Managing heavy menstrual bleeding
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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

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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

Managing heavy menstrual bleeding

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.

Managing heavy menstrual bleeding

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.

Managing heavy menstrual bleeding

  • 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.

Managing heavy menstrual bleeding

  • 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.

Managing heavy menstrual bleeding

  • 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.

Managing heavy menstrual bleeding

  • 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.”

Managing heavy menstrual bleeding

  • 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.

Managing heavy menstrual bleeding

  • Hysterectomy

    - 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?

Managing heavy menstrual bleeding

  • 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

Managing heavy menstrual bleeding

  • 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.

Managing heavy menstrual bleeding

  • Would you want to examine this patient?

  • Yes

Managing heavy menstrual bleeding

  • 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.

Managing heavy menstrual bleeding

  • 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.

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