Heavy menstrual bleeding

Question 1

A 48-year-old woman complains of heavy periods and fatigue. She appears pale and has palmar and conjunctival pallor. Abdominal and pelvic examination were normal. Her Hb was 68g/L. How would you assess and manage?

Answer 1

Impression
With heavy periods and signs/sx of anaemia on examination and a Hb of 68, this woman is likely suffering from heavy menstrual bleeding as the underlying cause for her anaemia. Given the woman being of an age approaching the menopause, I would want to rule out concerning causes of uterine bleeding including

Causes of abnormal uterine bleeding;
PPALM (structural causes)
- polyps
- adenomyosis
- Leiomyoma (fibroids)
- Malignancy + hyperplasia
COEIN (non-structural)
- coagulopathy
- ovulatory disorders (perimenopause, PCOS)
- endometrial disorders (endometritis, 
- iatrogenic

Question 2

Heavy menstrual bleeding - Assessment

Answer 2

Assessment
Given the woman has a significant anaemia, it would be pertinent to conduct an A to E assessment to ensure HD stability before proceeding with further assessment

Question 3

Heavy menstrual bleeding - history

Answer 3

History

• sx: heavy bleeding, how many pads, flow, days for in cycle, regularity of cycle, length, passing any clots? if new onset or for entirety of menstrual cycle, any assoc. dysmenorrhoea/dyspareunia. when was LMP (?pregnant), recent trauma/surgery?
• screen for any bowel.urinary sx (other causes of significant anaemia)
• consequences: fatigue, lethargy, pallor, SOB, chest pain, pica
• REDS: fever, night sweats, weight loss, intermenstrual/post-coital bleeding
• sexual history, contraception, etc
• PMHx, O&GHx, medications, allergies, SNAP

Question 4

Heavy menstrual bleeding - examination

Answer 4

Examination

• general appearance + vital signs
• haematological exam: signs of anaemia - palmar crease pallor, conjunctival pallor, splinter hb; signs of coagulopathy - petechiae, purport, ecchymosis
• abdominal exam: masses
• speculum examination: source of bleeding, visible abnormalities, opportunistic STI/CST if not up to date
• bimanual examination: size and contour of uterus, adnexal masses, tenderness

Question 5

Heavy menstrual bleeding - investigations

Answer 5

Investigations

• bedside: vitals, ECG, urine ß-HCG
• bloods: FBC, iron studies, coags,
• imaging: TA/PV US to identify structural causes
• other: consider hsyteroscopy +/- biopsy, biopsy can be done in office (pipelle)

Question 6

Heavy menstrual bleeding - management

Answer 6

Management
Goals are to treat the symptomatic anaemia and improve the heavy menstrual bleeding

Supportive

• likely requirement for transfusion given symptomatic anaemia (in consult with seniors). Also consider treatment with tranexamic acid if actively bleeding
• gynae referral
• analgesia
• patient education

Definitive
Highly dependent on the underlying cause. Structural problems may require surgical fixations in theatres, non-structural will have specific medical and surgical management depending on the actual cause itself.
- polyp/fibroid: surgical removal (if appropriate)
- total hysterectomy if indicated (if endometrial hyperplasia/malignany)
- PCOS with COCP and weight loss
- endometritis with ABx