Heavy menstrual bleeding

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

Not to be confused with Metrorrhagia.
Heavy menstrual bleeding
Other namesHypermenorrhea, menorrhagia
SpecialtyGynecology

Abnormal uterine bleeding can be caused by structural abnormalities in the reproductive tract, anovulation, bleeding disorders, hormone issues (such as hypothyroidism) or cancer of the reproductive tract. Initial evaluation aims at figuring out 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

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, or bleeding lasting for >7 days.[3][1] Deviations in terms of frequency of menses, duration of menses, or volume of menses qualifies as abnormal uterine bleeding. Bleeding in between menses is also abnormal uterine bleeding and thus requires further evaluation.

Complications of heavy menstrual bleeding could also be the initial symptoms. Excessive bleeding can lead to anemia which presents as fatigue, shortness of breath, and weakness. Anemia can be diagnosed with a blood test.

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).

Consideration
  • Excessive menses but normal cycle:
    • Painless:
      • Fibroids (leiomyoma) — fibroids in the wall of the uterus cause increased menstrual loss if they protrude into the central cavity and thereby increase endometrial surface area.
      • Coagulation defects (rare) — with the shedding of an endometrial lining's blood vessels, normal coagulation process must occur to limit and eventually stop the blood flow. Blood disorders of platelets (such as ITP) or coagulation (such as von Willebrand disease) or use of anticoagulant medication (such as warfarin) are therefore possible causes, although a rare minority of cases. Platelet function studies can also be used to ascertain platelet function abnormalities
      • Endometrial cancer (cancer of the uterine lining) — bleeding can also be irregular, in between periods, or after the menopause (post-menopausal bleeding or PMB)
      • Endometrial polyp
    • Painful (ie associated with dysmenorrhea):
      • Pelvic inflammatory disease
      • Endometriosis - extension of the endometrial tissue outside of the uterus tries to shed causing painful and abnormal bleeds
      • Adenomyosis - extension of the endometrial tissue into the wall of the uterus tries to shed causing painful and abnormal bleeds
      • Pregnancy related complication (i.e. miscarriage)
  • Short cycle (less than 21 days) but normal menses. These are always anovulatory cycles due to hormonal disorders.
  • Short cycle and excessive menses due to ovarian dysfunction and may be secondary to blockage of blood vessels by tumours.
  • Polycystic ovary syndrome.[3]
  • Systemic causes: thyroid disease, excessive emotional/physical stress.[3]
  • Sexually transmitted infection.[3]

Omega 6 and prostaglandins

HMB is associated with increased omega-6 AA in uterine tissues.[8] The endometrium of women with HMB have higher levels of prostaglandin (E2, F2alpha and others) when compared with women with normal menses.[9] It is thought that prostaglandins are a by product of omega 6 build up.[10]

Diagnosis

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."[11] 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.

  • Pelvic and rectal examination to ensure that bleeding is not from lower reproductive tract (i.e. vagina, cervix) or rectum
  • Pap smear to rule out cervical neoplasia
  • Pelvic ultrasound scan is the first line diagnostic tool for identifying structural abnormalities.[12]
  • Endometrial biopsy in women with high risk endometrial cancer or atypical hyperplasia or malignancy.[11]
  • Hysteroscopy (anaesthesia should be offered)[11]
  • Thyroid-stimulating hormone and thyrotropin-releasing hormone dosage to rule out hypothyroidism [13]

Treatment

Where an underlying cause can be identified, treatment may be directed at this. Clearly 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 by the woman 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 first line treatment option for women with HMB and no identified pathology, fibroids less than 3 cm in diameter, suspected or confirmed adenomyosis is the levonorgestrel-releasing intrauterine system (see IntraUterine System).[11] 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.[14][15] Fibroids may respond to hormonal treatment, and if they do not, then surgical removal may be required. Concerning 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."[11]

NICE guidelines says that for women (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. And options are hysterectomy and second generation endometrial ablation. With hysterectomy more effective than second generation endometrial ablation.[11]

Tranexamic acid tablets that may also reduce loss by up to 50%.[16] This may be combined with hormonal medication previously mentioned.[17]

Anti-inflammatory medication like NSAIDs may also be used. NSAIDs are the first-line medications in ovulatory heavy menstrual bleeding, resulting in an average reduction of 20-46% in menstrual blood flow. NSAIDs may be more effective than placebo in terms of reducing blood loss increasing women's subjective perception of improvement, they may be less effective than tranexamic acid. It is uncertain if there is any difference between NSAIDs and tranexamic acid in terms of women's subjective perception of bleeding.[9] For this purpose, NSAIDs are ingested for only 5 days of the menstrual cycle, limiting their most common adverse effect of dyspepsia.[18]

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 reduce 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).[19]

Medications

These have been ranked by the UK's National Institute for Health and Clinical Excellence:[12]

Surgery
  • Dilation and curettage (D&C) is not recommended for cases of simple heavy menstrual bleeding, having a reserved role if a spontaneous abortion is incomplete[20]
  • Endometrial ablation is not recommended for women with active or recent genital or pelvic infection, known or suspected endometrial hyperplasia or malignancy.[21]
  • Uterine artery embolization (UAE): The rate of serious complications is comparable to that of myomectomy or hysterectomy. The advantage of somewhat faster recovery time is offset by a higher rate of minor complications and an increased likelihood of requiring surgical intervention within two to five years of the initial procedure.[22]
  • Hysteroscopic myomectomy to remove fibroids over 3 cm in diameter
  • Hysterectomy

In the UK the use of hysterectomy for heavy menstrual bleeding has been almost halved between 1989 and 2003.[23] This has a number of causes: better medical management, endometrial ablation and particularly the introduction of IUS[24][25] which may be inserted in the community and avoid the need for specialist referral; in one study up to 64% of women cancelled surgery.[26]

Complications

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.

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See also

References
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  2. Bacon JL (June 2017). "Abnormal Uterine Bleeding: Current Classification and Clinical Management". Obstetrics and Gynecology Clinics of North America. 44 (2): 179–193. doi:10.1016/j.ogc.2017.02.012. PMID 28499529.
  3. O'Brien SH (2018). "Evaluation and management of heavy menstrual bleeding in adolescents: the role of the hematologist". Hematology. 30 (1): 390–398. doi:10.1182/asheducation-2018.1.390. PMC 6246024. PMID 30504337.
  4. Committee on Practice Bulletins—Gynecology (July 2013). "Practice bulletin no. 136: management of abnormal uterine bleeding associated with ovulatory dysfunction". Obstetrics and Gynecology. 122 (1): 176–85. doi:10.1097/01.AOG.0000431815.52679.bb. PMID 23787936.
  5. Bofill Rodriguez, M; Lethaby, A; Farquhar, C (19 September 2019). "Non-steroidal anti-inflammatory drugs for heavy menstrual bleeding". The Cochrane Database of Systematic Reviews. 9: CD000400. doi:10.1002/14651858.CD000400.pub4. PMC 6751587. PMID 31535715.
  6. Marjoribanks J, Lethaby A, Farquhar C (January 2016). "Surgery versus medical therapy for heavy menstrual bleeding". The Cochrane Database of Systematic Reviews (1): CD003855. doi:10.1002/14651858.CD003855.pub3. PMC 7104515. PMID 26820670.
  7. Kjerulff KH, Erickson BA, Langenberg PW (February 1996). "Chronic gynecological conditions reported by US women: findings from the National Health Interview Survey, 1984 to 1992". American Journal of Public Health. 86 (2): 195–9. doi:10.2105/ajph.86.2.195. PMC 1380327. PMID 8633735.
  8. Joseph E. Pizzorno, Michael T. Murray and Herb Joiner-Bey (2015). The Clinician's Handbook of Natural Medicine. doi:10.1016/C2010-0-67298-1. ISBN 9780702055140.CS1 maint: uses authors parameter (link)
  9. Bofill Rodriguez, M; Lethaby, A; Farquhar, C (19 September 2019). "Non-steroidal anti-inflammatory drugs for heavy menstrual bleeding". The Cochrane Database of Systematic Reviews. 9: CD000400. doi:10.1002/14651858.CD000400.pub4. PMID 31535715.
  10. Harel Z (December 2006). "Dysmenorrhea in adolescents and young adults: etiology and management". Journal of Pediatric and Adolescent Gynecology. 19 (6): 363–71. doi:10.1016/j.jpag.2006.09.001. PMID 17174824.
  11. NICE (2018). "Heavy menstrual bleeding (update)". National Guideline Alliance (UK). PMID 29634173.CS1 maint: uses authors parameter (link)
  12. "CG44 Heavy menstrual bleeding: Understanding NICE guidance" (PDF). National Institute for Health and Clinical Excellence (UK). 24 January 2007.
  13. Weeks AD (March 2000). "Menorrhagia and hypothyroidism. Evidence supports association between hypothyroidism and menorrhagia". BMJ. 320 (7235): 649. doi:10.1136/bmj.320.7235.649. PMC 1117669. PMID 10698899.
  14. Kaunitz AM, Meredith S, Inki P, Kubba A, Sanchez-Ramos L (May 2009). "Levonorgestrel-releasing intrauterine system and endometrial ablation in heavy menstrual bleeding: a systematic review and meta-analysis". Obstetrics and Gynecology. 113 (5): 1104–16. doi:10.1097/AOG.0b013e3181a1d3ce. PMID 19384127.
  15. Jensen JT, Parke S, Mellinger U, Machlitt A, Fraser IS (April 2011). "Effective treatment of heavy menstrual bleeding with estradiol valerate and dienogest: a randomized controlled trial". Obstetrics and Gynecology. 117 (4): 777–87. doi:10.1097/AOG.0b013e3182118ac3. PMID 21422847.
  16. Bonnar J, Sheppard BL (September 1996). "Treatment of menorrhagia during menstruation: randomised controlled trial of ethamsylate, mefenamic acid, and tranexamic acid". BMJ. 313 (7057): 579–82. doi:10.1136/bmj.313.7057.579. PMC 2352023. PMID 8806245.
  17. Lukes AS, Moore KA, Muse KN, Gersten JK, Hecht BR, Edlund M, Richter HE, Eder SE, Attia GR, Patrick DL, Rubin A, Shangold GA (October 2010). "Tranexamic acid treatment for heavy menstrual bleeding: a randomized controlled trial". Obstetrics and Gynecology. 116 (4): 865–75. doi:10.1097/AOG.0b013e3181f20177. PMID 20859150.
  18. A Shaw J (2014-09-29). "Menorrhagia Treatment & Management". Medscape. Retrieved 2015-01-04.
  19. Bofill Rodriguez, M; Lethaby, A; Grigore, M; Brown, J; Hickey, M; Farquhar, C (22 January 2019). "Endometrial resection and ablation techniques for heavy menstrual bleeding". The Cochrane Database of Systematic Reviews. 1: CD001501. doi:10.1002/14651858.CD001501.pub5. PMC 7057272. PMID 30667064.
  20. Duckitt K (September 2015). "Menorrhagia". BMJ Clinical Evidence. 2015. PMC 4574688. PMID 26382038.
  21. Louie M, Wright K, Siedhoff MT (2018). "The case against endometrial ablation for treatment of heavy menstrual bleeding". Curr Opin Obstet Gynecol. 30 (4): 287–292. doi:10.1097/GCO.0000000000000463. PMID 29708902.
  22. Gupta, Janesh K.; Sinha, Anju; Lumsden, M. A.; Hickey, Martha (2014-12-26). "Uterine artery embolization for symptomatic uterine fibroids". The Cochrane Database of Systematic Reviews (12): CD005073. doi:10.1002/14651858.CD005073.pub4. ISSN 1469-493X. PMID 25541260.
  23. Reid PC, Mukri F (April 2005). "Trends in number of hysterectomies performed in England for menorrhagia: examination of health episode statistics, 1989 to 2002-3". BMJ. 330 (7497): 938–9. doi:10.1136/bmj.38376.505382.AE. PMC 556338. PMID 15695496.
  24. Hurskainen R, Teperi J, Rissanen P, Aalto AM, Grenman S, Kivelä A, Kujansuu E, Vuorma S, Yliskoski M, Paavonen J (March 2004). "Clinical outcomes and costs with the levonorgestrel-releasing intrauterine system or hysterectomy for treatment of menorrhagia: randomized trial 5-year follow-up". JAMA. 291 (12): 1456–63. doi:10.1001/jama.291.12.1456. PMID 15039412.
  25. Istre O, Trolle B (August 2001). "Treatment of menorrhagia with the levonorgestrel intrauterine system versus endometrial resection". Fertility and Sterility. 76 (2): 304–9. doi:10.1016/S0015-0282(01)01909-4. PMID 11476777.
  26. Stewart A, Cummins C, Gold L, Jordan R, Phillips W (January 2001). "The effectiveness of the levonorgestrel-releasing intrauterine system in menorrhagia: a systematic review". BJOG. 108 (1): 74–86. doi:10.1016/S0306-5456(00)00020-6. PMID 11213008.
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