Blood loss that interferes with physical, social, emotional, or material aspect of a woman's life
Aetiology
Causes of heavy menstrual bleeeding
Fibroids (20-30%)
Benign smooth muscle tumours of the uterus
Polyps (5-10%)
Adenomyosis (5%)
Non-neoplastic endometrial glands and stroma in the myometrium
Associated with hyperplasia and hypertrophy of the surrounding myometrium
Coagulopathy
Most common is von Willebrand disease
May be caused by medication
Referral to haematology required
Malignancy
Risk factors
The two main risk factors for heavy menstrual bleeding are age (more likely at menarche and approaching the menopause), and obesity
There are also other risk factors that relate to the specific causes of HMB e.g. previous caesarean section as a risk factor for adenomyosis
Clinical presentation
Symptoms
Bleeding during menstruation deemed to be excessive for the individual woman
Fatigue
Shortness of breath (if associated anaemia)
Signs
Pallor (anaemia)
Palpable uterus or pelvic mass
Try to ascertain if the uterus is smooth or irregular (fibroids)
A tender uterus or cervical excitation point toward adenomyosis/endometriosis
Inflamed cervix/cervical polyp/cervical tumour
Vaginal tumour
Investigations
Exclude pregnancy
Bloods - FBC, coag screen if indicated
Cervical smear, swabs for infection
Transvaginal US is most clinically useful for assessing the endometrium and ovaries - should be considered if the uterus or a pelvic mass is palpable on examination, or if pharmacological treatment has failed
Pipelle endometrial biopsy
Indications for biopsy include persistent intermenstrual bleeding, >45 years old, and/or failure of pharmacological treatment
Hysteroscopy and endometrial biopsy
Typically performed when ultrasound identifies pathology, or is inconclusive
Management
1st line - mirena coil (levonorgestral-releasing intrauterine system, LNG-IUS)
2nd line - transexamic acid, COC
Depends on women's wishes for fertility - tranexamic acid taken only during menses to reduce bleeding, no effect on fertility
3rd line - progesterone only (oral norethisterone, depo or implant)
4th line - surgical management/referral to secondary care
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