Heavy menstrual bleeding

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Heavy menstrual bleeding
Other namesHypermenorrhea, menorrhagia
Specialty Gynecology
Symptoms bleeding more than usual
Complications Anemia, severe pain
Risk factors family history, anovulation, fibroids, polyps, and adenomyosis
Diagnostic method based on physical examination
Differential diagnosis Irregular menstruation
Medication tranexamic acid

Heavy menstrual bleeding (HMB), previously known as menorrhagia or hematomunia, is a menstrual period with excessively heavy flow. It is a type of abnormal uterine bleeding (AUB). [1] [2]

Contents

Abnormal uterine bleeding can be caused by structural abnormalities in the reproductive tract, anovulation, bleeding disorders, hormonal issues (such as hypothyroidism) or cancer of the reproductive tract. Initial evaluation aims at determining pregnancy status, menopausal status, and the source of bleeding. One definition is bleeding lasting more than 7 days or the loss of more than 80 mL of blood heavy flow. [3]

Treatment depends on the cause, severity, and interference with quality of life. [4] Initial treatment often involve birth control pills. Tranexamic acid, danazol, progesterone IUDs, and NSAIDs are also helpful. [5] Surgery can be an effective for those whose symptoms are not well-controlled with other treatments. [6] Approximately 53 in 1000 women are affected by AUB. [7]

Signs and symptoms

Symptoms of heavy menstrual bleeding, according to the decision aid from NHS England. WhatIsHMB.png
Symptoms of heavy menstrual bleeding, according to the decision aid from NHS England.

A normal menstrual cycle is 21–35 days in duration, with bleeding lasting an average of 5 days and total blood flow between 25 and 80 mL. Heavy menstrual bleeding is defined as total menstrual flow >80ml per cycle, soaking a pad/tampon at least every 2 hours, changing a pad/tampon in the middle of the night, or bleeding lasting for >7 days. [3] [1] [9] Deviations in terms of frequency of menses, duration of menses, or volume of menses qualifies as abnormal uterine bleeding. Bleeding in between menses, outside reproductive age, or after sex is also abnormal uterine bleeding and thus requires further evaluation. [10]

Causes

Usually, no causative abnormality can be identified and treatment is directed at the symptom, rather than a specific mechanism. However, there are known causes of abnormal uterine bleeding that need to be ruled out. Most common causes based on the nature of bleeding is listed below followed by the rare causes of bleeding (i.e. disorders of coagulation).

Pathophysiology

HMB is associated with increased omega-6 AA in uterine tissues. [11] The endometrium of people with HMB have higher levels of prostaglandin (E2, F2alpha and others) when compared with women with normal menses. [5] It is thought that prostaglandins are a by product of omega 6 build up. [12] Furthermore, prostaglandins have been found to trigger abnormal, painful uterine contractions, making it a source for targeted therapy. [13]

Diagnosis

Prevalence of heavy menstrual bleeding, amongst people of child-bearing age, and the proportion who seek medical help. Prevalence.png
Prevalence of heavy menstrual bleeding, amongst people of child-bearing age, and the proportion who seek medical help.

The NICE guidelines states that: "Many women presenting to primary care with symptoms of HMB can be offered treatment without the need for further examination or investigation. However, investigation via a diagnostic technique might be warranted for women for whom history or examination suggests a structural or endometrial pathology or for whom the initial treatment has failed." [15]

Diagnosis is largely achieved by obtaining a complete medical history followed by physical exam and vaginal ultrasonography. If need be, laboratory tests or hysteroscopy may be used. The following are a list of diagnostic procedures that medical professionals may use to identify the cause of the abnormal uterine bleeding.

Treatment

NICE Guidelines: Heavy Menstrual Bleeding - Treatment Workflow Heavy Menstrual Bleeding - Treatment Workflow.jpg
NICE Guidelines: Heavy Menstrual Bleeding - Treatment Workflow

Treatment depends on identified underlying cause and varies between medication, radiation, and surgery. Heavy periods at menarche and menopause may settle spontaneously (the menarche being the start and menopause being the cessation of periods).

If the degree of bleeding is mild, all that may be sought is the reassurance that there is no sinister underlying cause. If anemia occurs due to bleeding then iron tablets may be used to help restore normal hemoglobin levels. [1]

The treatment choices of those referred to hospital in the UK for heavy menstrual bleeding. TreatmentChoices.png
The treatment choices of those referred to hospital in the UK for heavy menstrual bleeding.

The first line treatment option for those with HMB and no identified pathology, fibroids less than 3 cm in diameter, and/or suspected or confirmed adenomyosis is the levonorgestrel-releasing intrauterine system (LNG-IUS). [15] Clinical trial evidence suggests that the LNG-IUS may be better than other medical therapy in terms of HMB and quality of life. [21] Though, a 10-year study found that LNG-IUS was only as effective as oral medicines (tranexamic acid, mefenamic acid, combined oestrogen–progestogen or progesterone alone); the same proportion of people had not had surgery for heavy bleeding and had similar improvements in their quality of life. [22] [23]

Usually, oral combined contraceptive or progesterone only pills may be taken for a few months, but for longer-term treatment the alternatives of injected Depo Provera or the more recent progesterone releasing IntraUterine System (IUS) may be used. In particular, an oral contraceptive containing estradiol valerate and dienogest may be more effective than tranexamic acid, NSAIDs and IUDs. [24] [25] Fibroids may respond to hormonal treatment, and if they do not, then radiation or surgical removal may be required. Regarding hormonal treatment, the NICE guidelines states that: "No evidence was found on MRI-guided transcutaneous focused ultrasound for uterine fibroids nor for the progestogen-only pill, injectable progestogens, or progestogen implants." [15] Progestogen pills, independently if taken in a short or long course, are not as effective at reducing menstrual blood loss as LNG-IUS or tranexamic acid. [26]

Tranexamic acid treatments, which reduce bleeding by inhibiting the clot-dissolving enzymes, appear to be more effective than anti-inflammatory treatment like NSAIDs, but are less effective than LNG-IUS. [27] Tranexamic acid tablets may reduce loss by up to 50%. [28] This may be combined with hormonal medication previously mentioned. [29]

NSAIDs are also used to reduce heavy menstrual bleeding by an average of 20-46% through inhibiting the production of prostaglandins. [5] For this purpose, NSAIDs are taken for only 5 days of the menstrual cycle, limiting their most common adverse effect of dyspepsia. [30]

The efficacy of different treatments for heavy menstrual bleeding. . Graphic from NHS decision aid (purple colour indicates hormonal medications, pale green indicates surgical procedures). EfficacyOfTreatments.png
The efficacy of different treatments for heavy menstrual bleeding. . Graphic from NHS decision aid (purple colour indicates hormonal medications, pale green indicates surgical procedures).
The side effects of surgical approaches to heavy menstrual bleeding. SurgicalSideEffects.png
The side effects of surgical approaches to heavy menstrual bleeding.

NICE guidelines says that for individuals with HMB and no identified pathology or fibroids less than 3 cm in diameter who do not wish to have pharmacological treatment and who do not want to conserve their fertility, surgical options could be considered as a first-line treatment option. Options include a hysterectomy and second generation endometrial ablation, with hysterectomy being more effective than second generation endometrial ablation. [15]

A definitive treatment for heavy menstrual bleeding is to perform hysterectomy (removal of the uterus). The risks of the procedure have been reduced with measures to minimize the risk of deep vein thrombosis after surgery, and the switch from the front abdominal to vaginal approach greatly minimizing the discomfort and recuperation time for the patient; however extensive fibroids may make the womb too large for removal by the vaginal approach. Small fibroids may be dealt with by local removal (myomectomy). A further surgical technique is endometrial ablation (destruction) by the use of applied heat (thermoablation). [60] The effectiveness of endometrial ablation is probably similar to that of LNG‐IUS but the evidence is uncertain if hysterectomy is better or worse than LNG-IUS for improving HMB. [21]

Medications

Side effects of medications used for heavy menstrual bleeding. SideEffects.png
Side effects of medications used for heavy menstrual bleeding.

These have been ranked by the UK's National Institute for Health and Clinical Excellence: [16]

Surgery

In the UK the use of hysterectomy for heavy menstrual bleeding has been almost halved between 1989 and 2003. [72] This has a number of causes: better medical management, endometrial ablation and particularly the introduction of IUS [73] [74] which may be inserted in the community and avoid the need for specialist referral; in one study up to 64% of women cancelled surgery. [75]

Complications

Previous studies have suggested a nontrivial reduction in the quality of life in individuals with HMB; however, there is no single metric that has been shown to be specific enough to measure health-related quality of life in individuals with HMB. [76] Evidence suggests that HMB can take a significant toll on the physical, psychological, and social aspects of individuals' lives. For example, a large, cross-sectional study in the United States identified significant associations between HMB and lower employment rates, lost earnings, and a lower self-rating of overall health compared to the general population. [77] Physical and social issues, including performance of house work, life causing embarrassment, and social life, have also been identified as significant reasons why individuals with HMB seek help. [78] While the main impacts of HMB are primarily physical and social, previous studies have also identified an inverse relationship between HMB and psychological scores. [59]

Aside from the social distress of dealing with a prolonged and heavy period, over time the blood loss may prove to be greater than the body iron reserves or the rate of blood replenishment, leading to anemia. [4] Symptoms attributable to the anemia may include shortness of breath, tiredness, weakness, tingling and numbness in fingers and toes, headaches, depression, becoming cold more easily, and poor concentration.

See also

Related Research Articles

Dilationand curettage (D&C) refers to the dilation of the cervix and surgical removal of sections and or layers of the lining of the uterus and or contents of the uterus such as an unwanted fetus, remains of a non viable fetus, retained placenta after birth or abortion as well as any abnormal tissue which may be in the uterus causing abnormal cycles by scraping and scooping (curettage). It is a gynecologic procedure used for treatment and removal as well as diagnostic and therapeutic purposes, and is the most commonly used method for first trimester abortion or miscarriage.

<span class="mw-page-title-main">Hysterectomy</span> Surgical removal of the uterus

Hysterectomy is the surgical removal of the uterus and cervix. Supracervical hysterectomy refers to removal of the uterus while the cervix is spared. These procedures may also involve removal of the ovaries (oophorectomy), fallopian tubes (salpingectomy), and other surrounding structures. The term “partial” or “total” hysterectomy are lay-terms that incorrectly describe the addition or omission of oophorectomy at the time of hysterectomy. These procedures are usually performed by a gynecologist. Removal of the uterus renders the patient unable to bear children and has surgical risks as well as long-term effects, so the surgery is normally recommended only when other treatment options are not available or have failed. It is the second most commonly performed gynecological surgical procedure, after cesarean section, in the United States. Nearly 68 percent were performed for conditions such as endometriosis, irregular bleeding, and uterine fibroids. It is expected that the frequency of hysterectomies for non-malignant indications will continue to fall given the development of alternative treatment options.

Abnormal uterine bleeding (AUB), also known as atypical vaginal bleeding (AVB), is vaginal bleeding from the uterus that is abnormally frequent, lasts excessively long, is heavier than normal, or is irregular. The term dysfunctional uterine bleeding was used when no underlying cause was present. Vaginal bleeding during pregnancy is excluded. Iron deficiency anemia may occur and quality of life may be negatively affected.

<span class="mw-page-title-main">Asherman's syndrome</span> Medical condition

Asherman's syndrome (AS) is an acquired uterine condition that occurs when scar tissue (adhesions) forms inside the uterus and/or the cervix. It is characterized by variable scarring inside the uterine cavity, where in many cases the front and back walls of the uterus stick to one another. AS can be the cause of menstrual disturbances, infertility, and placental abnormalities. Although the first case of intrauterine adhesion was published in 1894 by Heinrich Fritsch, it was only after 54 years that a full description of Asherman syndrome was carried out by Joseph Asherman. A number of other terms have been used to describe the condition and related conditions including: uterine/cervical atresia, traumatic uterine atrophy, sclerotic endometrium, and endometrial sclerosis.

<span class="mw-page-title-main">Adenomyosis</span> Extension of endometrial tissue into the myometrium

Adenomyosis is a medical condition characterized by the growth of cells that proliferate on the inside of the uterus (endometrium) atypically located among the cells of the uterine wall (myometrium), as a result, thickening of the uterus occurs. As well as being misplaced in patients with this condition, endometrial tissue is completely functional. The tissue thickens, sheds and bleeds during every menstrual cycle.

<span class="mw-page-title-main">Vaginal bleeding</span> Medical condition

Vaginal bleeding is any expulsion of blood from the vagina. This bleeding may originate from the uterus, vaginal wall, or cervix. Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductive system, such as abnormal uterine bleeding.

<span class="mw-page-title-main">Endometrial polyp</span> Mass on the interior lining of the uterus

An endometrial polyp or uterine polyp is a mass in the inner lining of the uterus. They may have a large flat base (sessile) or be attached to the uterus by an elongated pedicle (pedunculated). Pedunculated polyps are more common than sessile ones. They range in size from a few millimeters to several centimeters. If pedunculated, they can protrude through the cervix into the vagina. Small blood vessels may be present, particularly in large polyps.

<span class="mw-page-title-main">Uterine fibroid</span> Benign smooth-muscle tumors of the uterus

Uterine fibroids, also known as uterine leiomyomas or fibroids, are benign smooth muscle tumors of the uterus, part of the female reproductive system. Some people with fibroids have no symptoms while others may have painful or heavy periods. If large enough, they may push on the bladder, causing a frequent need to urinate. They may also cause pain during penetrative sex or lower back pain. Someone can have one uterine fibroid or many. It is uncommon but possible that fibroids may make it difficult to become pregnant.

<span class="mw-page-title-main">Uterine myomectomy</span> Surgical removal of uterine fibroid

Myomectomy, sometimes also called fibroidectomy, refers to the surgical removal of uterine leiomyomas, also known as fibroids. In contrast to a hysterectomy, the uterus remains preserved and the woman retains her reproductive potential. It still may impact hormonal regulation and the menstrual cycle.

<span class="mw-page-title-main">Hormonal intrauterine device</span> Intrauterine device

A hormonal intrauterine device (IUD), also known as an intrauterine system (IUS) with progestogen and sold under the brand name Mirena among others, is an intrauterine device that releases a progestogenic hormonal agent such as levonorgestrel into the uterus. It is used for birth control, heavy menstrual periods, and to prevent excessive build of the lining of the uterus in those on estrogen replacement therapy. It is one of the most effective forms of birth control with a one-year failure rate around 0.2%. The device is placed in the uterus and lasts three to eight years. Fertility often returns quickly following removal.

Progestogen-only pills (POPs), colloquially known as "mini pills", are a type of oral contraceptive that contain synthetic progestogens (progestins) and do not contain estrogens. They are primarily used for the prevention of undesired pregnancy, although additional medical uses also exist.

<span class="mw-page-title-main">Uterine artery embolization</span>

Uterine artery embolization is a procedure in which an interventional radiologist uses a catheter to deliver small particles that block the blood supply to the uterine body. The procedure is primarily done for the treatment of uterine fibroids and adenomyosis. Since uterine fibroids are the most common indication, it is also often referred to as uterine fibroid embolization. Compared to surgical treatment for fibroids such as a hysterectomy, in which a woman's uterus is removed, uterine artery embolization may be beneficial in women who wish to retain their uterus. Other reasons for uterine artery embolization are postpartum hemorrhage and uterine arteriovenous malformations.

<span class="mw-page-title-main">Endometrial ablation</span> Medical procedure

Endometrial ablation is a surgical procedure that is used to remove (ablate) or destroy the endometrial lining of the uterus. The goal of the procedure is to decrease the amount of blood loss during menstrual periods. Endometrial ablation is most often employed in people with excessive menstrual bleeding, who do not wish to undergo a hysterectomy, following unsuccessful medical therapy.

Menometrorrhagia, also known as heavy irregular menstrual bleeding, is a condition in which prolonged or excessive uterine bleeding occurs irregularly and more frequently than normal. It is thus a combination of metrorrhagia and menorrhagia.

<span class="mw-page-title-main">Menstrual disorder</span> Medical condition affecting menstrual cycle

A menstrual disorder is characterized as any abnormal condition with regards to a woman's menstrual cycle. There are many different types of menstrual disorders that vary with signs and symptoms, including pain during menstruation, heavy bleeding, or absence of menstruation. Normal variations can occur in menstrual patterns but generally menstrual disorders can also include periods that come sooner than 21 days apart, more than 3 months apart, or last more than 10 days in duration. Variations of the menstrual cycle are mainly caused by the immaturity of the hypothalamic-pituitary-ovarian (HPO) axis, and early detection and management is required in order to minimize the possibility of complications regarding future reproductive ability.

Polymenorrhea, also known as frequent periods, frequent menstruation, or frequent menstrual bleeding, is a menstrual disorder in which menstrual cycles are shorter than 21 days in length and hence where menstruation occurs more frequently than usual. Cycles are regular and menstrual flow is normal in the condition. Normally, menstrual cycles are 25 to 30 days in length, with a median duration of 28 days.

<span class="mw-page-title-main">Bicornuate uterus</span> Medical condition

A bicornuate uterus or bicornate uterus, is a type of Müllerian anomaly in the human uterus, where there is a deep indentation at the fundus (top) of the uterus.

<span class="mw-page-title-main">Intrauterine device</span> Form of birth control involving a device placed in the uterus

An intrauterine device (IUD), also known as intrauterine contraceptive device or coil, is a small, often T-shaped birth control device that is inserted into the uterus to prevent pregnancy. IUDs are a form of long-acting reversible birth control (LARC).

<span class="mw-page-title-main">FIGO classification of uterine bleeding</span>

The International Federation of Gynecology and Obstetrics is an international organization that links about 125 international professional societies of Obstetricians and Gynecologists. In 2011 FIGO recognized two systems designed to aid research, education, and clinical care of women with abnormal uterine bleeding (AUB) in the reproductive years. This page is a summary of the systems and their use in contemporary gynecology.

Menstrual suppression refers to the practice of using hormonal management to stop or reduce menstrual bleeding. In contrast to surgical options for this purpose, such as hysterectomy or endometrial ablation, hormonal methods to manipulate menstruation are reversible.

References

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