Chronic Heavy Uterine Bleeding

Chronic heavy uterine bleeding is heavy menstrual bleeding that has been present for at least 6 months and is bothering the woman, most often from fibroids, adenomyosis, endometrial polyps, ovulatory dysfunction, bleeding disorders and endometrial disease. It leads to long term iron deficiency anaemia and impaired quality of life, and it is a common reason for gynaecological surgery. It matters because planned treatment prevents anaemia and hysterectomy.

• Risk factors: fibroids, adenomyosis, obesity, age above 40 years, bleeding disorders, intrauterine copper device, polycystic ovary syndrome, anticoagulants.
• Iron deficiency often causes fatigue before anaemia appears.
• A planned stepwise approach leads to good control in most women.

Women have regular or irregular heavy periods for months to years, with clots, flooding, soaking of night clothes, tiredness, breathlessness, hair loss, pallor and reduced concentration. Pelvic pressure, bloating and frequency suggest fibroids.

• Enlarged irregular uterus (fibroids) or globular tender uterus (adenomyosis).
• Pallor, koilonychia and glossitis in prolonged iron deficiency.
• Differential diagnosis: fibroids, adenomyosis, endometrial polyp, endometrial hyperplasia or cancer, ovulatory dysfunction, bleeding disorder, chronic endometritis, hypothyroidism, caesarean scar niche, intrauterine device effect, anticoagulant effect.
• Complications: iron deficiency anaemia, fatigue and poor work performance, depression, infertility, hospital admission, hysterectomy.

The approach is to measure the anaemia, find the cause and plan treatment around fertility wishes.

• Menstrual diary; urine hCG; speculum and bimanual examination; cervical screening if due.
• Full blood count and ferritin; thyroid stimulating hormone; coagulation screen, von Willebrand tests and platelet function when bleeding has been heavy since menarche or there is a family history.
• Transvaginal ultrasound for fibroids, adenomyosis, polyps, endometrial thickness and scar niche; MRI for complex fibroids or adenomyosis; sonohysterography or hysteroscopy for cavity lesions.
• Endometrial sampling if age is 45 years or above, or if there is obesity, persistent bleeding or treatment failure.

The principle is correction of anaemia, long acting medical treatment first, and surgery or uterine artery embolisation for structural disease or failure of drugs.

• Supportive: menstrual diary; iron rich diet; weight management; stop smoking; shared decision making on fertility and surgery; psychological support.
• Pharmacological: levonorgestrel intrauterine system 52 mg for 5 years (first line); tranexamic acid 1 g oral 8-hourly for up to 4 days during bleeding (maximum 4 g daily); mefenamic acid 500 mg oral 8-hourly with food for up to 5 days; combined oral contraceptive pill with ethinylestradiol 30 micrograms and levonorgestrel 150 micrograms oral once daily for 21 days then 7 days free; norethisterone 5 mg oral 8-hourly on days 5 to 26 of the cycle; depot medroxyprogesterone 150 mg IM every 13 weeks; before surgery for fibroids: leuprorelin 3.75 mg IM every 4 weeks for up to 3 months with tibolone 2.5 mg oral once daily as add back if used longer; ferrous sulphate 200 mg oral 12-hourly for 3 to 6 months until ferritin is above 30 micrograms/L; iron sucrose 200 mg IV in 100 mL sodium chloride 0.9 percent over 30 minutes on alternate days for 3 to 5 doses (total 600 to 1000 mg) for haemoglobin below 8 g/dL or intolerance of oral iron; transfusion of packed red cells for haemoglobin below 7 g/dL or instability.
• Procedures: hysteroscopic polypectomy or fibroid resection; endometrial ablation after childbearing in a normal sized cavity; uterine artery embolisation or myomectomy for fibroids; hysterectomy for failure of other treatment or when preferred.
• Special groups: women with von Willebrand disease or other bleeding disorders have tranexamic acid with desmopressin 0.3 micrograms/kg IV over 30 minutes, or intranasal 300 micrograms (150 micrograms below 50 kg), under haematology advice; women on anticoagulants have the levonorgestrel intrauterine system and a specialist review of the drug and dose; women with renal impairment have tranexamic acid 15 mg/kg (usually 1 g) oral 12-hourly when creatinine is 120 to 249 micromol/L; women wishing to conceive have myomectomy or hysteroscopic surgery and tranexamic acid, and avoid hormonal treatments.
• Red flags: haemoglobin below 8 g/dL, endometrial thickness above 12 mm, intermenstrual or postcoital bleeding, rapidly growing fibroid, pelvic mass, no response to 3 months of drugs, weight loss.
• Follow-up: review at 3 months with diary and haemoglobin; ferritin at 3 months; review of the levonorgestrel intrauterine system at 3 to 6 months; surgical referral after 6 months of failed medical treatment; yearly review.