Management of Heavy Menstrual Bleeding – A Refresher
Heavy menstrual bleeding is a common gynaecology condition presented to family physicians and gynaecologists. About 1 in 4 women will seek medical attention for this problem. The term heavy menstrual bleeding (HMB) refers to the cyclical (or ovulatory) menses that are heavy or prolonged.
How do we define HMB? On average, a woman loses 30-40ml of blood over 3-7 days in 1 menstrual cycle. HMB is monthly menstrual blood loss of more than 80 ml. It is hard to quantify the amount of blood loss from history taking. Practically speaking, HMB is excessive blood loss that affects a woman’s quality of life. Patients often present with heavy periods that last more than 7 days and require frequent pad or tampon changes. They may pass large blood clots, wear more than one pad at a time or wake up during the night to change pads. Patients with HMB can also experience symptoms of anemia.
Other related symptoms are also important, such as intermenstrual bleeding, pelvic pain or pressure symptoms.
What are the causes of HMB? In 2011, the International Federation of Gynaecology and Obstetrics (FIGO) introduced a revised terminology system for classifying causes of abnormal uterine bleeding . The 9 main categories are arranged according to the acronym PALM-COEIN. Namely, polyp; adenomyosis; leiomyoma; malignancy and hyperplasia; coagulopathy; ovulatory dysfunction; endometrial; iatrogenic; and not yet classified. The term dysfunctional uterine bleeding, or DUB, previously used as a diagnosis when there was no identifiable structural or systemic cause is no longer used.
When should we treat patients with HMB? The general guide is to treat when patients have significant symptoms and when there is anaemia.
It is important to assess for underlying causes before commencing treatment. Depending on findings in history and physical examination, tests can be performed. Pregnancy has to be excluded, through urine and/or serum hCG tests. A full blood count is used to exclude anaemia. Thyroid function test may be performed if patient has signs and symptoms of thyroid disease. Tests for coagulation disorders may be indicated for patients with HMB since menarche or a personal or family history. The first line imaging test is the ultrasound of the pelvis. Structural causes such as fibroids or endometrial polyps can be picked up on ultrasound. Endometrial biopsy is indicated in patients with an increased risk of endometrial hyperplasia or cancer .
Treatment of HMB should be individualized to the patients’ conditions and their expectations. Considerations affecting treatment choices for HMB include the aetiology, the severity of bleeding, issues like infertility or pelvic pains, contraception needs, medical comorbidities and patients’ preferences regarding medical and surgical treatment options.
Levonorgestrel intrauterine devices (e.g. Mirena IUD) are highly effective in the treatment of HMB, with menstrual reduction of between 70 to 95 percent . UK NICE Guidelines recommend this as first line treatment of HMB . By the sixth month after IUD placement, most patients experience amenorrhea or occasional spotting. Other benefits include reduced dysmenorrhea, contraception and lowering the risk of endometrial cancer. For patients with endometrial cavity distortion due to uterine leiomyomas or adenomyosis, there is a higher expulsion rate.
Oestrogen-progestin contraceptives reduces menstrual blood loss of up to 70 percent . It also reduces dysmenorrhea and provide contraception. Most formulations are effective to treat HMB. However, these are contraindicated in patients with an increased risk of thromboembolism.
Depot medroxyprogesterone acetate (e.g. Depo-Provera) can be used for patients who have contraindications to oestrogen usage. It is administered three-monthly and about half of patients achieve amenorrhea after 1 year.
High-dose oral progestins (e.g. Norethisterone) is an option for patients who are still planning to conceive or patients who have contraindications to oestrogen usage. It requires daily dosing and may cause side effects including abdominal bloatedness, appetite changes, and mood changes.
Tranexamic acid, an antifibrinolytic agent, can be used for patients who prefer non-hormonal medical treatment. It is taken only during the menstrual period. It is generally avoided in patients with a risk of thromboembolic events although the association of increased risk of thrombosis remains controversial .
Nonsteroidal anti-inflammatory drugs (NSAIDS) are another treatment option for those who wish to avoid hormonal treatment. Common NSAIDS used for HMB include mefenamic acid, naproxen and ibuprofen. Medication are started on first day of menses and continued for about 5 days, or until menstrual period ends.
Image courtesy of Farrer Park Hospital
Surgical options are dependent on patient’s plans for fertility, the aetiology of HMB, the therapeutic objectives and patient’s preference.
Myomectomy is the surgical treatment option for uterine leiomyomas for patients wishing to preserve fertility. It can be performed through laparotomy or laparoscopy or hysteroscopy depending on size and location of fibroids.
Hysterectomy is the definitive treatment for HMB. It is is an option after medical treatment has failed in patient who has completed their families. The routes of hysterectomy can be vaginal, laparoscopic or abdominal.
Endometrial ablation provides long-term efficacy with less surgical and anaesthetic risks. The procedure can be done in the clinic or day surgery under sedation or anaesthesia. Pregnancy is contraindicated after ablation and patients should continue to use reliable contraception.
High intensity focused ultrasound (HIFU) is a new treatment option for uterine leiomyomas and adenomyosis. It is a computerized, non-invasive procedure that deploys multiple intersecting ultrasound beams to generate localized thermal energy to destroy the targeted tissues. HIFU is associated with lower procedural risks and short recovery period. This modality is at present only available at Farrer Park Hospital.
Other modalities like uterine artery embolism are less commonly performed with the availability of the above options.
Intraoperative finding of uterine leiomyoma during laparoscopy
When should the patients be referred to the gynaecologist? Most patients with HMB can be managed at the primary care setting with initial assessment and treatment. A referral is appropriate when endometrial sampling or IUD insertion is not available at the primary care setting. Referral should also be considered for patients who have persistent HMB despite initial treatment or who require or wish to explore surgical treatment.
- Munro MG et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gyn Obstet 2011; 113:3
- Setiawan VW et al. Type I and II endometrial cancers: have they different risk factors? J Clin Oncol 2013; 31:2607
- Kaunitz AM et al. Levonorgestrel-releasing intrauterine system and endometrial ablation in heavy menstrual bleeding: a systemic review and meta-analysis. Obstet Gynecol 2009; 113:1104
- NICE 2018. Heavy Menstrual Bleeding – Assessment and Management. Available at: https://www.nice.org.uk/guidance/ng88/chapter/Recommendations#management-of-hmb (accessed on 9th October 2018)
- Matteson KA et al. Nonsurgical management of heavy menstrual bleeding: a systemic review. Obstet Gynecol 2013; 121:632
- Sundstrom A et al. The risk of venous thromboembolism associated with the use of tranexamic acid and other drugs to treat menorrhagia: a case-control study using general practice research database. BJOG 2009; 116:91
A Specialist’s Point of View – Written by Dr. Hong Sze Ching
Dr. Hong Sze Ching is a Consultant Obstetrician and Gynaecologist who specialises in laparoscopic surgery, obstetric care and management of general gynaecological conditions. In addition, she is amongst pioneers in Singapore who can perform the High Intensity Focused Ultrasound (HIFU) treatment for Uterine Fibroids, Adenomyoma, Adenomyosis and certain cancers. She is currently practising at SOG – SC Hong Clinic for Women located at Mount Alvernia, Farrer Park Hospital and SATA Commhealth Woodlands Medical Centre.