QuestionSBA
QuestionChoice
Combined hormonal contraceptive patches such as Evra are contraindicated when less than 6 weeks post partum and breastfeeding. This is because of the increased risk for VTE post natally which would be increased further with the use of a combined hormonal contraceptive patch.
62212
e
Combined hormonal contraceptive patch
QuestionChoice
Contraception is not required for the first 21 days post partum, however, beyond that contraception is recommended even if still breastfeeding. Lactational amenorrhea is a temporary lack of fertility whilst breast feeding. Lactational amenorrhea method (LAM) is sometimes used as a form of 'natural' contraception. If used correctly it is effective with only 2 in 100 people becoming pregnant in the first 6 months post partum. However, it requires consistent and exclusive breast feeding and amenorrhoea. It is only effective for the first 6 months post-partum. It is therefore recommended by the Faculty of Sexual and Reproductive Healthcare to implement contraception before 21 days.
62209
b
Reassure her that no contraception is needed when breastfeeding
QuestionChoice
The IUD, also known as the copper coil, can commonly cause periods to be heavier. As this patient has a history of menorrhagia it is not a suitable option for her.
62211
d
Intrauterine device (IUD)
QuestionChoice
The POP has no adverse affects on lactation or infant outcomes such as growth and development. Very small amounts of progesterone can be found in breast milk of those taking the POP.
62208
a
Progesterone only pill (POP)
QuestionChoice
The COCP is contraindicated less than 6 weeks post partum and breast feeding. There is an increased risk for VTE post-natally, this would be increased by use of COCP.
62210
c
Restart the COCP
Concept
Chapter
# Summary
  
 
Menorrhagia is defined as excessive menstrual bleeding that significantly impacts a woman's quality of life. It is often characterised by heavy or prolonged menstrual periods and may result in iron deficiency anaemia. There is no set cut-off when defining menorrhagia: it is the patient who determines if bleeding is heavy to them or not. However, thorough clinical evaluation, including a full blood count, clotting studies, and possibly a transvaginal ultrasound, is necessary to identify potential underlying causes. Management strategies largely depend on the cause and may involve medical treatments like the Mirena® coil, mefenamic acid, tranexamic acid, hormonal contraceptives, or surgical interventions in refractory cases.
  
 
# Definition
  
 
Menorrhagia is a clinical condition defined as excessive blood loss during a menstrual period to an extent that it substantially affects a woman's quality of life.
  
 
# Epidemiology
  
 
Menorrhagia is a common gynaecological complaint. In about half of cases, no underlying pathology is found, and the condition is referred to as dysfunctional uterine bleeding.
  
 
# Aetiology
  
 
The aetiology of menorrhagia can be categorised into two groups: local and systemic. 
  
Local causes include:
  
  - Fibroids
  - Adenomyosis
  - Endometrial polyps
  - Endometriosis
  - Pelvic inflammatory disease
  - Endometrial cancer (be highly suspicious of this if there is postmenopausal bleeding)
  
 
Systemic causes encompass:
  
 
  - Bleeding disorders
  - Hypothyroidism
  - Liver and kidney disease
  - Obesity
  
 
# Signs and Symptoms
  
 
The primary symptom of menorrhagia is **heavy or prolonged menstrual bleeding**. 

However, other associated signs and symptoms may be present, depending on the underlying cause (see differential diagnosis). If severe enough, menorrhagia can also cause anaemia, which would present with **fatigue, weakness, shortness of breath and palpitations.**


  
 
# Differential Diagnosis
  
 
The differential diagnosis for menorrhagia includes conditions that cause abnormal uterine bleeding. These may include:
  
 
  - **Fibroids:** Often asymptomatic, but can cause heavy or prolonged periods, pelvic pain or pressure, and frequent urination.
  - **Adenomyosis:** Symptoms can include prolonged, heavy menstrual bleeding, severe menstrual cramps, and pain during intercourse.
  - Endometrial polyps: Can cause irregular menstrual bleeding, bleeding between periods, excessively heavy periods, or postmenopausal bleeding.
  - **Endometrial cancer:** Symptoms include abnormal vaginal bleeding, pelvic pain, and pain during intercourse.
- **Hypothyroidism:** Causes fatigue, weight gain and constipation.
- **Clotting disorders:** Leads to excessive bleeding from minor injuries. 
 
 
# Investigations
  
 
The investigation of menorrhagia should include:
  
**Bedside:**

- Speculum and bimanual examination: This helps rule out causes such as cervical ectropion, or to investigate fibroids by feeling pelvic masses. 

**Bloods:**

- FBC and iron studies: To rule out anaemia. 
- LFTs and clotting screen: To rule out liver and clotting disorders. 
- TFTs, if clinically indicated: To rule out hypothyroidism. 

**Imaging:**

- Transvaginal ultrasound: To identify underlying causes such as fibroids or endometrial polyps.

  
# Management
  
 
The management of menorrhagia largely depends on the underlying cause. If an underyling cause is found, the primary management involves treatment of that cause. 
Otherwise, if the cause is dysfunctional uterine bleeding, potential treatments include:
  
**Medical:**

  - Mirena® coil: This is first line and most effective treatment option for menorrhagia. 

Otherwise:
  
  - Mefenamic acid: NSAID that prevents bleeding and helps relieve pain. 
  - Tranexamic acid: Reduces bleeding but no effect on pain. 
  - Combined oral contraceptive pill: Reduces bleeding, particularly helpful if the patient also requires contraception. 

**Surgical:**

- Endometrial ablation (will require ongoing contraception)
- Hysterectomy 
  
These options are only applicable in rare cases refractory to medical management. 
 

# Complications

- Anaemia: Occurs if bleeding is sufficiently severe.
- Low mood, including depression and anxiety: The welfare and social complications (e.g. interference with work and social life) can have significant mental health impacts.  

# NICE Guidelines
  
 
[Click here for more information on menorrhagia](https://cks.nice.org.uk/topics/menorrhagia/)
  
# References

[BMJ Best Practice](https://bestpractice.bmj.com/topics/en-gb/171)

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A 36 year old female attends her GP practice to discuss contraception. She is 4 weeks post partum and is currently breast feeding. She is on day 2 of her first period since giving birth.
She has a past medical history of menorrhagia, she does not take any regular medication.
She previously took a combined oral contraceptive pill (COCP).

Which of the following is most appropriate next step in managing this patient?
a