Heavy Menstrual Bleeding

Heavy menstrual bleeding is also called menorrhagia. On average, women lose 40 ml of blood during menstruation. Excessive menstrual blood loss involves more than an 80 ml loss. The volume of blood loss is rarely measured in practice. 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”. Heavy menstrual periods can have a significant impact on quality of life.

 

Causes

  • 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

 

History

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

 

Investigations

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.

 

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

 

Outpatient hysteroscopy should be arranged if the is:

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

 

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

 

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

 

Management

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.

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)

 

Management when contraception is wanted or acceptable:

  1. Mirena coil (first line)
  2. Combined oral contraceptive pill
  3. 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).

 

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).

 

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

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.

 

Last updated June 2020
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