23 July 2018

Managing heavy menstrual bleeding in general practice

Clinical Women

“Heavy menstrual bleeding” is the new term for menorrhagia. 

This under-treated condition is easy to screen for in general practice. And screening for it is important as, apart from the discomfort, inconvenience, disturbed sleep, embarrassment and expense associated heavy menstrual bleeding causes, it is a major cause of iron deficiency in women. 

Common causes of heavy menstrual bleeding include hormonal variations relating to menarche and menopause, polycystic ovarian syndrome, polyps, fibroids and coagulation disorders.

Identifying heavy menstrual bleeding initially involves discussing menstrual patterns with patients, as the diagnosis relies on the subjective experience of the woman as it affects her physical, emotional, social and/or material quality of life. 

Women may be unsure whether their periods are abnormally heavy compared with other women. 

Questions that may assist in the diagnosis of  heavy menstrual bleeding include asking whether a woman needs to wear both a pad and a tampon simultaneously to prevent leakage, whether she has to use super pads and/or tampons and needs to change them every three hours or less, whether she is concerned about flooding or staining during the day and avoids social activities as a result, whether she regularly takes time off work at the time of her period, whether she has to get up several times overnight to change her pad or tampon, whether she frequently passes clots (often this is associated with significant period pain), and finally, how the issue is affecting her quality of life.  It is also important to inquire about associated symptoms such as pain, bloating and feelings of pressure on the bladder or bowel.

Investigations usually include iron studies, a full blood count and a pelvic ultrasound. Ideally the ultrasound should be transvaginal as well as transabdominal.

Also, ideally, the ultrasound should be conducted between days five to 10 of the menstrual cycle, as this is when the uterine lining is less echogenic and scanning at this time reduces the chance of missing lesions such as polyps, within the uterine cavity. 

It should be noted that heavy menstrual bleeding may be a symptom of malignancy, especially in women over the age of 45 years.

 Other more specialised tests may also be indicated, such as coagulation studies, if there is suggestion of a bleeding diathesis.

Once malignancy has been excluded as a cause of the bleeding, management usually includes hormonal control of the ovulation cycle, such as with the combined oral contraceptives. These reduce bleeding by 30%.  

An excellent alternative is the hormonal intrauterine system (Mirena®). 

If the woman prefers not to use such methods and is not at risk of pregnancy, tranexamic acid or norethisterone, 5mg three times daily, from days five to 26 of the menstrual cycle, can be used. 

NSAIDS such as mefenamic acid are most effective if commenced just prior to the onset of bleeding and continued into the first few days. 

Surgical management of heavy menstrual bleeding is usually indicated for women who have completed their families. 

The less invasive options include endometrial ablation and embolisation of fibroids. 

Hysterectomy is generally reserved for women in whom less invasive treatments have been unsuccessful, where there is a particular indication (such as large fibroids causing pressure symptoms) or less commonly, at the woman’s request.