OPD Services
Heavy Menstrual Bleeding (HMB)
Heavy menstrual bleeding (also known as menorrhagia) is a common disorder among women. It refers to menstrual bleeding lasting more than seven days and involves more blood flow than is typical during menstruation. In other words we can say that, it is excessive menstrual blood loss which interferes with a woman’s physical, social, emotional or material quality of life. For Illustration, woman have to take a leave from work/school because of inability to go out in public, inability to do household work or unable to carry day to day activities.
Symptoms / When to see a doctor.
- When amount of blood loss is more than 100 ml.
- 6 or more fully soaked pads in a day.
- When 3 or more tampons are used per day.
- When menstrual cup collects more than 30 ml in a day.
- Need to change the pad every hour or few hours in a row.
- When there is Soaking/Staining of clothes.
- Passing of clots.
- Period lasting for more than 8 days.
- Symptoms of anemia, such as tiredness, fatigue or shortness of breath
Causes
- Fibroids
- Polyp
- Blood coagulation disorder.
- Thyroid disorder
- Drugs and Medications
- Hormonal cause
- Uterus, cervical cancer
- HTN, Diabetes
Fibroid Uterus
Heavy Menstrual Bleeding (HMB)
Fibroids or leiomyomas are non cancerous tumors that develop in the uterus. They originate from smooth muscles of the uterine wall. Their sizes can vary from small seedling ones to huge ones. Approximately, 1 in 3 females in India suffer from fibroids.
Risk Factors
Multifactorial, more common in childbearing agegroup. Growth of fibroids is dependant on female hormones, i.e estrogens and progesterones.
- Not having children
- Family history
- Obesity
- Early age of menarche
- Late menopause
Symptoms
Fibroids can be asymptomatic in many cases. Those who are symptomatic can have:
- Heavy menstrual bleeding, which can be in form of increased flow, passage of clots or prolonged cycles.
- Dysmenorrhoea or painful periods.
- Pain lower abdomen
- Difficulty in passing urine or retention of urine.
- Frequent urination.
- Constipation rarely.
- Backache.
- Difficulty in conception
- Recurrent abortions.
Types
They are broadly of 3 types:
- Submucous: Located towards the uterine cavity
- Subserous: Located towards the outside of uterus
- Intramural :Placed inside the uterine wall.
Diagnostic Modalities
- Clinical Examination: Per vaginal examination done by clinician.
- Ultrasound: First line investigation of choice.
- Transvaginal sonography(TVS) is more accurate than transabdominal ultrasound(TAS).
- Saline Infusion Sonography (SIS)
- Hysteroscopy: Useful for the diagnosis of fibroids located inside the uterine cavity.
- MRI: Highly sensitive modality. Helps to differentiate fibroids from adenomyosis. Also useful in diagnosis fibroids with malignant change.
Treatment
- Expectant Treatment: In asymptomatic cases. Yearly follow up recommended.
- Medical treatment: Effective in certain cases. Various options include NSAIDs, Combined Oral contraceptives and other hormones. SPRMs, GnRH analogues are also used in selective cases.
Surgery Management
- Myomectomy: Removal of only fibroid, is done in patients who wish to preserve the uterus, family is not complete, or in young patients. Chances of recurrence after surgery is 30-40%.
- Myomectomy can be performed by Laparoscopic, hysteroscopic or abdominal route.
- Hysterectomy: In perimenopausal patients, where family is complete hysterectomy is preferred. Hysterectomy can be performed by abdominal or laproscopic route.
- Uterine artery embolization: Also used in patients who wish to preserve uterus.
Adenomyosis
Adenomyosis is a disorder in which the inner lining of the uterus (endometrium) breaks through the muscle wall of the uterus ( myometrium). Adenomyosis can cause menstrual cramps, lower abdominal pressure, and bloating before menstrual periods and can result in heavy periods.
Endometriosis
Its defined as presence of uterine lining outside the cavity of uterus, anywhere in the abdomen. Common sites include ovary, fallopian tubes, ligaments connecting the uterus to the walls and floor of pelvic cavity, urinary bladder, rectum, intestines etc.
Symptoms
- Painful menses
- Pain lower abdomen, heaviness in abdomen.
- Painful defecation, painful micturition.
- Blood in stools
- Blood in urine
- Infertility
- Complications: Like malignant transformation.
Risk Factors
- Family history of endometriosis
- Late pregnancy and childbirth
- Abnormal uterus e.g uterine malformations like bicornuate uterus.
Investigations
- Ultrasonography: Abdominal or
- Transvaginal sonography
- CT Scan
- MRI
Treatment
- Medical treatment: Hormones: Oral contraceptives, Progesterones.
- NSAIDs
- Surgical treatment: Laproscopic removal of ovarian endometrioma, with or without removal of ovaries.
- Risk of recurrence can be upto 40 %.
- Open surgery
- Hysterectomy with or without removal of both ovaries, if family is complete.
PCOS
Polycystic ovary syndrome (PCOS) is a hormonal disorder among women of reproductive age. Females with PCOS may have irregular or prolonged menstrual durations or excess male hormone.
Polycystic ovarian syndrome (PCOS) is a heterogenous disorder characterized by androgen excess, ovarian dysfunction and polycystic ovaries.
Causes
Not clearly known.
- Changes in lifestyle, diet and stress may lead to it.
- Genetic factors e.g CYP 21 gene mutation may play a role.
- Family history of PCOS or diabetes.
Symptoms
- Absence of periods or delayed cycles
- Irregular cycles.
- Infertility
- Hirsuitism i.e increased hair growth over face and body.
- Acne
- Obesity
- Alopecia
In adults cycles interval of >45 days, <8 cycles per year needs evaluation for PCOS. In adolescents 1 year post menarche delayed cycle for >90 days needs evaluation.
PCOS is also associated with various other disorders such as Diabetes, Cardiovascular diseases and Metabolic syndrome.
How is it diagnosed?
Based on Rotterdam criteria, where two of the following should be present,
- Oligo or anovulation characterized by delayed cycles or absence of menses.
- Clinical or biochemical evidence of hyperandrogenism i.e acne, hirsuitism or alopecia or lab evidence.
- Ultrasound criteria: To be used only in adults. Using TVS a follicle number of ≥20 per ovary, and/or ovarian volume of ≥10ml of either ovary.
Investigation
- Calculated free testosterone or free androgen index is assessed.
- Thyroid profile and other hormones are evaluated according to symptoms.
- Lipid profile
- Screening for diabetes is also done. 75 gm oral Glucose tolerance test is done.
- Ultrasonography: Transvaginal ultrasound is preferred if patient is sexually active. Ultrasound not a reliable criteria for diagnosis in adolescents.
Management
- Lifestyle Modification: Includes Dietary advice and Regular physical activity.
- Dietary advice: 1200 -1500 Kcal diet is recommended. 30 % calorie deficit diet is advised to patients with excess weight.
- Patients are recommended to cut down on refined sugar, refined oil and simple carbs. Intake of complex carbohydrates, seasonal fruits and vegetable is advised.
- Regular Physical Activity: 30-45 mins of moderate physical activity is recommended at least 5 times a week in adults.
- 60 mins of moderate physical activity is recommended in adolescents.
- Those who keep an account of steps, 10000 steps per day is adequate to maintain it.
- Adequate water intake: 3 liters per day.
- Other lifestyle changes: Follow a schedule. Early to bed and early to rise rule should be followed.
- Yoga, Meditation helps to keep stress levels down.
Treatment
Drug Therapy
Combined oral contraceptives: Low dose OCP is the first treatment option for patients with PCOS.
OCPs with antiandrogen like cyproterone is preferred for cases with hirsuitism or biochemical evidence of hyperandrogenism.
Insulin Sensitizers: Metformin is indicated in cases with impaired glucose tolerance, high BMI, acanthosis nigricans (dark patches on folds of skin like neck).
Antiandrogens: For hirsuitism.
Newer therapies: Myoinositol derivatives
Surgical Management:
Laproscopic ovarian drilling:
Can improve fertility rates.
Pelvic Inflammatory Disease (PID)
Pelvic inflammatory disease (PID) is an infection of the female reproductive organs. It most often occurs when sexually transmitted bacteria spread from your vagina to your uterus, fallopian tubes or ovaries.
Ovarian Cysts
Hyperplasia
Hyperplasia, is an expansion of an organ or tissue as a result of an growth in the amount of natural tissue that outcomes from cell proliferation. it may lead to the gross enlargement of an organ, and the term is sometimes confused with benign neoplasia or benign tumor.
Clinical Team
Doctor Name
Degree, Speciality
Doctor Name
Degree, Speciality