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Managing Heavy Menstrual Bleeding. By Dr. Rebecca Cox & Dr. Nabeela Hasan. Aims & Objectives. Defining heavy menstrual bleeding Why is it important Causes Case Scenarios Familiarise new NICE guidelines. What is heavy menstrual bleeding?.

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managing heavy menstrual bleeding

Managing Heavy Menstrual Bleeding


Dr. Rebecca Cox


Dr. Nabeela Hasan

aims objectives
Aims & Objectives
  • Defining heavy menstrual bleeding
  • Why is it important
  • Causes
  • Case Scenarios
  • Familiarise new NICE guidelines
what is heavy menstrual bleeding
What is heavy menstrual bleeding?

Heavy menstrual bleeding (HMB) can be defined as excessive menstrual blood loss which interferes with a woman’s physical, social, emotional and/or material quality of life.

(NICE guidelines for Heavy Menstrual Bleeding : January 2007)

why is it important
Why is it important ?
  • 1 in 20 women aged 30-49 years consults her GP with HMB
  • Once referred to gynaecologist, surgical intervention is highly likely
  • 1 in 5 women in the UK will have a hysterectomy before age 60
  • In at least ½ of those who undergo hysterectomy, HMB is the main presenting problem
  • About ½ of all women who have a hysterectomy for HMB have a normal uterus removed
  • Only 58% of women receive medical therapy for HMB before referral to a specialist
  • NICE issued new guidelines for HMB in Jan 2007

( menorrhagia module 2004/5)

causes for hmb erratic bleeding
Benign: Fibroids





Malignant: Endometrial Ca

Cervical Ca

Ovarian Ca

Systemic: thyroid disease

coagulation disorders

Causes For HMB & Erratic Bleeding
case 1
Case 1
  • A 28 year old lady comes to see you as she is tired of having heavy periods.
  • She says she has always had heavy and painful periods for a long time but is finally at the end of her tether with them.
  • What do you do first?
  • Frequency of bleeding:

- Has to change tampon and pad every 2-3 hrs

- has flooded several times and is always worried about this.

- Bleeds heavily for 4 days.

  • Menstrual cycle: regular 28 day cycle, bleeds for 6 days.
  • Pelvic pain only when menstruating
  • No IMB
  • No dyspareunia, No PCB
  • No discharge
  • Married for 8 yrs, no other partners.
  • Smear aged 25 - normal
  • PMH: Nil significant, smoker
  • FH: Nil signiicant.
would you examine her
Would you examine her?
  • Abdominal examination – YES
  • Pelvic exmination +/_ swabs – NO
  • O/E: Abdomen soft, no tenderness or masses.
nice guidelines re abdominal examination
NICE guidelines Re: abdominal examination
  • Abdominal examination is recommended for patients with:
    • Abdominal pain
    • Bloating
    • Constipation
    • Back pain
    • Urinary symptoms
nice guidelines re pelvic examination
Nice GuidelinesRe: pelvic examination
  • Pelvic examination: If history suggests HMB without structural or histological abnormality, pharmaceutical therapy can be started without pelvic examination or further investigations unless choice of therapy is the IUCD.
  • If history suggests HMB with structural or histological abnormality eg.IMB, post-coital bleeding, pelvic pain or pressure symptoms then pelvic examination and further investigations should be carried out.
what investigations would you request
What investigations would you request?
  • FBC – indicated in all women with heavy menstrual bleeding
  • Coagulation – only indicated if heavy bleeding since menarche, other symptoms or FH.
  • TFT’s and Ferritin not required unless clinically indicated.
  • What management options would you offer?
nice guidelines re pharmaceutical options
Nice Guidelines re: pharmaceutical options

1. Levonorgestrel-releasing intrauterine system.

  • IUCD which slowly releases progesterone and prevents proliferation of the endometrium.
  • Pelvic exam needed first
  • Acts as contraceptive
  • Side effects: Irregular bleeding, hormone related problems
2. Tranexamic Acid, NSAIDs or COCPs..
  • Can be used while investigations are being carried out.
  • Stop tranexamic or NSAIDs after 3 cycles if no improvement.
  • NSAIDs preferred if dysmenorrhoea
  • Side effects- see hand out.
3. Oral progestogen (northisterone) or Injected progestogen.
  • Prevent proliferation of the endometrium.
  • 15mg daily for days 5-26 of the menstrual cycle or long acting injection.
  • Contraceptive
  • Side effects- irregular bleeding, hormonal symptoms, bone density loss
case 2
Case 2
  • A 30 year old woman had the mirena coil put in one month ago for heavy menstrual bleeding.
  • Before this she was on the COC which did not control her periods.
  • Unfortunately she presents today because the coil was expelled a few days ago.
  • She said this was because her bleeding was so heavy.
  • She is now on her fourth day of her heavy period & suffering mild discomfort. She goes through 10 pads per day & has passed a few small clots.
  • She said she had to take 2 days off work because she had to change her pads so often, was fearful of accidents & had pain.
She wants something done about her periods.
  • She is adamant that she does not want another mirena inserted as she feels it won’t work.
  • What other treatments could you offer her?
management options
Management options
  • Tranexamic acid
  • NSAIDs
  • COC
  • Oral progesterones
  • Injected/implanted progesterones.
  • Consider referral to a specialist.
She now decides that she does not want any further hormonal treatment as when she was on the pill, she noticed severe changes in her mood & breast tenderness.
  • After discussion of all the options, you both agree a trial of tranexamic acid.
  • You also organise a pelvic USS scan.
  • She tries tranexamic acid for 3 months.
3 months later she comes back and says that tranexamic acid has made very little difference to her periods.
  • Her USS was normal.
  • She has been discussing matters with her mother who had a hysterectomy in her 30s.
  • She says she would like to be referred for a hysterectomy.
What could you do next?
  • Discuss another less invasive technique such as ablation
  • Make a referral
nice guidelines
NICE Guidelines
  • When a 1st pharmaceutical treatment proves ineffective, a 2nd can be considered rather than immediate referral to surgery.
  • However following 2 failed management options it is recommended that the patient is referred.
nice guidelines re imaging
NICE guidelines re: imaging
  • Imaging is recommended in the form of USS if
    • pharmaceutical treatment fails
    • VE examination reveals a pelvic mass of unknown origin
    • the uterus is palpable abdominally
nice guidelines re endometrial ablation
NICE guidelines: re endometrial ablation
  • Endometrial ablation should be considered in women:
    • where bleeding has a severe impact on QoL & they do not want to conceive in future
    • with HMB who have a normal uterus & with small uterine fibroids(<3cm in diameter)
    • preferentially to a hysterectomy alone when the uterus is no bigger than 10/40 & suffer from HMB alone
  • Women must be advised to avoid subsequent pregnancy & the need to use effective contraception, if required
case 3
Case 3
  • A 41yr old lady comes to see you with a 12 month history of increasingly heavy and painful periods significantly affecting her quality of life.
  • No dysuria, frequency or incontinence
  • LMP 2 weeks ago, Menstrual cycle: 7/28
  • She has 2 children
  • Her last smear was normal
  • PMH: Nil significant
  • FH: Grandmother had fibroids
what would you do next
What would you do next?
  • Abdominal and pelvic examination
  • Obtain swabs for infection
  • O/E: Abdominal exam: Suprapubic uterine mass. Pelvic examination reveals a bulky uterus.
  • You suspect she has uterine fibroids however cannot at this stage rule out anything more sinister.
  • Pregnancy Test – Negative
  • Urine Dipstix - NAD
  • FBC
  • USS: first line investigation for detecting structural abnormalities
  • Hysteroscopy – only if USS inconclusive
  • USS confirms large uterine fibroids, the largest being 3.6cm diameter.
do you refer
Do you refer?
  • Yes:
  • “Women with fibroids that are palpable abdominally or who have intracavity fibroids and/or whose uterine length as measured at ultrasound or hysteroscopy is greater than 12 cm should be offered immediate referral to a specialist.”
What management should she be offered next?
  • Endometrial Ablation? No,

- This can be offered to women with small fibroids <3cm diameter

management options1
Management options
  • Uterine Artery Embolisation

- for women who want to preserve uterus and avoid surgery. May remain fertile.

  • Myomectomy

- for women who want to preserve uterus.

May remain fertile.


- if other treatments fail, if the women no longer wishes to retain her uterus or fertility

- if she has been fully informed

- if she wishes to have amenorrhoea

case 4
Case 4
  • A 58 year old lady has been menopausal for the past 5 years.
  • She comes to the surgery because she has had 2 days of period like bleeding.
  • She is concerned.
  • What would you do next?
Obtain further history
      • Degree of bleeding
      • Confirm start of menopause
      • Has it happened before
      • Weight loss
      • Pressure symptoms – esp. pelvic pain, urinary frequency/ incontinence, constipation, bloating
      • Other GU & GI symptoms
      • O&G hx esp.smears
      • FHx of Ca
      • PMH
The lady says that before this bleeding that she has no had a period for 5 years.
  • This is the first time that this bleeding has happened.
  • She has noticed some bloating for the past 2 days. No other symptoms
  • She is nulliparous. Last smear 1yr ago-NAD
  • No significant PMH or FHx.
You perform a pelvic and abdominal examination.
  • O/E:
    • abdomen soft & non-tender. No masses. Normal bowel sounds.
    • Pelvic exam shows an atrophic looking vaginal walls. Small cystocele. Normal cervix. No blood.
    • You feel a small 5cm postmenopausal uterus. No masses.
    • You take swabs for infection.
Would you refer this patient?
  • Yes
  • Why?
  • To rule out endometrial ca/atypical hyperplasia by endometrial sampling and hysteroscopy
  • Urgent/non-urgent referral?
  • Urgent
  • Would you do anything else?
  • Consider USS
nice guidelines re urgent referrals
NICE guidelines re: urgent referrals
  • PMB is endometrial Ca until proven otherwise
  • Urgent referral is made within one working day
  • Refer urgently patients with:
      • Not on HRT with PMB
      • ON HRT with persistent /unexplained PMB after cessation of HRT for 6 weeks
      • Taking tamoxifen with PMB
      • With clinical features suggestive of cervical Ca
      • Unexplained vulval lump
      • With vulval bleeding due to ulceration
  • Consider urgent referral for persistent IMB & negative pelvic exam
nice guidelines re pelvic examination1
NICE guidelines re: pelvic examination
  • Full pelvic examination including speculum examination is recommended for the following symptoms:
    • Alterations in menstrual cycle
    • IMB
    • PCB
    • PMB
    • Vaginal discharge
endometrial biopsy
Endometrial biopsy
  • Nice Guidelines for HMB recommend that biopsy is indicated for:
    • Persistent IMB
    • Women aged >45
    • Following treatment failure


  • When referring patients with a suspicion of endometrial cancer, it is highly likely that they will require an endometrial biopsy, usually via hysteroscopy in this trust.