Heavy menstrual bleeding

Centre for Women's and Children's Health and Professor Mary Ann Lumsden, professor of gynaecology, University of Glasgow.

1. AETIOLOGY AND EPIDEMIOLOGY

Studies show that heavy menstrual bleeding has an adverse effect on the quality of life of women. Research shows that rapid adverse blood chemistry changes take place at menstrual blood loss levels of between 60ml and 120ml. However, studies show the link between menstrual blood loss and the impact of menstrual blood loss is not linear.

There is little correlation between the objective and subjective assessment of menstrual blood loss and it is rarely measured, except in a research context. In addition, measurement of menstrual blood loss alone does not take account of the impact on quality of life. This is the main reason for the NICE guideline not using a definition of heavy menstrual bleeding based on menstrual blood loss alone but also taking into account quality of life.

In the majority of cases no underlying cause for heavy menstrual bleeding is identified, but conditions such as uterine fibroids, endometriosis and coagulation disorders are all known to be associated with heavy menstrual bleeding with or without other menstrual problems.

Referral
Heavy menstrual bleeding is not associated with significant mortality but many women seek help from their GPs because of the morbidity it causes and it is a common reason for referral into secondary care.

An estimated 1.5 million women consult their GP each year with heavy menstrual bleeding in England and Wales, and menstrual disorders account for about 20 per cent of all referrals to specialist gynaecology services.

NICE definition
'For clinical purposes, heavy menstrual bleeding should be defined as excessive menstrual blood loss which interferes with the woman's physical, emotional, social and material quality of life, and which can occur alone or in combination with other symptoms. Any interventions should aim to improve quality-of-life measures.'

Source: NICE

2. MAKING A DIAGNOSIS

The initial history taking is very important for the correct management of heavy menstrual bleeding (see box). This will provide information as to whether there is likely to be any pathology associated with the heavy menstrual bleeding.

Physical examination
No examination is required at the first consultation if heavy menstrual bleeding is the sole symptom.

However, if pathology, such as uterine fibroids, is suspected, if signs or symptoms of structural or histological abnormalities are present or the suggested treatment is a levonorgestrel-releasing intrauterine system, then a physical examination is required.

If none of these is present then pharmaceutical treatment can be started straight away.

Laboratory tests
An FBC should be undertaken on a woman with heavy menstrual bleeding to assess the presence of anaemia.

However, no other tests are routinely required - for example, for thyroid or coagulation disorders - as evidence suggests these are not linked with heavy menstrual bleeding alone.

Other signs and symptoms of the particular disease are likely to be present.

An ultrasound investigation should be arranged if the uterus is palpable abdominally, if vaginal examination reveals a pelvic mass of uncertain origin, or if pharmaceutical treatment fails to improve symptoms.

However, it is very important that the person performing the scan is appropriately trained or misleading results may be obtained.

History to determine treatment

Nature of bleeding

  • How heavy - assessed by the impact on the woman's life.
  • Regular or irregular*.
  • Presence of bleeding between periods or after intercourse.

Signs if possible pathology

  • Pressure symptoms.
  • Onset of dysmenorrhoea in the fourth or fifth decade.
  • Abdominal pain between periods.

Other features that may determine treatment

  • A woman's idea and concerns regarding heavy menstrual bleeding and its treatment.

3. MANAGING THE CONDITION

The range of treatments available for heavy menstrual bleeding is considerable. An algorithm for management from NICE can be found at http://guidance.nice.org.uk/CG44/quickrefguide/pdf/English.

Medical treatment
The guideline outlines the order in which pharmaceutical treatments should be considered. These are a levonorgestrel-releasing intrauterine system (for at least 12 months) then tranexamic acid or NSAIDs (for at least three months), then norethisterone 15mg daily from days five to 26 of the menstrual cycle, or injected long-acting progestogens (for at least three months).

This sequence depends on a number of factors, not least of which is whether the woman wishes to conceive - in which case a treatment that is contraceptive would not be appropriate.

Insertion of the levonorgestrel-releasing intrauterine system is easier in multiparous women, although data do not suggest that side-effects are more common in those who have not been pregnant.

Oral treatment can be started while waiting for the device to be inserted.

Referral criteria When to refer a woman for specialist care depends on three factors: if the heavy menstrual bleeding is likely to have a pathological cause, such as fibroids; if the heavy menstrual bleeding has not been relieved by the treatments tried so far and surgical treatment is under consideration; if the woman wishes to discuss her problem with a doctor with a specialist interest and expertise.

Specialist care
While GPs will not provide specialist treatments, they must be aware of the options. There are four surgical options recommended in the NICE guideline.

Endometrial ablation is recommended where no pathology is found, but is not suitable if a woman wants to become pregnant in the future.

Commonly used methods that have been scrutinised by the Health Technology Authority are microwave endometrial ablation and thermal balloon endometrial ablation.

Uterine artery embolisation is recommended where fibroids are found and potentially allows women to become pregnant in future, but there is a risk that fibroids will reoccur.

Myomectomy is also recommended where fibroids are found and potentially allows a woman to become pregnant in the future, but again there is a risk that fibroids will reoccur.

Hysterectomy is recommended for any indication, but only where other options have been considered and rejected by both the health professional and the woman.

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