Heavy Menstrual Bleeding

Question 1

What is heavy menstrual bleeding?

Answer 1

Heavy menstrual bleeding is also called menorrhagia.

Question 2

How much ml of blood is lost in each period?

Answer 2

On average, women lose 40 ml of blood during menstruation.

Question 3

How much ml of blood is lost in heavy menstrual bleeding?

Answer 3

Excessive menstrual blood loss involves more than an 80 ml loss.

Question 4

How is heavy menstrual bleeding diagnosed?

Answer 4

The diagnosis is based on symptoms, such as changing pads every 1 – 2 hours, bleeding lasting more than seven days and passing large clots. A diagnosis can be made based on a self-report of “very heavy periods”.

Question 5

Give examples of causes of heavy menstrual bleeding

Answer 5

• Dysfunctional uterine bleeding (no identifiable cause)
• Extremes of reproductive age
• Fibroids
• Endometriosis and adenomyosis
• Pelvic inflammatory disease (infection)
• Contraceptives, particularly the copper coil
• Anticoagulant medications
• Bleeding disorders (e.g. Von Willebrand disease)
• Endocrine disorders (diabetes and hypothyroidism)
• Connective tissue disorders
• Endometrial hyperplasia or cancer
• Polycystic ovarian syndrome

Question 6

What questions should be asked in a history of heavy menstrual bleeding?

Answer 6

There are key things to ask about in any presentation with a gynaecological problem:

• Age at menarche
• Cycle length, days menstruating and variation
• Intermenstrual bleeding and post coital bleeding
• Contraceptive history
• Sexual history
• Possibility of pregnancy
• Plans for future pregnancies
• Cervical screening history
• Migraines with or without aura (for the pill)
• Past medical history and past drug history
• Smoking and alcohol history
• Family history

Question 7

What examination should be performed for heavy menstrual bleeding?

Answer 7

Pelvic examination with a speculum and bimanual should be performed, unless there is straightforward history heavy menstrual bleeding without other risk factors or symptoms, or they are young and not sexually active. This is mainly to assess for fibroids, ascites and cancers.

Question 8

What investigations should be ordered for heavy menstrual bleeding?

Answer 8

Full blood count should be performed in all women with heavy menstrual bleeding, to look for iron deficiency anaemia.

Outpatient hysteroscopy and pelvic and transvaginal ultrasound should be arranged if the certain criteria are met.

Additional tests to consider in women with additional features:

• Swabs if there is evidence of infection (e.g. abnormal discharge or suggestive sexual history)
• Coagulation screen if there is a family history of clotting disorders (e.g. Von Willebrand disease) or periods have been heavy since menarche
• Ferritin if they are clinically anaemic
• Thyroid function tests if there are additional features of hypothyroidism

Question 9

When should outpatient hysteroscopy be arranged?

Answer 9

Outpatient hysteroscopy should be arranged if there is:

• Suspected submucosal fibroids
• Suspected endometrial pathology, such as endometrial hyperplasia or cancer
• Persistent intermenstrual bleeding

Question 10

When should pelvic and transvaginal ultrasound be arranged?

Answer 10

Pelvic and transvaginal ultrasound should be arranged if the is:

• Possible large fibroids (palpable pelvic mass)
• Possible adenomyosis (associated pelvic pain or tenderness on examination)
• Examination is difficult to interpret (e.g. obesity)
• Hysteroscopy is declined

Question 11

What is the initial management of heavy menstrual bleeding?

Answer 11

Start by excluding underlying pathology such as anaemia, fibroids, bleeding disorders and cancer. Where causes are identified, these should be managed initially. For example, menorrhagia caused by a copper coil should resolve when the coil is removed. The next step is to establish whether contraception is required or acceptable.

Question 12

Briefly describe the non-contraceptive management of heavy menstrual bleeding

Answer 12

When the woman does not want contraception; treatment can be used during menstruation for symptomatic relief, with:

• Tranexamic acid when no associated pain (antifibrinolytic – reduces bleeding)
• Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)

Question 13

Briefly describe the contraceptive management of heavy menstrual bleeding

Answer 13

Management when contraception is wanted or acceptable:

• Mirena coil (first line)
• Combined oral contraceptive pill
• Cyclical oral progestogens, such as norethisterone 5mg three times daily from day 5 – 26 (although this is associated with progestogenic side effects and an increased risk of venous thromboembolism)

Progesterone only contraception may also be tried, as it can suppress menstruation. This could be the progesterone-only pill or a long-acting progesterone (e.g. depo injection or implant).

Question 14

When should referral to secondary care be considered in heavy menstrual bleeding?

Answer 14

Referral to secondary care for further investigation and management is indicated if treatment is unsuccessful, symptoms are severe or there are large fibroids (more than 3 cm).

Question 15

What are the final options for managing heavy menstrual bleeding?

Answer 15

The final options when medical management has failed are endometrial ablation and hysterectomy.

Question 16

Briefly describe the role of endometrial ablation in heavy menstual bleeding

Answer 16

Endometrial ablation involves destroying the endometrium. The first generation of ablative techniques involved a hysteroscopy and direct destruction of the endometrium. This has been replaced by second generation, non-hysteroscopic techniques that are safer and faster. A typical example of one of these techniques involves passing a specially designed balloon into the endometrial cavity and filling it with high-temperature fluid that burns the endometrial lining. This is called balloon thermal ablation.