Heavy Menstrual Bleeding (HMB)

HEAVY MENSTRUAL BLEEDING

By Dr. Mona Ahmed

Definitions

• HMB: Excessive menstrual blood loss
• IMB: Bleeding between periods
• PCB: Bleeding after intercourse
• PMB: Bleeding more than 1 year after cessation of periods

HMB

Heavy menstrual bleeding (HMB) is now replacing the older term ‘menorrhagia’.

• HMB is defined as a blood loss of greater than 80 mL per period.
  • Methods to quantify menstrual blood loss are both inaccurate and impractical
  • Clinical diagnosis based on the patient’s own perception of blood loss.
  • The presentation of HMB is common because women are having fewer children and consequently more menstrual cycles.

Symptoms Associated with HMB and Related Pathologies

Associated Symptoms	Suggestive of
Irregular bleeding Intermenstrual bleeding Postcoital bleeding	Endometrial or cervical polyp
Excessive bruising/bleeding from other sites History of postpartum haemorrhage (PPH) Excessive postoperative bleeding Excessive bleeding with dental extractions Family history of bleeding problems	Coagulation disorder (will be present in 20% of those presenting with ‘unexplained’ heavy menstrual bleeding.)
- Unusual vaginal discharge	Pelvic inflammatory disease
- Urinary symptoms	Pressure from fibroids
Weight change Skin changes Fatigue	Thyroid disease

Aetiology

• Hormonal
• Structural, with common causes:
  • Fibroids
  • Adenomyosis
  • Endometrial polyps
• Coagulation disorders (e.g., Von Willebrand disease)
• Pelvic inflammatory disease (PID)
• Thyroid disease
• Drug therapy (e.g., warfarin) $
• Intrauterine devices (IUDs)
• Endometrial/cervical carcinoma

Often no pathology can be identified. DUB is the diagnosis of exclusion.

History and Examination

Patients will have different ideas as to what constitutes a ‘heavy period’.

• Useful questions include:
  • How often sanitary wear needs to be used?
  • Is there presence of clots?
  • Is the bleeding so heavy (flooding)?
  • Have you had to take any time off work due to this bleeding?
• Is it causing symptoms & signs of anaemia?
• Examining:
  • Signs of anaemia
  • Abdominal and pelvic examination for masses
  • Cervical visualization for polyps/carcinoma
  • Take swabs if pelvic infection is suspected
  • Cervical smear to be taken if one is due

Investigations

• Hormonal profile

• Full blood count:

  • Anaemia

• Coagulation screen

• Pelvic ultrasound scan:

  • When a pelvic mass is palpated on examination (fibroids)
  • When symptoms suggest an endometrial polyp (e.g., irregular or intermenstrual bleeding)
  • When drug therapy for HMB is unsuccessful

• High vaginal and endocervical swabs:

  • When unusual vaginal discharge
  • Where there are risk factors for PID

• Endometrial biopsy

• Thyroid function tests

• Hysteroscopy with guided biopsy may be indicated - polyps

Management

• Reassure: For some women, the demonstration that their blood loss is in fact ‘normal’
• Medical treatments (temporary)
• Surgical treatments (incompatible with desired fertility)

When selecting management, it is important to consider and discuss:

• The patient’s preference of treatment

• Risks/benefits of each option

• Contraceptive requirements:

  • Family complete?
  • Current contraception?

• Past medical history:

  • Any contraindications to medical therapies for HMB?
  • Suitability for an anaesthetic. Previous surgical history?

Medical Treatments

Mefenamic Acid

Reduction in menstrual blood loss of 20–25 percent.

• Benefits:

  • Effective analgesia (useful if any dysmenorrhoea)

• Disadvantages:

  • Contraindicated with a history of duodenal ulcer or severe asthma
  • Long-term usage may cause difficulties in conceiving

• Recommended dose: 500 mg p.o. tds

Tranexamic Acid

Reduction in menstrual blood loss (MBL) 50 percent.

• Recommended dose: 1 g p.o. qds to be taken when menstruating heavily

contraindicated in DVT

Combined Oral Contraceptive Pill

• Benefits: Doubles up as a very effective contraceptive when taken properly
• Disadvantages:
  1. It is contraindicated for patients who have risk factors for thromboembolism
  2. It is unsuitable for patients over 35 years old who smoke
  3. It is unsuitable if there is a personal or family history of breast cancer
  4. It is unsuitable for patients who are grossly overweight

Norethisterone

(Progestogen) taken in a cyclical pattern.

• Benefits:

  • It is a safe and effective oral preparation

• Disadvantages:

  • It is not a contraceptive
  • Can cause irregular bleeding

GnRH Agonists

• Act on the pituitary to stop the production of oestrogen (results in amenorrhoea)

• Only used in the short term due to the resulting hypoestrogenic state (osteoporosis) when used > 6months

• Benefits:

  • They are effective for associated dysmenorrhoea
  • mainly used for anemic patients on during gyn surgery

• Disadvantages:

  • They can cause irregular bleeding
  • They can be associated with flushing and sweating
    • menopausal symptoms

Levonorgestrel intrauterine system

– alternative to surgical treatment

Reduces the target condition by 95 % within one year of insertion.

Benefits

• Contraceptive effect.
• Alleviates associated dysmenorrhoea.
• 30 % of users become amenorrhoeic by the end of the first year.

Disadvantages

• Irregular menses may occur during the first 3–9 months after insertion.

Surgical Treatments

When?

• If medical treatments have failed
• Women who have completed their families

1. Endometrial Ablation

Endometrial lining destructive procedures.

• Reduction in blood loss around 90 percent
• They are two types:
  • First-generation techniques include:
    • Electrical diathermy ablation
  • Second-generation techniques include:
    • Controlled endometrial ablation
    • Thermal uterine balloon
    • Microwave ablation

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2. Uterine Artery Embolization (UAE)

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3. Hysterectomy

A hysterectomy may be achieved using three approaches:

• Abdominal
• Vaginal
• Laparoscopic

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IMB

IMB: bleeding between periods, often seen with:

• Endometrial polyp
• Cervical polyps
• Endometriosis

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PCB

PCB: bleeding after sex. Causes:

• Associated with cervical abnormalities
• Infection
• Malignancy

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Post-Menopausal Bleeding

PMB: is defined as vaginal bleeding after the menopause. This is abnormal and should always be investigated.

Aetiology

• Atrophic vaginitis - most common - 90%
• Endometrial polyps
• Endometrial hyperplasia
• Endometrial carcinoma - most severe
• Cervical carcinoma

Majority of women with PMB have atrophic vaginitis.

What is Atrophic Vaginitis?

• Vaginal epithelium thins and breaks down in response to low oestrogen levels
• This is a benign condition
• Easily treated with topical oestrogens

10 percent of patients with PMB will have endometrial cancer. The risk of endometrial cancer progressively increases with age.

History and Examination for PMB

History

• When was your last period? (i.e., confirm menopausal)
• Was the bleeding post-coital? (i.e., think cervical polyp/cervical malignancy)
• When was your last smear done? Have they always been normal? (i.e., think cervical malignancy)

Examination

• ✓ Abdominal examination
• ✓ Vaginal examination to detect any pelvic masses
• ✓ Speculum to visualize:
  • Vagina for atrophy
  • Cervix for polyps or potential carcinoma
• ✧ A smear should be taken if due

Investigations for PMB

• Ultrasound scan:
  • To assess endometrial thickness
  • If thickness is 3 mm or less:
    • Reassurance - No further investigation is required
  • If thickness > 3 mm:
    • Endometrial biopsy
• Hysteroscopy - if polyp
• MRI - if pregnancy, lymph node involvement
• Other investigations (CBC, CXR, ECG, RFT, LFT) - elderly inv

Endometrial Cancer Overview

Endometrial cancer is most prevalent in the postmenopausal age group.

Risk Factors

• Nulliparity
• Obesity
• Early menarche & late menopause
• Tamoxifen exposure

Diagnosis

• By Endometrial biopsy

Treatment

• Total abdominal hysterectomy + washings + bilateral salpingo-oophorectomy and lymph node evaluation (then staging)
• Postoperative radiotherapy
• Or chemotherapy

Prognosis

• Good if detected early

Risk Factors for Endometrial Cancer

• Age
• HNPCC
• Obesity
• Nulliparity
• PCOS
• Diabetes

Information Required for Abnormal Uterine BleedingY

Information Required	Relevant Factors	Possible Diagnoses
Developmental history including menarche	Delayed/incomplete	Congenital malformation or chromosomal abnormality
Menstrual history	Oligomenorrhoea Secondary amenorrhoea	PCOS POF
Reproductive history	Infertility	PCOS
Cyclical symptom	Cyclical pain without menstruation	Congenital malformation Imperforate hymen
Hair growth	Hirsutism	PCOS
Weight	Dramatic weight loss Difficulty losing weight	Hypothalamic malfunction PCOS
Lifestyle	Exercise, stress	Hypothalamic malfunction
Past medical history	Systemic diseases, e.g., sarcoidosis	Hypothalamic malfunction
Past surgical history	Evacuation of uterus	Asherman’s
Visual disturbance		Pituitary adenoma
Drug history	Dopamine agonists, HRT	Hypothalamic malfunction
Headache		Pituitary adenoma
Galactorrhoea		Prolactinoma