Heavy Menstrual Bleeding

PRESENTERS: Dr. AMNA FARID MIRZA

Dr. MAIRA SHAHID
SUPERVISOR: Dr. SURAIYYA
This presentation will cover:

Definitions & Diagnosis

The evidence base for recommended
management
What tests are necessary & when
Treatment
– Medical & Surgical
– Indications & Options
– Risks & Side Effects
 A Few Definitions

Intermenstrual bleeding (IMB)

– Episodes of bleeding between menstrual
periods
– Postcoital bleeding is a type of IMB

Abnormal Uterine Bleeding (AUB)

- Changes in frequency of menses, duration of
flow or amount of blood loss
Heavy menstrual bleeding is
defined as:
Excessive menstrual blood loss which
interferes with a woman’s…
– physical
– emotional
– social or
– material quality of life
This can occur alone or in combination
with other symptoms
This implies that the woman herself is
the primary judge of severity
While a pathological description is
impractical:
That is, the menstrual loss of an amount of blood
loss that is likely to lead to health sequelae
But because treatment options have risk & cost
implications, we are obliged to indicate to patients
some criteria for diagnosis like:
– Sufficient to cause iron deficiency (exclude other causes)
– Escapes from accepted menstrual protection
– Requires changes < 4 hourly
– Up at night more than once
– Passage of large clots
– Lasts for >7 days (full flow)
Menstrual Bleeding – What is Normal?

One study of 179 normal women found that 97% menstruate

for 3-8 days but the range is 1 – 19 days
Most studies demonstrate an effect of age on the duration
and amount of bleeding, as well as cycle length
– For teenagers mean menstrual loss is 4.7 days, the mean cycle
length is 30.8 days (10th to 90th centile range is 25 – 31days)
– For ♀ >40 yrs mean menstrual loss is 4.1 days, the mean cycle
length is 28.4 days (10th to 90th centile range is 25 – 32 days)
– Mean measured loss is 34 ml at 15 yrs, peaks at 50 ml at 30
years then declines to 43 at 45 years
Excessive blood loss is variously reported as >45, >80 or >120
ml based on when anemia & iron deficiency begins
But at least 30% of women who complain of HMB will have
<80 ml blood loss
Incidence of Heavy Menstrual Bleeding
The Impact on Women
Cross sectional studies indicate that 5 – 50% of women will
complain of “heavy periods”
Quantified studies show that ≈ 10% of women will have
menstrual losses that ≥ 80 ml
Many studies indicate that the condition is associated with…
– Reduced employment options
– Work absences
– Decreased earning capacity
– Depression and anxiety
– Mood changes, irritability
– As well as effects on social life, hobbies etc
Can be summarised in “Quality of Life” measures
Some Causes of Heavy Menstrual Bleeding
Fibroids
Adenomyosis
Endometriosis & Chronic PID
Endometrial cancer
Bleeding disorders
– Idiopathic and acquired thrombocytopenia
– Other known disorders of coagulation

Physiological
– Includes dysfunctional uterine bleeding
– All studies show >50% have no identified pathology
 Some History-taking Points
How many days does your period last for?
How many heavy days? What do you mean by heavy?
What do you use for menstrual protection?
How often do you change? Why do you change so often?
What do you use at night?
Do you change at night? How many times?
Do you pass clots? How big are the clots? How often?
Any accidents? (escape from menstrual protection)
What do you mean by flooding?
Do you have to modify your life when you have your periods?
What do you do for contraception in your relationship?
Do you experience any other bleeding or bruising?
Are you taking iron tablets?
 History-taking Essentials
Consider the cultural context
Explore parity, fertility requirements etc
Consider occupation and activities
The extent of examination and investigations will depend on
– Age >45
– Intermenstrual bleeding
– Any pelvic pain or pressure symptoms
Details of any previous gynaecological interventions
Other illnesses or conditions that may influence treatment options , like:
– Infertility
– Prolapse
– Urinary incontinence
Family History
 Examination
A general examination of all patients
– Height & weight
– Signs of anaemia
– Signs of endocrinopathy
• Thyroid
• Androgen excess
Abdominal & PV examination
– For significant uterine enlargement
• Only rewarding in slim patients
• A palpable uterus is >12w size

Patients should not be sent for US without

prior VE
 Laboratory Tests

A Complete Blood Count (CBC) for all patients

– Look for iron-deficiency anaemia
– Check the platelet count
S Ferritin
– Is the most sensitive indicator of Iron deficiency
– But it is an acute phase reactant
Thyroid function tests
– Only when clinically indicated
Female hormones
– Have no role
– Even when the diagnosis is dysfunctional uterine bleeding
 Indications for Tests
of Coagulation Disorders

Symptoms from menarche

Positive Family History
Other personal bleeding or bruising
There is thrombocytopenia
Tests to do:
– Renal and Liver Function Tests
– Bleeding time and Coagulation time
– Seek specialist haematological advice
The most commonly identified abnormality is von
Willebrands Disease
 Imaging

Ultrasound is the imaging of choice

– But is not required unless the uterus is enlarged
– Required for uncertainty after pelvic examination
– Required after a failure of primary medical treatment

Required information from this examination

include:
– Uterine size including endometrial thickness
– Myometrial abnormalities
– Any adnexal pathology
Considerable caution is required when...
– Comments about endometrial thickness are reported as abnormal
– Fibroids <4 cm in size are reported
– Multiple fibroids are reported but there is no clinical evidence of an
irregular uterus
– Adnexal cysts <5 cm diameter are reported
What is the risk of significant pathology?

This is mostly about the risk of endometrial cancer

Distinguishing between HMB and AUB is difficult
The risk of endometrial Ca is age dependent
– For women <30 yrs age the risk is 1:10,000
– For those >45 years the risk is 8:10,000
– And the risk of endometrial hyperplasia is ≈ 4X higher
Who is at risk of Endometrial Cancer?
– Early Menarche
– Late Menopause
– Nulliparity
– Those with unopposed Estrogen, like – PCO, Obesity, HRT
– Patients on chronic Tamoxifen therapy
– With Diabetes Mellitus
– Positive Family History for Endometrial, Ovarian, Breast or Colon
Carcinoma
What is the chance of any pathology?

There are many studies…

Overall about 30% have “significant fibroids”

– But only ≈50% of patients with “significant fibroids” have HMB

About 10% have endometrial polyps

– But there is no evidence that polyps cause HMB

About 15% have endometriosis

– But pain is more important for this disease

Up to 50% of patients undergoing hysterectomy have Adenomyosis

– But these are a selected group

Up to 20% patients with HMB have a coagulation disorder

 How is pathology identified?

There is no gold standard short of hysterectomy & histology

The tools of investigation are best regarded as complementary
and should be used selectively
D&C is no longer regarded as an acceptable investigation
Most studies have compared:
– Transvaginal ultrasound (TVS)
– Saline hysterography (SHG)
– Hysteroscopy
• Which can be inpatient or outpatient
• Electrolyte , non-electrolyte distension medium or CO2
• Fixed or fibreoptic
– With attention to the role of Endometrial Biopsy to exclude
Ca
 Which Test?
What is the Evidence?
Systematic Review of TVS (10 studies), Saline Hysterography
(SHG, 11 studies) and Hysteroscopy (3 studies) for the identification
of any pathology
TVS
– Sensitivity 48 – 100%
– Specificity 12 – 100%
SHG
– Sensitivity 85 – 100%
– Specificity 50– 100%
Hysteroscopy
– Sensitivity 90 – 97%
– Specificity 62 – 93%
Ultrasound is better for the identification of fibroids
HSG and Hysteroscopy are better for the identification of polyps
Exclusion of Endometrial Cancer

Hysteroscopy with biopsy will identify >99.5% of

endometrial cancers
Pipelle endometrial biopsy (an outpatient
procedure) has an overall sensitivity of only
70% for endometrial pathology
– Because it will often be negative with benign
endometrial polyps
But Pipelle has a 99% negative predictive
value for endometrial cancer
 Pipelle Endometrial Biopsy

Is best done in association with ultrasound

Indications:
– Prior to therapy in patients at increased risk of
endometrial cancer
– Age >45
– Those with intermenstrual bleeding
– Obese, Family history etc.
Will be unsuccessful in up to 20% of patients
No sample will be obtained in up to 50%
– But that in itself may be diagnostic enough
Who Requires Hysteroscopy?
High risk patient who has had a failed Pipelle

Negative Pipelle but continuing symptoms

Ultrasound findings inconclusive for submucous fibroid

or endometrial pathology
– A post menstrual study is required
Failure of primary treatment

Prior to endometrial ablation

Patient’s Choice For Treatment

Information about the condition and options for

treatment should be given including...
– expected outcome and its duration of effect
– the type and frequency of risks, side effects and complications
of all methods of treatment
– any potential impact on fertility

The patient should be involved in the treatment

choice
– But safety and cost effectiveness need to be borne in mind
Medical Options for the Treatment
of Heavy Menstrual Bleeding
Hormonal
• Levonorgestrel IUS (“Mirena”)
• Combined COC
• Cyclical oral Progestins
• Injected Progestin (“Depo Provra”)
• Danazol
• GnRH analogues

Non Hormonal
• NSAIDs
• Tranexamic Acid
Surgical Options for Treatment
for Heavy Menstrual Bleeding
Endometrial Ablation
• Hysteroscopic endometrial resection
• 2nd generation techniques
– Thermal balloon endometrial ablation (TBEA)
– Microwave endometrial ablation (MEA)

Myomectomy
Uterine Artery Embolisation
Hysterectomy
• Abdominal, vaginal or laparoscopic
• Subtotal or total
• With or without bilateral oophorectomy
 Potential unwanted outcomes
Information for women about treatment for HMB
 Potential unwanted outcomes
Information for women about treatment for HMB
 Potential unwanted outcomes
Information for women about treatment for HMB
 The Mirena IUS for HMB
What is the Evidence?
Systematic Review of 10 RCT’s that compare Mirena with other
hormonal methods of treatment, endometrial ablation & hysterectomy
Reduces mean menstrual loss by 71 – 96%
Up to 50% of patients amenorrhoeic after 6m depending on age
≈ 85% patients are satisfied (and continuation rate)
≈ 1% rate of troublesome hormonal side effects
When compared to endometrial ablation (EA)
– Mean reduction in blood loss is greater with EA
– But overall satisfaction equal
– And Mirena better in the longer term (1 small study)
When compared to hysterectomy
– Overall satisfaction rates are equal
– But Mirena is half the cost even when up to 40% of patients go on to
hysterectomy
 Oral Hormones for HMB
What is the Evidence?
Only one RCT of 45 patients for Combined oral contraceptive (COC)
Mean blood loss (MBL) was reduced by 43%
Better than Danazol and one NSAID but not another trialed
Risks in older women and smokers plus side effects limit its use
Progestin e.g. Norethisterone 5 mg TDS from Day 5 to 27 of a cycle is
effective in reducing (MBL)
– Luteal phase progestins are not effective
Not as effective as NSAIDs and Tranexamic acid
But MBL was reduced by 83% with long term use in 44 women CF
Mirena (94%) and this difference is not significant
Side effects are limiting – weight gain, headaches, acne, mood
changes, mastalgia
They are of most use in the short term treatment of DUB at the
extremes of reproductive life
 IM Depo Provera for HMB

≈10% of patients are amenorrhoic after 3m

of 150 mg every 12w

≈50% amenorrhoic after 12m

Continuation rates are low, however,

presumably due to side effects

And there is a small risk of bone mineral loss

with long term use
 GnRH analogues for HMB

Most studies have been directed at the reduction of uterine size

with these agents that induce a “reversible menopause”
Reductions in uterine size up to 75% over 6m can occur
And up to 90% of patients achieve amenorrhea
This can be very useful prior to hysterectomy
Estrogen-deficiency symptoms i.e. hot flushes, vaginal atrophy
and bone loss are limiting
But these can be overcome with add-back therapy using small
doses of oral estrogen, COC, progestin or tibilone
GnRH are currently very expensive drugs
 Tranexamic Acid for HMB

Inhibits plasminogen activation but has no effect on

blood clotting in healthy vessels
Reduces fibrin breakdown in spiral arterioles
Systematic reviews confirm that mean blood loss
during menstruation is reduced by ≈ 50%
12% of women experience side effects
• Nausea, vomiting, dyspepsia
• Diarrhoea
• No apparent risk of thromboembolism
• Visual side effects are rare
Dose 1G every 6 – 8 hours
It is not contraceptive nor cycle regulating
 NSAIDs for HMB

Systematic reviews confirm that mean menstrual

blood loss during menstruation is reduced by ≈ 30%
Mefanamic acid better than Ibufren
Side effects are well known but risk is reduced by
intermittent use
Dose 1 – 2 tablets 4 – 6 hourly
Particularly useful when dysmenorrhoea is also a
problem
Not recommended if there is a known bleeding
disorder loss
Summary of Non-Hormonal Drugs Rx

Tranexamic Acid is more effective than NSAIDs

But both can be used together
And either can be continued long term if benefit is
obtained
But should be stopped if there is no response after 3
cycles
Neither is contraceptive or cycle regulating
NSAID is the drug of 1st choice when there is
concomitant dysmenorrhoea
All of the trials excluded women with fibroids so their
role in HMB with fibroids is uncertain
Endometrial Ablation or Hysterectomy
What is the Evidence?
Systematic review 1999 of 5 RCTs with 706 patients
Hysterectomy reduced MBL more
Greater patient satisfaction at 12m & 24m
Less pelvic pain on follow up
Better social functioning
Endometrial ablation had shorter hospital stay
Fewer adverse outcomes
More likely to require further surgery (1 out of 5 patients go on to
hysterectomy)
Hysterectomy is as cost effective as EA
But is associated with ↑rate of long term urinary symptoms
Endometrial Ablation Techniques
All techniques are equivalent for outcomes but 2nd
generation techniques are:
– Safer & Quicker
– Easier to learn & perform
Reduces MBL by 10 – 40 %
Problems include:
– Equipment failure
– Continuing pelvic pain
– Infection & Haematometra
– Uterine perforation & fluid overload with hysteroscopic EA
TBEA does not require prior endometrial thinning
MEA best done in the 1st half of the cycle
Uterine Artery Embolisation (UAE) or
Hysterectomy?
5 RCT’s 157+ patients showed that UAE better than hysterectomy in terms
of:
– Procedure time (Mean 16min less)
– Less blood loss (minimal with UAE CF av. 400 ml for hysterectomy )
– Fewer blood transfusions
– Shorter hospital stay (Mean 3.3 days less)
– Quicker return to normal duties (Mean 27 days less)
– Cheaper (UAE costs 65% those of hysterectomy)
No difference between UAE and hysterectomy in terms of:
– Patient satisfaction
– Complication rates
But UAE result in more readmissions
And 13 – 30% UAE patients require further surgery
Uterine Artery Embolisation (UAE) or
Myomectomy?
One RCT and one cohort study
Myomectomy performed against UAE as for
hysterectomy in terms of operating time, blood
loss, hospitalization and return to normal
activities
Equivalent results in terms of mean menstrual
blood loss and complications
But myomectomy better in terms of pelvic
pain on follow up
And fewer required re operation
NICE Recommendations on Surgical
Options
Endometrial resection by a 2nd generation technique
be offered to all women with HMB provided that
they have completed their family
If the uterus is <10w in size and or fibroids < 3 cm
diameter
A hysteroscopic technique is used when there are
submucous fibroids
Practitioners and institutions be trained and
competent for EA
Hysterectomy, uterine artery embolisation or
myomectomy be considered for fibroids >4 cm or
uterus >10w size
NICE Recommendations for Uterine
Fibroids
For patients with heavy menstrual bleeding and fibroids >3 cm
size (and especially those with pelvic pain or other symptoms)
then…
– Hysterectomy, Uterine artery embolisation (UAE) and
myomectomy should all be offered
– Myomectomy recommended if fertility is desired
– Hysteroscopic resection of the entire fibroid with endometrial
resection is appropriate if the fibroid (s) are submucous
Pre treatment with GnRH analogue for 3 - 4m is worthwhile
before hysterectomy and myomectomy
– Reduces uterine size and makes surgery easier
– Better Hb pre op and less bleeding
But GnRH analogues are contraindicated before UAE