Barking and Havering Health Authority

Adaptation of the Royal College of Obstetricians and Gynaecologists’ guideline for the initial management of menorrhagia

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CLINICAL EVALUATION OF THE COMPLAINT OF MENORRHAGIA

HISTORY A HISTORY OF HEAVY REGULAR CYCLICAL MENSTRUAL LOSS OVER SEVERAL CONSECUTIVE CYCLES WITHOUT ANY INTERMENSTRUAL OR POSTCOITAL BLEEDING SHOULD BE OBTAINED   1. Symptoms suggestive of other pathology:
  • Irregular bleeding
  • Sudden change in blood loss
  • Intermenstrual bleeding
  • Postcoital bleeding
  • Dyspareunia
  • Pelvic pain
  • Premenstrual pain
      2. Risk factors for endometrial cancer:
  • Tamoxifen
  • Unopposed oestrogen treatments
  • Polycystic ovary syndrome
  • Obesity
EXAMINAT-ION        
Abdominal and bimanual examination. Cervical smear if due.   Uterus significantly enlarged, pelvic mass, tenderness   Consider REFERRAL or different management outside the scope of this Guideline
  Normal or slightly enlarged uterus    
       
INVESTIG-ATIONS FULL BLOOD COUNT    
       
  Treat with iron if anaemic    
       
  NO NEED FOR:

TFTs unless other symptoms of thyroid disease

   If no treatment requested and Hb normal: REASSURE
  Other endocrine investigations

Endometrial assessment

   If treatment indicated or requested by the patient, manage as OVERLEAF

 

MEDICAL MANAGEMENT OF THE COMPLAINT OF MENORRHAGIA

 

1. Does not require contraception or prefers non-hormonal treatment

  
       

Mefenamic acid 500mg tds starting on first day of period for days of heavy flow

    

Tranexamic acid 1g tds starting on first day of period for days of heavy flow
 
 

Use for 3 months

  
 

If the blood flow is reduced to an acceptable level and no side effects treatment can continue indefinitely

    

If the blood flow is not reduced to an acceptable level, or unacceptable side-effects, try the other drug whilst awaiting REFERRAL
   

2. Has copper or non-hormonal IUCD in situ

3. Needs contraception as well
 

Add tranexamic or mefenamic acid (dosage as above)

  

Change to progestogen IUCD (Mirena*)

Combined oral contraceptive pill

Progestogen IUCD

(Mirena*)

Long acting progestogens
 

If flow still unacceptable, REMOVE IUCD and suggest alternative contraception

Review after 3 months. Add mefenamic acid if necessary

    
 
  Review after 3 months. If flow still unacceptable REFER   Review after 6 months. If flow still unacceptable REFER  
 

*The progestogen-releasing IUCD ("Mirena") is an effective treatment for menorrhagia. Its current licence only covers use where contraception.is required.
 

Cyclical oral progestogens e.g. norethisterone, duphaston and primolut are ineffective in reducing menstrual loss and are not recommended.
 
REFERRAL ARRANGEMENTS
Referrals made as a result of following this guideline should be made to:
King George Hospital

One-stop menstrual disorders clinic

 OR Harold Wood or Oldchurch Hospitals EITHER Mr Weeks’ menstrual disorders clinic OR Any consultant’s general gynaecology OP clinic