Heavy Menstual Bleeding

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Heavy Menstual Bleeding

• 2007

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Definition

• Excessive menstrual blood loss which interferes
  with a womans physical, emotional, social and
  material quality of life, and which can occur
  alone or in combination with other symptoms.

3
Surgery

• With HMB alone and uterus no bigger than 10/52
  pregnant
• Endometrial ablation rather than hysterectomy
• If hysterectomy essential then
• First line vaginal hysterectomy
• Second line abdominal hysterectomy

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Management

• History
• Menstrual cycle
• PMB
• IMB
• Vaginal discharge
• Previous Gynae problems
• Pregnancy history

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Management

• Examination
• Abdominal exam
• Pelvic exam if appropriate
• Swabs if discharge
• Fbc (not in nice guidelines)
• Arrange imaging if
• Second line drug treatment fails
• Uterus is palpable abdominally or on PV

6
Management

• Consider endometrial biopsy for
• Persistent intermenstrual bleeding
• Women gt 45
• Treatment failure
• Ineffective treatment

7
Management

• No structural abnormality
• First line drug therapy
• If fails
• Second line drug therapy
• Consider imaging - ultrasound
• HMB structural uterine abnormality i.e.
  Palpable uterus
• Arrange imaging

8
Treatment

• If history and investigations indicate that drug
  treatment is appropriate, drugs should be tried
  in the following order
• MIRENA
• Tranexamic acid, COC, NSAIDS
• Norethisterone 15mg/day from day 5-26 of cycle or
  injection of long acting progesterones

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Management

• If drug therapy fails and severe impact on life
  no desire to conceive normal uterus or small
  fibroids lt 3cm then
• Endometrial ablation or
• Hysterectomy

10

• If severe impact on life or fibroids gt 3cm then
  consider
• Hystercetomy
• Myomectomy
• Uterine artery ablation

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Management

• If other
• treatments have failed or are contraindicated or
  declined
• Desire for amenorrhoea
• Fully informed women requests it
• No desire to retain uterus and fertility
• Hysterectomy but dont remove healthy ovaries

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Not recommended

• Direct or indirect menstrual blood loss
  measurement
• Serum ferritin test
• Female hormone testing
• Thyroid testing
• D C

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Not recommended

• Oral progesterones in luteal phase only
• Danazol
• Etamsylate
• D C