Heavy Menstrual Bleeding

Question 1

Heavy Menstrual Bleeding:

How to quantify/Define?

Answer 1

• 6 soaked tampons/pads for 4 -5 days or menses >7 days
OR
• Interferes with quality of life

Question 2

Heavy Menstrual Bleeding:

Important history?

Answer 2

• Symptomatology
• PHx – CST abnormalities
• Meds – Tamoxifen
• Smoking
• Menstruation
HMB in adolescence is almost always immaturity of Hypothalamic-Pituitary-Ovarian axis which can take 6-8years post menarche
• Sexual
• Symptoms of:
-Anaemia (fatigue, SOBOE, lightheaded, palpitations)
-Hypothyroidism (fatigue, cold sensitivity, dry skin, brittle hair, constipation, weight gain)
-Hyperandrogenism (hirsutism, acne, alopecia)
-Pituitary lesion (visual disturbance, headaches, fatigue, galactorrhoea)
-Hypothalamic pituitary axis suppression (fatigue, weakness, lightheadedness/hypotension)

• *Risk factors for endometrial cancer
• 6 months of unsuccessful treatment for AUB
• Over 45yo
• chronic anovulation/PCOS
• unopposed oestrogen
• Exposure to tamoxifen
• Strong family history of endometrial or colon cancer (Lynch syndrome)
• Nulliparity
• Obesity
• Endometrial thickness > 8mm

Question 3

Heavy Menstrual Bleeding:

Common causes?

Answer 3

PRIMARY
• normal periods but abnormal haemostasis (50%)

ANATOMICAL = on USS
• Fibroids 30%
• Polyps 10%

ANOVULATORY
• PCOS
• Perimenopausal

Question 4

Heavy Menstrual Bleeding:

Managment?

Answer 4

Conservative Management

Non hormonal (equivalent to each other)
1) Prostaglandin inhibitors (20 – 49% effective)
• Ibuprofen 400mg TDS – QID for 5 days
• Mefenamic acid 500mg TDS for 5 days
• Naproxen 500mg then 250mg TDS – QID for 5 days

2) Antifibrinolytics (29 – 58% effective)
• Tranexamic acid 1- 1.5g TDS – QID for 4 -5 days
There is no risk of thrombosis as previously thought

Hormonal (Superior control)
•	LNG IUD 52mg (71 – 94% effective)
•	Any COCP (43% effective)
-Qlaira (Oestradiol) \$\$
-Zoely (Oestradiol) \$\$
-Valette (Dionogest) \$\$
•	Northisterone 15mg/d 5 – 26 days (83% effective) for max 6 months
•	Depot provera 

*If no improvement after trying 2 methods in 6 months then refer