Heavy Menstrual Bleeding

Question 1

HMB is the most common gynaecological presentation. True or false?

Answer 1

True

1/10 of all gynae referrals

Question 2

What is another term for heavy menstrual bleeding?

Answer 2

Menorrhagia

Question 3

What is the most common cause?

Answer 3

Dysfunctional uterine bleeding (DUB) - heavy menstrual bleeding with no recognisable pelvic pathology
= a diagnosis of exclusion

Question 4

60% of menorrhagia is due to…

Answer 4

Dysfunctional uterine bleeding

Question 5

What pathological causes are there?

Answer 5

Fibroids
Adenomyosis 
Endometriosis 
Polyps
Pelvic infection e.g PID 
IUCD

Question 6

Why can the IUD make periods heavier?

Answer 6

Copper toxicity causes inflammation of the endometrium, which cause increase bleeding

Question 7

What medical causes are there?

Answer 7

Hypothyroidism

Liver disease

Question 8

What abnormal clotting disorders can cause menorrhagia?

Answer 8

Von Willibrand disease
Thrombocytopenia 
Platelet disorders
Leukaemia 
Coagulation disorders

Question 9

What type of cancer can cause menorrhagia?

Answer 9

Endometrial carcinoma

Also hyperplasia can cause menorrhagia

Question 10

What percentage of those with subjective menorrhagia have greater than normal loss?

Answer 10

50%

Question 11

What percentage of women with MBL greater than 80ml/ cycle consider their periods heavy?

Answer 11

60%

Question 12

It is difficult to measure blood loss, so what questions can you ask to help quantify blood loss?

Answer 12

Impact on quality of life and presence of anaemia
Ask about number of pads/ tampons used in a day and how soaked they are
Do they need to take a change of clothing when they go out?
Is sleep disrupted by bleeding?
Do they bleed through clothes?
Clots or flooding?
Do they plan day around proximity to toilet?

Question 13

What symptoms and signs are associated?

Answer 13

Heavy, prolonged vaginal bleeding
Often worse at extremes of reproductive life
Dysmenorrhea
Symptoms of anaemia
IMB and PCB are abnormal - need investigation

Question 14

What could an enlarged uterus suggest?

Answer 14

Fibroids

Adenomyosis

Question 15

What investigations should be done?

Answer 15

Exclude pregnancy
FBC and haematinics if indicated 
TFTs if clinically hypothyroid 
Cervical smear if due
STI screen 
If over 45 with risk factors or failed medical therapy:
Transvaginal ultrasound 
Hysteroscopy +/- biopsy

Question 16

When would a women be considered low risk?

Answer 16

Less than 45
No IMB and regular cycle
No risk factors for endometrial cancer

Question 17

What test should be carried out for all women with HMB?

Answer 17

FBC

Question 18

When should testing for coagulation disorders be done?

Answer 18

Have had HMB since period started

Personal or family history suggesting a coagulation disorder

Question 19

When should a women be considered high risk?

Answer 19

Over 45
IMB
Suspected pathology
RFs for endometrial cancer

Question 20

What are risk factors for endometrial cancer?

Answer 20

Obesity
Early menarche and late menopause
Nulliparity 
PCOS
Unapposed oestrogen 
Tamoxifen 
Previous breast or ovarian cancer
BRCA 1/2
Endometrial polyps or hyperplasia
DM, HTN, Parkinson’s 
FH HNPCC

Question 21

What medical treatment options are there?

Answer 21

Symptom control:
Tranexamic acid 1g TDS for up to 4 days
Mefenamic acid 500mg / 8hrs
(Combination of both works well, if women can have NSAIDS)

Hormone control:
Mirena IUS - should be considered first line
POP
COCP

Question 22

How does mirena IUS work?

Answer 22

Releases levonorgestrel into endometrial cavity leading to atrophy

Question 23

By how much does the IUS reduce bleeding?

Answer 23

By up to 86% at 3 months and 97% by one year

30% are amenorrhoeic by a year

Question 24

What side effects are associated with the IUS?

Answer 24

Irregular bleeding for first 4-6 months

Progestogenic effects

Question 25

When is tranexamic acid taken?

Answer 25

Taken during bleeding

Question 26

What is treatment tailored to?

Answer 26

Patient’s needs and clinical situation
E.g if trying to conceive, would not go for hormonal
Surgery not compatible with future child bearing

Question 27

How does tranexamic acid work?

Answer 27

An anti fibrinolytic

Prevents conversion of plasminogen to plasmin, which reduces fibrin clot breakdown

Question 28

How does mefenamic acid work?

Answer 28

Inhibits prostaglandin synthesis

Question 29

Is tranexamic acid or mefenamic acid more effective?

Answer 29

Tranexamic acid - reduce blood loss by 49%

Question 30

When is mefenamic acid particularly helpful?

Answer 30

If dysmenorrhea also present

Question 31

What is norethisterone?

Answer 31

Type of progestogen
Used to stop heavy bleeding in short term
Not for long term use
Example of use: 3w on 1w off if trying to control bleeding before planned surgery takes place

Question 32

If polyps are the cause, what management options are there?

Answer 32

Hysteroscopic removal

Question 33

What surgical options are there for HMB?

Answer 33

Endometrial ablation - NOVASURE
Hysterectomy
Only if family is complete

Question 34

If fibroids are the cause, what can be done?

Answer 34

Myomectomy

Uterine artery embolisation

Question 35

Is contraception required after endometrial ablation?

Answer 35

Yes

If not used, pregnancy commoner in those who bleed

Question 36

What percentage become amenorrhoeic after endometrial ablation?

Answer 36

30%

The remainder usually have reduced flow

Question 37

If pregnancy does occur after endometrial ablation, what is more likely to occur?

Answer 37

Miscarriage

Question 38

What can be used for short term control of HMB?

Answer 38

Tranexamic acid
Noresthisterone
GnRH analogues - used once bleeding controlled to avoid more bleeding and maximise Hb stores (often used to allow for correction of anaemia and iron stores before another intervention) - induces a temporary menopause state

Question 39

What examinations should be done?

Answer 39

General examination
Abdominal examination
Pelvic (bimanual examination)