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Notation. A. In all cases, the presence or absence of each criterion is noted using
“0” if absent, “1” if present, and “?” if not yet assessed. Each of the cases shown has 1
abnormality identified. From the top: at least one submucosal leiomyoma (LSM);
adenomyosis (A)—focal and/or diffuse; endometrial polyps (P); and an absence of any
abnormality, leaving endometrial causes (E) as a diagnosis of exclusion. B. Each of the cases
shown has more than 1 positive category. From the top: submucosal leiomyoma and
atypical endometrial hyperplasia (M), as diagnosed by endometrial sampling; endometrial
polyps and adenomyosis; endometrial polyps and subserosal leiomyoma (LO); and
adenomyosis, subserosal leiomyoma and coagulopathy (C), as determined by positive
screening test and subsequent biochemical confirmation of von Willebrand dis
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Exclusion of malignant
causes is vital i.e.
endometrial cancer or
hyperplasia.
Benign organic causes of
menorrhagia include
endometrial polyps and sub
mucous fibroids.
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People with risk factors for endometrial cancer
or hyperplasia. The following were found to be
independently associated.
1. Obesity(>90kg);
2. Infertility
3. Nulliparity;
4. Age >45 yrs; ( At 40 yrs 5/100,000, 45 yrs
13/100000, 55 yrs 32/100000)
5. Family history of colon cancer
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D&C is not performed as an
initial work up. Should be
performed in conjunction with
hysteroscopy to evaluate
endometrial cavity.
Pipelle endometrial biopsy
appears at least as accurate as
D&C, has high levels of patient
acceptability, lower
complication rates and do not
require inpatient admission or
GA.
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No tissue found
◦ Most likely endometrium is atrophic and
requires estrogen
Simple proliferative
◦ This is normal and does not require treatment
Endometrial hyperplasia
◦ Except atypical adenomatous requires
progestins regimens
◦ Atypical adenomatous hyperplasia,
hysterectomy advised
Endometrial carcinoma
◦ Refer onco team
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Overall health and the medical history
Cause and severity of condition
Tolerance of medications
Future childbearing plans
Effect of condition on lifestyle
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Bleeding patterns of LNG-containing
intrauterine systems (Mirena®):
-3 -2 -1 1 2 3 4 5 6 7 8 9 10 11
In the first 3-6 months irregular bleeding and
spotting
shorter, lighter and less painful periods
about 20% of women may have no bleeding after 1
year
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Mirena effectively reduces menstrual blood
loss (MBL)
0
50
100
150
200
Before
insertion
3 6 12
Months of Mirena use
MedianMBL(mL)
* * *
* p<0.001
─86%
─97%─91%
%
Reduction
(80mL MBL = menorrhagia)
Andersson JK, Rybo G. Levonorgestrel-releasing intrauterine device in the
treatment of menorrhagia. Br J Obstet Gynaecol. 1990; 97: 690-4
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IUS
0
10
20
30
40
50
60
70
80
90
100
Mirena Control
Proportionofwomen(%)
*p<0.001; between groups
. Lähteenmäki P, Haukkamaa M, Puolakka J, et al. Open randomised study of use of
levonorgestrel releasing intrauterine system as an alternative to hysterectomy. BMJ
1998; 316: 1122-6
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Compared to endometrial ablation
◦ Slightly less mean reduction of blood loss but
equal patient satisfaction
◦ Similarly equal satisfaction to hysterectomy
◦ Higher continuation rate
◦ More cost effective
◦ Should be considered in women who failed
medical therapy
◦ Added advantage of reliable contraception
◦ Risk of expulsion 10-20%
◦ Need trained staff for insertion
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Small vessels are
accessed using a
microcatheter
Once the catheter
is in place, PVA
particles are
introduced until
the blood flow
stopped
