Red flag symptoms: Heavy menstrual bleeding

Possible causes of heavy menstrual bleeding (menorrhagia) include uterine and ovarian pathologies, pelvic inflammatory disease, endometrial cancer, and polycystic ovary syndrome.

Menorrhagia is an excessive menstrual blood loss that interferes with a woman's social, emotional and/or material quality of life.

About 30% of patients describe their periods as `heavy’. Menstrual disorders are the second most common gynaecological condition, resulting in 12% of all gynaecology referrals.1

Red flag symptoms

  • Persistent intermenstrual or postcoital bleeding.
  • An unexplained vulval lump or vulval bleeding as a result of ulceration.
  • A palpable abdominal mass that is not obviously uterine fibroids.

Around half of women with menorrhagia have dysfunctional uterine bleeding and do not have any underlying cause. Other possible causes are listed below.

Possible causes

  • Uterine and ovarian pathologies: uterine fibroids, endometriosis and adenomyosis
  • Pelvic inflammatory disease and pelvic infection
  • Endometrial polyps, hyperplasia or carcinoma
  • Polycystic ovary syndrome
  • Systemic diseases and disorders: hypothyroidism, liver or renal disease
  • Coagulation disorders such as von Willebrand disease
  • Anticoagulant therapy
  • Chemotherapy
  • Intrauterine contraceptive device (blood loss may be increased by 40–50% over 6–12 months compared with pre-insertion values)

History

When taking a history, ask about:

  • Age of menarche
  • Length of the menstrual cycle
  • Excessive bleeding
  • Clots
  • Persistent intermenstrual bleeding
  • Postcoital bleeding
  • Underlying systemic disorders
  • Family history of endometriosis or coagulation disorder
  • Cervical smear status
  • Contraceptive use and family planning
  • Impact on quality of life

Examination

If there are no related symptoms such as persistent intermenstrual bleeding, pelvic pain and/or pressure symptoms, then NICE advises that we can consider pharmacological treatment without a physical examination.2

If there are related symptoms, or an intrauterine system is being considered, then a pelvic examination should be done. This would include vulval examination for evidence of external bleeding and signs of infection, and a speculum examination of vagina and cervix.

High vaginal, endocervical, and chlamydia swabs should be obtained if infection is suspected. Bimanual palpation should be undertaken to identify uterine or adnexal enlargement or tenderness.

Look for systemic signs of underlying disease (including endocrine disease) such as hirsutism, striae, thyroid enlargement, nodularity or skin pigmentation. Bruises or petechiae may suggest coagulation disorders.

Investigations

Full blood count should be performed for all women to rule out iron deficiency anaemia. Thyroid function testing should only be carried out if symptoms or signs are suggestive of thyroid disease. NICE advises that ferritin should not be routinely requested.2

Test for bleeding disorders (for example von Willebrand disease) if the woman has had menorrhagia since her menarche and has a personal or family history that suggests a bleeding disorder. Cervical screening should be done opportunistically if due and if the woman is not bleeding at the time of examination.

NICE guidance

The NICE guidance in 2018 gave us a marked change in practice, taking the focus very much away from ultrasound as an initial investigation in many women.2

NICE advises that any woman with intermenstrual bleeding or risk factors for endometrial pathology (listed below) should be referred for a hysteroscopy, with ultrasound being reserved for those who refuse hysteroscopy referral. In this situation ‘the limitations of this technique [ultrasound] for detecting uterine cavity causes of HMB [heavy menstrual bleeding]’ should be explained.

Risk factors for endometrial pathology include:

  • women with persistent intermenstrual or persistent irregular bleeding
  • women with infrequent heavy bleeding who are obese or have polycystic ovary syndrome
  • women taking tamoxifen.

Ultrasound should, however, be offered if the uterus is palpable abdominally, the history or examination suggests a pelvic mass or the examination is difficult or inconclusive. It should also be considered if adenomyosis is suspected because of period pain since the menarche or a bulky tender uterus on examination.

Any scan should ideally be transvaginal; if this is refused then the woman should be made aware that a transabdominal scan can be done, but has limitations.

Management

For women with no identified pathology, or fibroids of <3cm, which are not indenting the cavity, the treatment of choice is the levonorgestrel-releasing intrauterine system.3,4 This is also the case for those with suspected adenomyosis. Second choices include tranexamic acid and NSAIDs (although these should be avoided in renal disease and those with gastrointestinal ulcers).

A third choice could be cyclical oral progestogens or a combined hormonal contraceptive, if not contraindicated. NICE does not recommend progesterone-only contraceptives as a treatment but reminds us that some of these methods will suppress menstruation, which could be beneficial to the woman; the desogestrel pill will do this for some women but not all.

Gonadotropin-releasing hormone analogues (for example leuprorelin or buserelin) are not recommended for use in primary care, but are an option in secondary care, usually as pre-treatment before hysterectomy or myomectomy.

Rapid treatment of heavy bleeding

Oral norethisterone, 5mg three times a day for 10 days, usually stops bleeding within 1-3 days.1 A withdrawal bleed occurs 2-4 days after stopping treatment. This is equally as thrombogenic as combined hormonal contraception and should therefore not be used in women for whom combined hormonal contraception would be contraindicated for any reason. These women can use medroxyprogesterone.

If bleeding is exceptionally heavy ('flooding'), 10mg three times a day may provide better results but the patient needs to understand that this treatment carries an increased thromboembolic risk. This should then be tapered down to 5mg three times a day for about a week once bleeding has stopped.

When to refer

Referral for women with no fibroids (or those <3cm) should be done if treatment is unsuccessful or declined or if symptoms are severe. Referral may be for further investigations, pharmacological options not yet tried or surgical options such as endometrial ablation or hysterectomy.

For women with fibroids of 3cm or more, referral should be considered earlier for additional investigations and treatment options (see those discussed previously, along with uterine artery embolisation and myomectomy). While women are waiting to be seen we can offer the primary care management already outlined.

The NICE guidance on suspected cancer should, of course, be followed if cancer is suspected – this can be done before doing any investigations in primary care.

  • This article, originally by Dr Anita Somalanka was first published in January 2018 and updated in August 2020 by Dr Toni Hazell aGP in London.


Visit MIMS Learning for an interactive version of this article and a CPD certificate.

References

  1. Duckitt K. Menorrhagia. BMJ Clin Evid 2015 Sep 18; 2015.
  2. NICE. Heavy menstrual bleeding: assessment and management. NG88. March 2020.
  3. NICE. Clinical Knowledge Summaries. Menorrhagia. December 2018.
  4. Gupta JK, Daniels JP, Middleton LJ, et al. A randomised controlled trial of the clinical effectiveness and cost-effectiveness of the levonorgestrel-releasing intrauterine system in primary care against standard treatment for menorrhagia: the ECLIPSE trial. NIHR 2015 Health Technology Assessment, No. 19.88.

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