Heavy Menstrual Bleeding

Heavy menstrual bleeding is excessive menstrual blood loss (above 80 mL per cycle, or any loss the woman finds interferes with her physical, social or emotional life). Causes are polyps, adenomyosis, leiomyoma, malignancy and hyperplasia (structural), and coagulopathy, ovulatory dysfunction, endometrial disorders, iatrogenic causes and unclassified causes (non structural). It is common in women of reproductive age, and matters because it causes iron deficiency anaemia, time lost from work and school, and distress.

• Risk factors: fibroids, adenomyosis, obesity, bleeding disorders (von Willebrand disease), anticoagulants, intrauterine copper device, thyroid disease, age above 40 years.
• Flooding, clots larger than 2.5 cm, changing a pad every 1 to 2 hours and bleeding at night suggest heavy loss.
• The levonorgestrel intrauterine system is an effective first-line treatment.

Women have heavy periods with clots, flooding, soaking of clothes and bedding, tiredness, breathlessness, dizziness and palpitations from anaemia, and sometimes pelvic pain or pressure.

• Pallor, tachycardia, enlarged uterus or palpable pelvic mass.
• Bruising, nosebleeds or heavy bleeding since menarche suggest a bleeding disorder.
• Differential diagnosis: fibroids, adenomyosis, endometrial polyp, endometrial hyperplasia or cancer, anovulatory bleeding, bleeding disorder, hypothyroidism, chronic endometritis, pelvic infection, intrauterine device effect, anticoagulant effect, pregnancy complication.
• Complications: iron deficiency anaemia, fatigue, hospital admission and transfusion, reduced quality of life, infertility, hysterectomy.

The approach is to exclude pregnancy, measure haemoglobin and find a structural or bleeding disorder cause.

• Urine hCG; full blood count and ferritin (anaemia, low ferritin); thyroid stimulating hormone; coagulation screen, von Willebrand tests and platelet count if heavy bleeding began at menarche or there is a family history.
• Speculum and bimanual examination; cervical screening if due; chlamydia test.
• Transvaginal ultrasound for fibroids, adenomyosis, polyps and endometrial thickness; hysteroscopy with biopsy if the uterine cavity is distorted or bleeding persists.
• Endometrial sampling if age is 45 years or above, or for women with obesity, persistent bleeding or treatment failure.

The principle is to reduce blood loss with a hormonal or nonhormonal drug matched to the woman's wishes for fertility, to correct anaemia, and to treat structural causes surgically when drugs fail.

• Supportive: menstrual diary; iron rich diet; explanation of options; weight loss in obesity; stop smoking.
• Pharmacological: first line: levonorgestrel intrauterine system 52 mg inserted for 5 years; 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 during bleeding 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; ferrous sulphate 200 mg oral 12-hourly for 3 to 6 months; iron sucrose 200 mg IV in 100 mL sodium chloride 0.9 percent over 30 minutes on alternate days for 3 to 5 doses for haemoglobin below 8 g/dL or intolerance of oral iron.
• Procedures: hysteroscopic removal of polyps or submucous fibroids; endometrial ablation for women with completed families and a normal cavity; uterine artery embolisation or myomectomy for fibroids; hysterectomy when other treatments fail or are declined; transfusion of packed red cells for haemoglobin below 7 g/dL or instability.
• Special groups: women with von Willebrand disease or other bleeding disorders have tranexamic acid 1 g oral 8-hourly for 5 days and desmopressin 0.3 micrograms/kg IV over 30 minutes, or intranasal 300 micrograms (150 micrograms below 50 kg), under haematology advice; women with previous clot, or taking anticoagulants, avoid combined pills and have the levonorgestrel intrauterine system, with the anticoagulant plan reviewed by the specialist; women with renal impairment have tranexamic acid reduced to 15 mg/kg (usually 1 g) oral 12-hourly when creatinine is 120 to 249 micromol/L; adolescents have anaemia correction, tranexamic acid or the combined pill, and a bleeding disorder screen.
• Red flags: haemoglobin below 8 g/dL, syncope, flooding that soaks a pad every hour, intermenstrual or postcoital bleeding, endometrial thickness above 12 mm, pelvic mass, no response to 3 months of treatment.
• Follow-up: review at 3 months with menstrual 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 therapy.