Managing Heavy Menstrual Bleeding

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Managing Heavy Menstrual Bleeding

• By
• Dr. Rebecca Cox
• Dr. Nabeela Hasan

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Aims Objectives

• Defining heavy menstrual bleeding
• Why is it important
• Causes
• Case Scenarios
• Familiarise new NICE guidelines

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What is heavy menstrual bleeding?

• Heavy menstrual bleeding (HMB) can be defined
  as excessive menstrual blood loss which
  interferes with a womans physical, social,
  emotional and/or material quality of life.
• (NICE guidelines for Heavy Menstrual
  Bleeding January 2007)

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Why is it important ?

• 1 in 20 women aged 30-49 years consults her GP
  with HMB
• Once referred to gynaecologist, surgical
  intervention is highly likely
• 1 in 5 women in the UK will have a hysterectomy
  before age 60
• In at least ½ of those who undergo hysterectomy,
  HMB is the main presenting problem
• About ½ of all women who have a hysterectomy for
  HMB have a normal uterus removed
• Only 58 of women receive medical therapy for HMB
  before referral to a specialist
• NICE issued new guidelines for HMB in Jan 2007
• (www.doctorsnet.uk- menorrhagia module 2004/5)

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Causes For HMB Erratic Bleeding

• Benign Fibroids
• DUB
• PID
• Endometriosis
• Polyps
• Malignant Endometrial Ca
• Cervical Ca
• Ovarian Ca

• Systemic thyroid disease
• coagulation disorders

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Case 1

• A 28 year old lady comes to see you as she is
  tired of having heavy periods.
• She says she has always had heavy and painful
  periods for a long time but is finally at the end
  of her tether with them.
• What do you do first?

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History

• Frequency of bleeding
• - Has to change tampon and pad every 2-3 hrs
• - has flooded several times and is always
  worried about this.
• - Bleeds heavily for 4 days.
• Menstrual cycle regular 28 day cycle, bleeds for
  6 days.
• Pelvic pain only when menstruating
• No IMB
• No dyspareunia, No PCB
• No discharge
• Married for 8 yrs, no other partners.
• Smear aged 25 - normal
• PMH Nil significant, smoker
• FH Nil signiicant.

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Would you examine her?

• Abdominal examination YES
• Pelvic exmination /_ swabs NO
• O/E Abdomen soft, no tenderness or masses.

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NICE guidelines Re abdominal examination

• Abdominal examination is recommended for patients
  with
• Abdominal pain
• Bloating
• Constipation
• Back pain
• Urinary symptoms

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Nice GuidelinesRe pelvic examination

• Pelvic examination If history suggests HMB
  without structural or histological abnormality,
  pharmaceutical therapy can be started without
  pelvic examination or further investigations
  unless choice of therapy is the IUCD.
• If history suggests HMB with structural or
  histological abnormality eg.IMB, post-coital
  bleeding, pelvic pain or pressure symptoms then
  pelvic examination and further investigations
  should be carried out.

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What investigations would you request?

• FBC indicated in all women with heavy menstrual
  bleeding
• Coagulation only indicated if heavy bleeding
  since menarche, other symptoms or FH.
• TFTs and Ferritin not required unless clinically
  indicated.
• What management options would you offer?

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Nice Guidelines re pharmaceutical options

• 1. Levonorgestrel-releasing intrauterine system.
• IUCD which slowly releases progesterone and
  prevents proliferation of the endometrium.
• Pelvic exam needed first
• Acts as contraceptive
• Side effects Irregular bleeding, hormone related
  problems

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• 2. Tranexamic Acid, NSAIDs or COCPs..
• Can be used while investigations are being
  carried out.
• Stop tranexamic or NSAIDs after 3 cycles if no
  improvement.
• NSAIDs preferred if dysmenorrhoea
• Side effects- see hand out.

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• 3. Oral progestogen (northisterone) or Injected
  progestogen.
• Prevent proliferation of the endometrium.
• 15mg daily for days 5-26 of the menstrual cycle
  or long acting injection.
• Contraceptive
• Side effects- irregular bleeding, hormonal
  symptoms, bone density loss

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Case 2

• A 30 year old woman had the mirena coil put in
  one month ago for heavy menstrual bleeding.
• Before this she was on the COC which did not
  control her periods.
• Unfortunately she presents today because the coil
  was expelled a few days ago.
• She said this was because her bleeding was so
  heavy.
• She is now on her fourth day of her heavy period
  suffering mild discomfort. She goes through 10
  pads per day has passed a few small clots.
• She said she had to take 2 days off work because
  she had to change her pads so often, was fearful
  of accidents had pain.

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• She wants something done about her periods.
• She is adamant that she does not want another
  mirena inserted as she feels it wont work.
• What other treatments could you offer her?

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Management options

• Tranexamic acid
• NSAIDs
• COC
• Oral progesterones
• Injected/implanted progesterones.
• Consider referral to a specialist.

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• She now decides that she does not want any
  further hormonal treatment as when she was on the
  pill, she noticed severe changes in her mood
  breast tenderness.
• After discussion of all the options, you both
  agree a trial of tranexamic acid.
• You also organise a pelvic USS scan.
• She tries tranexamic acid for 3 months.

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• 3 months later she comes back and says that
  tranexamic acid has made very little difference
  to her periods.
• Her USS was normal.
• She has been discussing matters with her mother
  who had a hysterectomy in her 30s.
• She says she would like to be referred for a
  hysterectomy.

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• What could you do next?
• Discuss another less invasive technique such as
  ablation
• Make a referral

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NICE Guidelines

• When a 1st pharmaceutical treatment proves
  ineffective, a 2nd can be considered rather than
  immediate referral to surgery.
• However following 2 failed management options it
  is recommended that the patient is referred.

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NICE guidelines re imaging

• Imaging is recommended in the form of USS if
• pharmaceutical treatment fails
• VE examination reveals a pelvic mass of unknown
  origin
• the uterus is palpable abdominally

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NICE guidelines re endometrial ablation

• Endometrial ablation should be considered in
  women
• where bleeding has a severe impact on QoL they
  do not want to conceive in future
• with HMB who have a normal uterus with small
  uterine fibroids(lt3cm in diameter)
• preferentially to a hysterectomy alone when the
  uterus is no bigger than 10/40 suffer from HMB
  alone
• Women must be advised to avoid subsequent
  pregnancy the need to use effective
  contraception, if required

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Case 3

• A 41yr old lady comes to see you with a 12 month
  history of increasingly heavy and painful periods
  significantly affecting her quality of life.
• No dysuria, frequency or incontinence
• LMP 2 weeks ago, Menstrual cycle 7/28
• She has 2 children
• Her last smear was normal
• PMH Nil significant
• FH Grandmother had fibroids

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What would you do next?

• Abdominal and pelvic examination
• Obtain swabs for infection
• O/E Abdominal exam Suprapubic uterine mass.
  Pelvic examination reveals a bulky uterus.
• You suspect she has uterine fibroids however
  cannot at this stage rule out anything more
  sinister.

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Investigations

• Pregnancy Test Negative
• Urine Dipstix - NAD
• FBC
• USS first line investigation for detecting
  structural abnormalities
• Hysteroscopy only if USS inconclusive

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Results..

• USS confirms large uterine fibroids, the largest
  being 3.6cm diameter.

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Do you refer?

• Yes
• Women with fibroids that are palpable
  abdominally or who have intracavity fibroids
  and/or whose uterine length as measured at
  ultrasound or hysteroscopy is greater than 12 cm
  should be offered immediate referral to a
  specialist.

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• What management should she be offered next?
• Endometrial Ablation? No,
• - This can be offered to women with small
  fibroids lt3cm diameter

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Management options

• Uterine Artery Embolisation
• - for women who want to preserve uterus and
  avoid surgery. May remain fertile.
• Myomectomy
• - for women who want to preserve uterus.
• May remain fertile.

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• Hysterectomy
• - if other treatments fail, if the women no
  longer wishes to retain her uterus or fertility
• - if she has been fully informed
• - if she wishes to have amenorrhoea

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Case 4

• A 58 year old lady has been menopausal for the
  past 5 years.
• She comes to the surgery because she has had 2
  days of period like bleeding.
• She is concerned.
• What would you do next?

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• Obtain further history
• Degree of bleeding
• Confirm start of menopause
• Has it happened before
• Weight loss
• Pressure symptoms esp. pelvic pain, urinary
  frequency/ incontinence, constipation, bloating
• Other GU GI symptoms
• OG hx esp.smears
• FHx of Ca
• PMH

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• The lady says that before this bleeding that she
  has no had a period for 5 years.
• This is the first time that this bleeding has
  happened.
• She has noticed some bloating for the past 2
  days. No other symptoms
• She is nulliparous. Last smear 1yr ago-NAD
• No significant PMH or FHx.

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• Would you want to examine this patient?
• Yes

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• You perform a pelvic and abdominal examination.
• O/E
• abdomen soft non-tender. No masses. Normal
  bowel sounds.
• Pelvic exam shows an atrophic looking vaginal
  walls. Small cystocele. Normal cervix. No blood.
• You feel a small 5cm postmenopausal uterus. No
  masses.
• You take swabs for infection.

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• Would you refer this patient?
• Yes
• Why?
• To rule out endometrial ca/atypical hyperplasia
  by endometrial sampling and hysteroscopy
• Urgent/non-urgent referral?
• Urgent
• Would you do anything else?
• Consider USS

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NICE guidelines re urgent referrals

• PMB is endometrial Ca until proven otherwise
• Urgent referral is made within one working day
• Refer urgently patients with
• Not on HRT with PMB
• ON HRT with persistent /unexplained PMB after
  cessation of HRT for 6 weeks
• Taking tamoxifen with PMB
• With clinical features suggestive of cervical Ca
• Unexplained vulval lump
• With vulval bleeding due to ulceration
• Consider urgent referral for persistent IMB
  negative pelvic exam

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NICE guidelines re pelvic examination

• Full pelvic examination including speculum
  examination is recommended for the following
  symptoms
• Alterations in menstrual cycle
• IMB
• PCB
• PMB
• Vaginal discharge

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Endometrial biopsy

• Nice Guidelines for HMB recommend that biopsy is
  indicated for
• Persistent IMB
• Women aged gt45
• Following treatment failure
• BUT
• When referring patients with a suspicion of
  endometrial cancer, it is highly likely that they
  will require an endometrial biopsy, usually via
  hysteroscopy in this trust.

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