Heavy menstrual bleeding


Heavy menstrual bleeding, previously known as menorrhagia or hematomunia, is a menstrual period with excessively heavy flow. It is a type of abnormal uterine bleeding.
Abnormal uterine bleeding can be caused by structural abnormalities in the reproductive tract, skipping ovulation, bleeding disorders, hormonal issues or cancer of the reproductive tract.
Initial evaluation during diagnosis aims at determining pregnancy status, menopausal status, and the source of bleeding. One definition for diagnosing the condition is bleeding lasting more than 7 days or the loss of more than 80 mL of blood.
Treatment depends on the cause, severity, and interference with quality of life. Initial treatments often involve birth control pills, tranexamic acid, danazol and hormonal intrauterine device. Painkillers are also helpful. Surgery can be effective for those whose symptoms are not well-controlled with other treatments. Approximately 53 in 1000 women are affected by AUB.

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, changing a pad/tampon in the middle of the night, or bleeding lasting for >7 days. Deviations in terms of frequency of menses, duration of menses, or volume of menses qualifies as abnormal uterine bleeding. Bleeding in between menses, outside reproductive age, or after sex is also abnormal uterine bleeding and thus requires further evaluation.

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.
  • Excessive menses but normal cycle:
  • * Painless:
  • ** Fibroids — 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 — 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 or coagulation or use of anticoagulant medication are therefore possible causes, although a rare minority of cases. Platelet function studies can also be used to ascertain platelet function abnormalities
  • ** Endometrial cancer — bleeding can also be irregular, in between periods, or after the menopause
  • ** Endometrial polyp
  • * Painful :
  • ** Pelvic inflammatory disease
  • ** Adenomyosis - extension of the endometrial tissue into the outer muscular wall of the uterus which can cause pain and abnormal bleeds when the endometrium sheds
  • ** Pregnancy related complication
  • ** Endometriosis
  • Short cycle but normal menses.
  • Short cycle and excessive menses due to ovarian dysfunction and may be secondary to blockage of blood vessels by tumours.
  • Polycystic ovary syndrome.
  • Systemic causes: thyroid disease, excessive emotional/physical stress.
  • Sexually transmitted infection.
  • Copper intrauterine device

    Pathophysiology

HMB is associated with increased omega-6 AA in uterine tissues. The endometrium of people with HMB have higher levels of prostaglandin when compared with women with normal menses. It is thought that prostaglandins are a by product of omega 6 build up. Furthermore, prostaglandins have been found to trigger abnormal, painful uterine contractions, making it a source for targeted therapy.

Diagnosis

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 or rectum
  • Pap smear to rule out cervical neoplasia
  • Pelvic ultrasound scan is the first line diagnostic tool for identifying structural abnormalities.
  • Endometrial biopsy in those with high risk endometrial cancer or atypical hyperplasia or malignancy.
  • Sonohysterography to assess for abnormalities within the uterine lining
  • Hysteroscopy
  • Thyroid-stimulating hormone and thyrotropin-releasing hormone dosage to rule out hypothyroidism
In the UK, 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."

Treatment

Treatment depends on identified underlying cause and varies between medication, radiation, and surgery. Heavy periods at menarche and menopause may settle spontaneously.
If the degree of bleeding is mild, all that may be sought 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.
The first line treatment option for those with HMB and no identified pathology, fibroids less than 3 cm in diameter, and/or suspected or confirmed adenomyosis is the levonorgestrel-releasing intrauterine system. Clinical trial evidence suggests that the LNG-IUS may be better than other medical therapy in terms of HMB and quality of life.
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 may be used. In particular, an oral contraceptive containing estradiol valerate and dienogest may be more effective than tranexamic acid, NSAIDs and IUDs. Fibroids may respond to hormonal treatment, and if they do not, then radiation or surgical removal may be required.
In the UK, regarding 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." Progestogen pills, independently if taken in a short or long course, are not as effective at reducing menstrual blood loss as LNG-IUS or tranexamic acid.
Tranexamic acid treatments, which reduce bleeding by inhibiting the clot-dissolving enzymes, appear to be more effective than anti-inflammatory treatment like NSAIDs, but are less effective than LNG-IUS. Tranexamic acid tablets may reduce loss by up to 50%. This may be combined with hormonal medication previously mentioned.
NSAIDs are also used to reduce heavy menstrual bleeding by an average of 20-46% through inhibiting the production of prostaglandins. For this purpose, NSAIDs are taken for only 5 days of the menstrual cycle, limiting their most common adverse effect of dyspepsia.
In the UK, NICE guidelines says that for individuals 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. Options include a hysterectomy and second generation endometrial ablation, with hysterectomy being more effective than second generation endometrial ablation.
A definitive treatment for heavy menstrual bleeding is to perform hysterectomy. The risks of the procedure have been reduced with measures to minimize 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. A further surgical technique is endometrial ablation by the use of applied heat. The effectiveness of endometrial ablation is probably similar to that of LNG‐IUS but the evidence is uncertain if hysterectomy is better or worse than LNG-IUS for improving HMB.

Medications

These have been ranked by the UK's National Institute for Health and Clinical Excellence:
In the UK the use of hysterectomy for heavy menstrual bleeding has been almost halved between 1989 and 2003. This has a number of causes: better medical management, endometrial ablation and particularly the introduction of IUS which may be inserted in the community and avoid the need for specialist referral; in one study up to 64% of women cancelled surgery.