Tutorial 12: Heavy Menstrual Bleeding (HMB) Flashcards
What is the definition of heavy menstrual bleeding?
Excessive menstrual bleeding, or >80mL menstrual loss (normally 20-80mL)
What questions about menstrual history should you ask for a patient with ?HMB?
- Amount (no of pads/tampons, flooding, clots and clot size- 20c piece/50c),
- Cycle regularity/length (21-35d is normal): Irregular menstrual bleeding may be secondary to endometrial polyps
- Duration of bleeding
- Bleeds in between period
- Social embarrassment
- Age of menarche/LMP
What should you cover in your history taking for a woman with Heavy Menstrual Bleeding?
- Menstrual History
-
Exclude pregnancy
- Are you sexually active
- Do you use condoms or other form of contraceptive
- Could you be pregnant
- Parity: Endometrial adenomyosis is associated with multiple pregnancies.
- Symptoms of thyroid disease: Fatigue, increased cold sensitivity, constipation, dry skin, unexplained weight gain, hair changes.
- Symptoms of anaemia: Fatigue, lethargy, feeling faint, SOB.
- Associated symptoms e.g. abdo pain
- Constitutional symptoms could indicate malignancy: Night sweats, weight loss, fatigue, malaise
- Weight/BMI: Influences management because you can’t prescribe COC.
What are the 3x main categories of causes of Heavy Menstrual Bleeding?
- Systemic
- Pelvic
- Dysfunctional Uterine Bleeding (DUB)
What are some systemic causes of Heavy Menstrual Bleeding?
- Platelet disorders
- Coagulation disorders
- Thyroid disorders: feeds back to the HPG axis (hypothyroidism casing oligo-/a-menorrhoea)
What are some pelvic causes of heavy menstrual bleeding?
- Uterus (fibroids, endometrial hyperplasia and polyps)
- Carcinoma of cervix or endometrium
- Adenomyosis (ectopic glandular tissue found in muscle)
- Incomplete miscarriage
What is dysfunctional Uterine Bleeding and what are the two main types?
DUB = Abnormal bleeding from uterus in the **absence of organic disease** of the genital tract (i.e. a _Diagnosis of exclusion)_.
- Ovulatory DUB = with regular bleeding
-
Anovulatory DUB = with irregular bleeding.
- common in puberty, >30yrs, PCOS.
What would you include in your examination of a lady with heavy menstrual bleeding?
- Signs of anaemia: Pallor (pale conjunctiva and nail beds)
- Signs of hypothyroidism: Obesity, hair loss, brittle nails, non-pitting oedema, Enlarged thyroid gland
- Signs of androgen excess/PCOS: Hirsuitism, acne, acanthosis nigricans. (Nb: Acanthosis nigricans is also associated with insulin resistance which can be associated with anovulation.)
- Signs of liver disease (could indicate a coagulopathy): Hepatomegaly, jaundice, ecchymoses
- Bimanual Exam: Adnexal masses, Tender uterus (Fibroids, Adenomyosis, Pregnancy, Endometritis)
- Vaginal examination (unless adolescent). May show lower vaginal/cervical lesions as cause of bleeding.
- Cervical inspection and Cervical smear - CIN
What investigations would you perform for a woman presenting with heavy menstrual bleeding?
- Urine pregnancy test
- Routine FBC (Hb), Iron studies (ferritin). There is an increased likelihood of HMB loss >80mls/cycle if Hb <120g/l. Consider pictorial blood loss assessment charts for women with normal Hb
- Coag testing: PT/APTT. Specific testing for von Willebrand disease
- Thyroid function – if symptoms of thyroid disease
- Endometrial biopsy (if > 45 years or increased BMI > 30) – outpatient pipelle - to exclude endometrial hyperplasia (>12mm thickness is bad).
- Pelvic USS: to diagnose uterine wall and cavity disorders such as fibroids or polyps. Can visualise cysts on the ovaries in PCOS
- Hysteroscopy (gold standard for endometrial hyperplasia) 98% sensitive for detecting intrauterine pathology, performed to exclude pathology such as polyps and fibroids.
- Dilatation & curettage (a diagnostic test not treatment!) only 65% sensitive for IU pathology, not specific. Provides a sample of endometrium.
What is the medical management of Heavy Menstrual Bleeding?
- NSAIDs: Cause PG inhibition →vasoconstriction, decrease blood loss by 15%, take only while menstruating- 3month trial. PG Synthetase Inhibitor (1st line)- decreases blood loss by 20-30%
- Tranexamic Acid (Antifibrinolytic agent) - blocks 40-50%, as effective as OCP
- COCP: Combined Oral Contraceptive - For anovulatory (e.g. PCOS where increased oestrogen- or endometrial hyperplasia) use OCPs (Norethesterol) - 43 % reduction.
- Oral Progestogen (day 5-25) (e.g. Depo provera, or medoxyprogestogen acetate) – 87% reduction in bleeding.
- Danazol: Synthetic steroid with mild androgenic properties which causes atrophy of the endometrium. Useful in the treatment of DUB. Second line due to side effect profile.
- Mirena IUS- levonorgestrel- vaginal spotting for first 3-6m, uterine cramps if not well placed, spontaneous discharge, risk of perforation, infection migration
What is the medical management of prolonged, excessive, heavy menstrual bleeding?
Interruption of bleeding > 10days
- Medroxyprogesterone acetate (MAP) 20 – 30mg daily for4 weeks.
- Norethisterone (NET) 10-15mg daily for 4 weeks
Maintenance therapy
- MPA or NET 5-10mg day 5-25 of each calendar month (if anovulatory)
What would you do if a woman fails medical therapy for her heavy menstrual bleeding?
Women who have no improvement in menstrual blood loss with medical therapy should have:
- TVS
- Specialist referral for hysteroscopy (as submucous fibroids may be present.)
What are the surgical treatment options for heavy menstrual bleeding?
- Endometrial resection or ablation: Once finished family- currently uses microwave endometrial ablation, destruction of the endometrial layer.
- Hysterectomy (Gold Standard): Complete cure of DUB, recovery may take 3- 6wks, post-op complications include haemorrhage, infection and venous thrombosis, bladder rupture, ureter rupture, chronic pain post surgery.
What are some potential post-op complications of a hysterectomy?
- haemorrhage
- infection and venous thrombosis
- bladder rupture and ureter rupture
- chronic pain post surgery.
