Tutorial 12: Heavy Menstrual Bleeding (HMB)

Question 1

What is the definition of heavy menstrual bleeding?

Answer 1

Excessive menstrual bleeding, or >80mL menstrual loss (normally 20-80mL)

Question 2

What questions about menstrual history should you ask for a patient with ?HMB?

Answer 2

1. Amount (no of pads/tampons, flooding, clots and clot size- 20c piece/50c),
2. Cycle regularity/length (21-35d is normal): Irregular menstrual bleeding may be secondary to endometrial polyps
3. Duration of bleeding
4. Bleeds in between period
5. Social embarrassment
6. Age of menarche/LMP

Question 3

What should you cover in your history taking for a woman with Heavy Menstrual Bleeding?

Answer 3

1. Menstrual History
2. Exclude pregnancy
   
   1. Are you sexually active
   2. Do you use condoms or other form of contraceptive
   3. Could you be pregnant
3. Parity: Endometrial adenomyosis is associated with multiple pregnancies.
4. Symptoms of thyroid disease: Fatigue, increased cold sensitivity, constipation, dry skin, unexplained weight gain, hair changes.
5. Symptoms of anaemia: Fatigue, lethargy, feeling faint, SOB.
6. Associated symptoms e.g. abdo pain
7. Constitutional symptoms could indicate malignancy: Night sweats, weight loss, fatigue, malaise
8. Weight/BMI: Influences management because you can’t prescribe COC.

Question 4

What are the 3x main categories of causes of Heavy Menstrual Bleeding?

Answer 4

1. Systemic
2. Pelvic
3. Dysfunctional Uterine Bleeding (DUB)

Question 5

What are some systemic causes of Heavy Menstrual Bleeding?

Answer 5

1. Platelet disorders
2. Coagulation disorders
3. Thyroid disorders: feeds back to the HPG axis (hypothyroidism casing oligo-/a-menorrhoea)

Question 6

What are some pelvic causes of heavy menstrual bleeding?

Answer 6

1. Uterus (fibroids, endometrial hyperplasia and polyps)
2. Carcinoma of cervix or endometrium
3. Adenomyosis (ectopic glandular tissue found in muscle)
4. Incomplete miscarriage

Question 7

What is dysfunctional Uterine Bleeding and what are the two main types?

Answer 7

DUB = Abnormal bleeding from uterus in the **absence of organic disease** of the
genital tract (i.e. a _Diagnosis of exclusion)_.

1. Ovulatory DUB = with regular bleeding
2. Anovulatory DUB = with irregular bleeding.
   
   • common in puberty, >30yrs, PCOS.

Question 8

What would you include in your examination of a lady with heavy menstrual bleeding?

Answer 8

1. Signs of anaemia: Pallor (pale conjunctiva and nail beds)
2. Signs of hypothyroidism: Obesity, hair loss, brittle nails, non-pitting oedema, Enlarged thyroid gland
3. Signs of androgen excess/PCOS: Hirsuitism, acne, acanthosis nigricans. (Nb: Acanthosis nigricans is also associated with insulin resistance which can be associated with anovulation.)
4. Signs of liver disease (could indicate a coagulopathy): Hepatomegaly, jaundice, ecchymoses
5. Bimanual Exam: Adnexal masses, Tender uterus (Fibroids, Adenomyosis, Pregnancy, Endometritis)
6. Vaginal examination (unless adolescent). May show lower vaginal/cervical lesions as cause of bleeding.
7. Cervical inspection and Cervical smear - CIN

Question 9

What investigations would you perform for a woman presenting with heavy menstrual bleeding?

Answer 9

1. Urine pregnancy test
2. Routine FBC (Hb), Iron studies (ferritin). There is an increased likelihood of HMB loss >80mls/cycle if Hb <120g/l. Consider pictorial blood loss assessment charts for women with normal Hb
3. Coag testing: PT/APTT. Specific testing for von Willebrand disease
4. Thyroid function – if symptoms of thyroid disease
5. Endometrial biopsy (if > 45 years or increased BMI > 30) – outpatient pipelle - to exclude endometrial hyperplasia (>12mm thickness is bad).
6. Pelvic USS: to diagnose uterine wall and cavity disorders such as fibroids or polyps. Can visualise cysts on the ovaries in PCOS
7. Hysteroscopy (gold standard for endometrial hyperplasia) 98% sensitive for detecting intrauterine pathology, performed to exclude pathology such as polyps and fibroids.
8. Dilatation & curettage (a diagnostic test not treatment!) only 65% sensitive for IU pathology, not specific. Provides a sample of endometrium.

Question 10

What is the medical management of Heavy Menstrual Bleeding?

Answer 10

1. NSAIDs: Cause PG inhibition →vasoconstriction, decrease blood loss by 15%, take only while menstruating- 3month trial. PG Synthetase Inhibitor (1st line)- decreases blood loss by 20-30%
2. Tranexamic Acid (Antifibrinolytic agent) - blocks 40-50%, as effective as OCP
3. COCP: Combined Oral Contraceptive - For anovulatory (e.g. PCOS where increased oestrogen- or endometrial hyperplasia) use OCPs (Norethesterol) - 43 % reduction.
4. Oral Progestogen (day 5-25) (e.g. Depo provera, or medoxyprogestogen acetate) – 87% reduction in bleeding.
5. Danazol: Synthetic steroid with mild androgenic properties which causes atrophy of the endometrium. Useful in the treatment of DUB. Second line due to side effect profile.
6. Mirena IUS- levonorgestrel- vaginal spotting for first 3-6m, uterine cramps if not well placed, spontaneous discharge, risk of perforation, infection migration

Question 11

What is the medical management of prolonged, excessive, heavy menstrual bleeding?

Answer 11

Interruption of bleeding > 10days

1. Medroxyprogesterone acetate (MAP) 20 – 30mg daily for4 weeks.
2. Norethisterone (NET) 10-15mg daily for 4 weeks

Maintenance therapy

1. MPA or NET 5-10mg day 5-25 of each calendar month (if anovulatory)

Question 12

What would you do if a woman fails medical therapy for her heavy menstrual bleeding?

Answer 12

Women who have no improvement in menstrual blood loss with medical therapy should have:

1. TVS
2. Specialist referral for hysteroscopy (as submucous fibroids may be present.)

Question 13

What are the surgical treatment options for heavy menstrual bleeding?

Answer 13

1. Endometrial resection or ablation: Once finished family- currently uses microwave endometrial ablation, destruction of the endometrial layer.
2. Hysterectomy (Gold Standard): Complete cure of DUB, recovery may take 3- 6wks, post-op complications include haemorrhage, infection and venous thrombosis, bladder rupture, ureter rupture, chronic pain post surgery.

Question 14

What are some potential post-op complications of a hysterectomy?

Answer 14

1. haemorrhage
2. infection and venous thrombosis
3. bladder rupture and ureter rupture
4. chronic pain post surgery.