Heavy menstrual bleeding

Heavy menstrual bleeding (HMB), previously known as menorrhagia or hematomunia, is a menstrual period with excessively heavy flow. It is a type of abnormal uterine bleeding (AUB).<ref name="Munro 3–13"/><ref name=Bac2017>Template:Cite journal</ref>

Abnormal uterine bleeding can be caused by structural abnormalities in the reproductive tract, skipping ovulation (anovulation), bleeding disorders, hormonal issues (such as hypothyroidism) or cancer of the reproductive tract.<ref name="HMBH2018" />

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.<ref name="HMBH2018">Template:Cite journal</ref>

Treatment depends on the cause, severity, and interference with quality of life.<ref name="ncbi.nlm.nih.gov">Template:Cite journal</ref> Initial treatments often involve birth control pills, tranexamic acid, danazol and hormonal intrauterine device. Painkillers (NSAIDs) are also helpful.<ref name="BofillRodriguez_2019" /> Surgery can be effective for those whose symptoms are not well-controlled with other treatments.<ref>Template:Cite journal</ref> Approximately 53 in 1000 women are affected by AUB.<ref>Template:Cite journal</ref>

Signs and symptoms

File:WhatIsHMB.png

CitationClass=web }}</ref>

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.<ref name=HMBH2018/><ref name="Munro 3–13">Template:Cite journal</ref><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> 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.<ref name="Abnormal Uterine Bleeding">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

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 (i.e. disorders of coagulation).

• Excessive menses but normal cycle:
  • Painless:
    • Fibroids (leiomyoma) — 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 (rare) — 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 (such as ITP) or coagulation (such as von Willebrand disease) or use of anticoagulant medication (such as warfarin) are therefore possible causes, although a rare minority of cases. Platelet function studies can also be used to ascertain platelet function abnormalities
    • Endometrial cancer (cancer of the uterine lining) — bleeding can also be irregular, in between periods, or after the menopause (post-menopausal bleeding or PMB)
    • Endometrial polyp
  • Painful (i.e. associated with dysmenorrhea):
    • 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 (i.e. miscarriage)
    • Endometriosis
• Short cycle (less than 21 days) 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.<ref name=HMBH2018/>
• Systemic causes: thyroid disease, excessive emotional/physical stress.<ref name=HMBH2018/>
• Sexually transmitted infection.<ref name=HMBH2018/>
• Copper intrauterine device

Pathophysiology

HMB is associated with increased omega-6 AA in uterine tissues.<ref name=HMBbook2015>Template:Cite book</ref> The endometrium of people with HMB have higher levels of prostaglandin (E2, F2alpha and others) when compared with women with normal menses.<ref name="BofillRodriguez_2019"/> It is thought that prostaglandins are a by product of omega 6 build up.<ref name="Harel 2006">Template:Cite journal</ref> Furthermore, prostaglandins have been found to trigger abnormal, painful uterine contractions, making it a source for targeted therapy.<ref>Template:Cite book</ref>

Diagnosis

File:Prevalence.png

Prevalence of heavy menstrual bleeding, amongst people of child-bearing age, and the proportion who seek medical help.<ref>Template:Cite book</ref>

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 (i.e. vagina, cervix) or rectum
• Pap smear to rule out cervical neoplasia
• Pelvic ultrasound scan is the first line diagnostic tool for identifying structural abnormalities.<ref name="NICE44-2007"/>
• Endometrial biopsy in those with high risk endometrial cancer or atypical hyperplasia or malignancy.<ref name="NICE2018">Template:Cite book</ref>
• Sonohysterography to assess for abnormalities within the uterine lining<ref>{{#invoke:citation/CS1|citation

|CitationClass=web }}</ref>

• Hysteroscopy (anaesthesia should be offered)<ref name=NICE2018/>
• Thyroid-stimulating hormone and thyrotropin-releasing hormone dosage to rule out hypothyroidism <ref>Template:Cite journal</ref>

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."<ref name="NICE2018" />

Treatment

File:Heavy Menstrual Bleeding - Treatment Workflow.jpg

Heavy Menstrual Bleeding - Treatment Workflow<ref>Template:Cite journal</ref>

Treatment depends on identified underlying cause and varies between medication, radiation, and surgery. Heavy periods at menarche and menopause may settle spontaneously (the menarche being the start and menopause being the cessation of periods).

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.<ref name="Munro 3–13"/>

File:TreatmentChoices.png

The treatment choices of those referred to hospital in the UK for heavy menstrual bleeding.<ref>Template:Cite book</ref>

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 (LNG-IUS).<ref name="NICE2018" /> Clinical trial evidence suggests that the LNG-IUS may be better than other medical therapy in terms of HMB and quality of life.<ref name="Bofill2020">Template:Cite journal</ref>

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 (IUS) may be used. In particular, an oral contraceptive containing estradiol valerate and dienogest may be more effective than tranexamic acid, NSAIDs and IUDs.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> 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."<ref name=NICE2018/> 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.<ref>Template:Cite journal</ref>

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.<ref>Template:Cite journal</ref> Tranexamic acid tablets may reduce loss by up to 50%.<ref name="BonnarSheppard">Template:Cite journal</ref> This may be combined with hormonal medication previously mentioned.<ref>Template:Cite journal</ref>

NSAIDs are also used to reduce heavy menstrual bleeding by an average of 20-46% through inhibiting the production of prostaglandins.<ref name="BofillRodriguez_2019">Template:Cite journal</ref> For this purpose, NSAIDs are taken for only 5 days of the menstrual cycle, limiting their most common adverse effect of dyspepsia.<ref name="Shaw">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

File:EfficacyOfTreatments.png

The efficacy of different treatments for heavy menstrual bleeding.<ref name=":5">Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref name="Kaunitz 625">Template:Cite journal</ref><ref name=":6">Template:Cite journal</ref><ref>Template:Cite journal</ref><ref name=":7">Template:Cite journal</ref><ref name=":8">Template:Cite journal</ref><ref name=":9">Template:Cite journal</ref><ref>Template:Cite journal</ref><ref name=":2">Template:Cite journal</ref><ref name=":10">Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref name=":11">Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref name=":3">Template:Cite journal</ref> Graphic from NHS decision aid (purple colour indicates hormonal medications, pale green indicates surgical procedures).<ref name=":1" />

File:SurgicalSideEffects.png

The side effects of surgical approaches to heavy menstrual bleeding. <ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref name=":2" /><ref name=":3" /><ref name=":4" />

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.<ref name="NICE2018" />

A definitive treatment for heavy menstrual bleeding is to perform hysterectomy (removal of the uterus). 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 (myomectomy). A further surgical technique is endometrial ablation (destruction) by the use of applied heat (thermoablation).<ref>Template:Cite journal</ref> 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.<ref name="Bofill2020" />

Medications

File:SideEffects.png

Side effects of medications used for heavy menstrual bleeding.<ref name=":4" /><ref name=":10" /><ref name=":8" /><ref name=":9" /><ref name=":7" /><ref name="Kaunitz 625" /><ref name=":6" /><ref>Template:Cite journal</ref><ref name=":11" /><ref name=":5" /><ref>Template:Cite book</ref><ref>Template:Cite book</ref><ref>Template:Cite book</ref>

These have been ranked by the UK's National Institute for Health and Clinical Excellence:<ref name="NICE44-2007">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

• First line
  • Intrauterine device with progesterone
• Second Line
  • Tranexamic acid an antifibrinolytic agent
  • Nonsteroidal anti-inflammatory drugs (NSAIDs).
  • Combined oral contraceptive pills to prevent proliferation of the endometrium
• Third line
  • Oral progestogen (e.g. norethisterone), to prevent proliferation of the endometrium
  • Injected progestogen (e.g. Depo provera)
• Other options
  • File:CancerRisks.png

    The effects of long term hormonal medication use on cancer risks (in women of child-bearing age). <ref>Template:Cite journal</ref>
    Gonadotropin-releasing hormone agonist

Surgery

• Dilation and curettage (D&C) is not recommended for cases of simple heavy menstrual bleeding, having a reserved role if a spontaneous abortion is incomplete<ref>Template:Cite journal</ref>
• Endometrial ablation is not recommended for women with active or recent genital or pelvic infection, known or suspected endometrial hyperplasia or malignancy.<ref name=EA2018>Template:Cite journal</ref>
• Uterine artery embolization (UAE) is a common treatment with the etiology of a leiomyoma. The rate of serious complications is comparable to that of myomectomy or hysterectomy; however, UAE presents an increased risk of minor complications and requiring surgery within two to five years.<ref name=":0">Template:Cite journal</ref><ref>Template:Cite journal</ref>
• Hysteroscopic myomectomy is a minimally invasive surgical procedure to remove leiomyomas (otherwise known as fibroids). Though a safe and effective mode of treating for menstrual disorders but it is unclear whether or not it is beneficial for treating infertility.<ref>Template:Cite journal</ref>
• Hysterectomy is a surgical procedure consisting of the full removal of the uterus, and can include the removal of fallopian tubes (otherwise known as the uterine tubes), cervix and ovaries.<ref>Template:Cite journal</ref>

In the UK the use of hysterectomy for heavy menstrual bleeding has been almost halved between 1989 and 2003.<ref name="BMJ2005">Template:Cite journal</ref> This has a number of causes: better medical management, endometrial ablation and particularly the introduction of IUS<ref name="JAMA-5yr">Template:Cite journal</ref><ref name="FertSteril">Template:Cite journal</ref> which may be inserted in the community and avoid the need for specialist referral; in one study up to 64% of women cancelled surgery.<ref name="BJOG">Template:Cite journal</ref>

Complications

Previous studies have suggested a nontrivial reduction in the quality of life in individuals with HMB; however, there is no single metric that has been shown to be specific enough to measure health-related quality of life in individuals with HMB.<ref>Template:Cite journal</ref> HMB can take a significant toll on the physical, psychological, and social aspects of individuals' lives. For example, a large, cross-sectional study in the United States identified significant associations between HMB and lower employment rates, lost earnings, and a lower self-rating of overall health compared to the general population.<ref>Template:Cite journal</ref> Physical and social issues, including performance of house work, life causing embarrassment, and social life, have also been identified as significant reasons why individuals with HMB seek help.<ref>Template:Cite journal</ref> While the main impacts of HMB are primarily physical and social, previous studies have also identified an inverse relationship between HMB and psychological scores.<ref name=":4">Template:Cite journal</ref>

Aside from the social distress of dealing with a prolonged and heavy period, over time the blood loss may prove to be greater than the body iron reserves or the rate of blood replenishment, leading to anemia.<ref name="ncbi.nlm.nih.gov" /> Symptoms attributable to the anemia may include shortness of breath, tiredness, weakness, tingling and numbness in fingers and toes, headaches, depression, becoming cold more easily, and poor concentration.

Research

Both the levonorgestrel-releasing intrauterine system and medications (tranexamic acid, mefenamic acid, contraceptive pill with combined oestrogen–progestogen or progesterone alone) seem to be equally effective in reducing the impact of HMB.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref>

See also

• Menometrorrhagia
• Istihadha
• Menstruation
• Menstruation in Islam
• Culture and menstruation