7.2 - Heavy Menstrual Bleeding

Question 1

1 in 20 women have heavy menstrual bleeding. Define Heavy Menstrual Bleeding

Answer 1

Excessive menstrual bleeding affecting the patient’s QoL

Question 2

What are the main associated symptoms of Heavy menstrual bleeding?

Answer 2

Anemia
Dysmenorrhea
IMB, PCB
Impact on QoL

Question 3

What co-morbidies are most consistent with Heavy menstrual bleeding?

Answer 3

Past medical/family hx of
Thyroid disease (including cancer and autoimmune diseases)
Gynaecological-related carcinomas including vagina, cervix, uterus, ovarian, breast cancer, Bowel, colon

Question 4

Breast carcinomas are linked to what genetic mutations? (2)

Answer 4

Lynch 1 and 2

Question 5

State the Signs & Symptoms of Iron-deficiency Anemia.

Answer 5

Pallor, lethargy, SOB, chest pain, thinning of hair, dizziness/lightheadedness, angular stomatitis, glossitis, brittle nails.

Question 6

A patient presents to you complaining of heavy menstrual bleeding. Please outline the relevant questions to ask in the history (need 10)

Answer 6

1) Onset: recent vs long-standing
2) Quantify: How often do you change sanitary products? Flooding clothes/linen?
3) Clots: Bigger or smaller than a 2£ coin
4) Impact on QoL: How does this affect your day to day?
5) Dysmenorrhea (pain): SOCRATES
6) IMB, PCB
7) Pressure Symptoms: Are you feeling pressure? Bowel (constipation, reduced appetite), Bladder (Urgency/frequency)
8) Signs & Symptoms of Anemia: Pallor, lethargy, SOB, chest pain, thinning of hair, dizziness/lightheadedness, angular stomatitis, glossitis, brittle nails.
9) RF of endometrial neoplasia: Obesity, T2DM, increased age, nulliparous, early menarche, endometrial hyperplasia, hormonal therapy (including IUD), Radiotherapy, family hx of gynaecological/colon cancer.
10) Past medical hx or Fam Hx of Thyroid disease, coagulation disorder, PCOS, gynaecological/colon cancer
11) Investigations and treatment to date (always)
12) Desire for future fertility (always)

Question 7

You are performing an examination on a gynaecology patient. You note ecchymoses. Give 3 possible explanations

Answer 7

Liver disease
Coagulopathy (Von Willibrand, haemophilia)
Insulin injections (actrapid)
Innahep injections (LMWH)
Any SC medication administration.

Question 8

What are your differentials for a fixed uterus on bimanual examination?

Answer 8

PID
Endometriosis
Endometrial fibroids
Endometrial cancer
Adenomyosis
Pelvic adhesions
Any extrauterine masses => pelvic masses
Note: Not hyperplasia because that occurs within the endometrium.

Question 9

You have taken the history of a patient with heavy menstrual bleeding. Perform a focused examination stating what you are specifically looking for.
State as such: On inspection….

Answer 9

!!! Vital Signs first

On inspection, I am looking for
1) Symptoms of Anemia: Pallor, Angular stomatitis, brittle nails, hair thinning, glossitis
2) Symptoms of Coagulopathy: Petechiae, ecchymoses/bruising.

On palpation, I am looking for hepatomegaly (reduced clotting factors), Pelvic masses (fibroids, tumours, polyps), Pelvic nodes (infection/STI), and tenderness (rebound/guarding = peritonitis)

On Pelvic Examination
Speculum: Checking for cervical pathology such as inflammation, oedema, (prolapse?), mass, discharge, smear indicated if STD, HPV
Bimanual: Uterus mobility (fixed indicates endometriosis)

Question 10

You have performed your hx and examination of a patient presenting with heavy menstrual bleeding. Outline the investigations you would order for this patient and why you are ordering each

Answer 10

Bloods:
FBC for Hb and Platelet count for anaemia and coagulation etc..
B-HCG to rule out pregnancy
Coagulation screen to assess for Coagulopathy
LFTs. And U&E to assess for liver and renal function
TFTs: To rule out thyroid pathology involvement
Iron studies/Ferritin (essential due to loss of blood)

Trans vaginal ultrasound (may show endometrial thickening, cysts, masses/lesions
Endometrial biopsy via Hysteroscopy + D&C or Pipelle in OPD

Question 11

You note Endometrial thickening on trans vaginal ultrasound. What is considered to be a thick endometrium?

Answer 11

> 4 mm

Question 12

You want to obtain an endometrial biopsy. How would you obtain it in
OPD:
Theatre:
In the context of heavy menstrual bleeding, what are we looking for/rulingout

Answer 12

OPD - Pipelle
Theatre: Hysteroscopy D&C

Looking at the lining: Atrophy, hyperplasia, vascular fibrosis, tumours…

Question 13

A 28 year old patient, G1P0 presents with PV bleeding. Give your differentials.

Answer 13

PALM COEIN

Polyp
Adenomyosis
Leiomyoma
Malignancy/Hyperplasia

Coagulopathy
Ovulatory dysfunction
Endometrial
Infection/Iatrogenic
Not known/Idiopathic = Dysfunctional Uterine Bleeding

Question 14

Define Dysfunctional Uterine Bleeding
What is it associated with?

Answer 14

Abnormal bleeding in the absence of recognizable organic pathology

It is associated with anovulatory cycles at extremes of reproductive life (close to menarche/menopause)
It is not really a disease or syndrome, its just normal as the body tries to achieve homeostasis

Question 15

What treatment options are available for women with heavy menstrual bleeding with planning for future pregnancies?

Answer 15

Non-hormonal => Future planning
First Line: NSAIDS
Second Line: Anti-fibrinolytic Agents - Tranexamic Acid

Hormonal Therapy => Contraception but possibility for future planning in the future
First Line: LNG-IUS
Second Line: COCP
Third Line: Systematic Pregestogen
Fourth Line: Depot Progestogen
Fifth Line: GnRH Analogues

Question 16

Give the generic name for a Systemic Progestogen

Answer 16

Norethisterone

Question 17

A 24 year old patient with DM type 1 who suffers immensely with hypoglycaemic episodes, has a long history of poor adherence. They are suffering from heavy menstrual bleeding. They would like to avoid surgery at all costs. 3 Mirena could have fell out due to her heavy bleeding. What would you recommend this patient? Give the generic name as well.

Answer 17

Depot progestogen to be given every 3 months. Medroxyprogesterone.

Question 18

What is the main role of GnRh analogues in heavy menstrual bleeding?
Give 2 other uses
Give an example

Answer 18

Used for reducing Fibroid sizes

endometrial hyperplasia, reducing uterine size before hysterectomy
Decapeptyl

Question 19

What NSAIDs are used in the treatment of Heavy Menstrual Bleeding?

Answer 19

Iburpofen or Mefenamic acid

Question 20

What are the hormonal options for therapy in a patient with heavy menstrual bleeding?

Answer 20

Hormonal Therapy => Contraception but possibility for future planning in the future
First Line: LNG-IUS
Second Line: COCP
Third Line: Systematic Pregestogen
Fourth Line: Depot Progestogen
Fifth Line: GnRH Analogues

Question 21

Give 3 surgical managements for heavy menstrual bleeding

Answer 21

Surgical:
First Line: Endometrial Ablation
Second Line: Myomectomy (acceptable for future planning)
Third Line: Uterine Artery Embolisation
Fourth Line: Hysterectomy

Question 22

How is a myomectomy performed?

Answer 22

Can be done via hysteroscopy, laparoscopy, or laparotomy.

Question 23

What is the definitive treatment for heavy menstrual bleeding? Give 3 methods of performing the surgery:

Answer 23

Abdominal Hysterectomy +/- BSO
Laparoscopic Hysterectomy
Vaginal Hysterectomy (not suitable is large uterus due to fibroids)

Question 24

What is your approach to treating heavy menstrual bleeding in a patient suffering for the past 4 years? Include all management options

Answer 24

First ask if the women has any plans for future pregnancies.

Hormonal Therapy => Contraception but possibility for future planning in the future
First Line: LNG-IUS
Second Line: COCP
Third Line: Systematic Pregestogen
Fourth Line: Depot Progestogen
Fifth Line: GnRH Analogues

Non-hormonal => Future planning
First Line: NSAIDS
Second Line: Anti-fibrinolytic Agents - Tranexamic Acid

Surgical:
First Line: Endometrial Ablation
Second Line: Myomectomy (acceptable for future planning)
Third Line: Uterine Artery Embolisation
Fourth Line: Hysterectomy

Question 25

What does LNG-IUS stand for?
What type of drug is it releasing?
What are the main benefits of this?
How often does this need to be changed?

Answer 25

(Levonorgestrel-releasing intrauterine system)
Progestogen

52mg is the typical dose, it releases 20mcg everyday
With this, it reduced bleeding by 95% after 1 year, thins uterine lining, and in terms of contraception, it thickens cervical mucus.
It needs to be changed every 5 years for contraception and 8 years for bleeding. (recent studies suggest)

Question 26

A patient presents to the emergency department with severe heavy menstrual bleeding. You begin ABCDE, 2xlarge 14G bore cannulas, and give tranexamic acid, nothing seems to work. What is your immediate next step in management?

Answer 26

Vaginal balloon (bakri balloon)

Question 27

What is the medical term for Fibroids?
What are the different types? which complicate heavy menstrual bleeding?
What do you expect to find on exam?
What symptoms of a large fibroid would you want to ask about in the history?
What treatment options are available for the treatment of fibroids?

Answer 27

Leiomyoma

Intracavitary => Increased SA => worse
Submucosal > Intramural > Subserosal>Pedunculated

Large, firm, immobile uterus with irregular bumpy masses.

Pressure symptoms including constipation, tenesmus, pain, discomfort, urinary frequency and incontinence.

1) GnRH analogues (Decapeptyl)
2) Uterine artery embolisation
3) Myomectomy