oral medications or the levonorgestrel-releasing IUD for controlling bleeding symptoms; however, by 5 years, there is no difference in long-term outcomes or patient satisfaction.
Hysterectomy is a curative procedure that comes with more serious side effects. It is often used when medical care has failed or when another indication, such cancer, is present.

Impaired quality of life, acute significant blood loss, iron deficiency anemia, are the  complications