Heavy Menstural Bleeding (HMB) HMB ‘menorrhagia’ is defined as a blood loss of greater than 80 ml per period. In reality, methods to quant...
Heavy Menstural Bleeding (HMB)
HMB ‘menorrhagia’ is defined as a blood loss of greater than 80 ml per period. In reality, methods to quantify menstrual blood loss are both inaccurate (poor correlation with haemoglobin level) and impractical, and so a clinical diagnosis based on the patient’s own perception of blood loss is preferred.
The women of reproductive age, 20–30% more suffer from HMB.
Aetiology of HBM
The aetiology of HBM may be hormonal or structural, with common causes listed below:
• Fibroids: 30% of HMB is associated with fibroids.
• Adenomyosis: 70% of women will have AUB/HMB.
• Endometrial polyps.
• Coagulation disorders (e.g. von Willebrand disease).
• Pelvic inflammatory disease (PID).
• Thyroid disease.
• Drug therapy (e.g. warfarin).
• Intrauterine devices (IUDs).
• Endometrial/cervical carcinoma.
•
Symptoms of HMB
• Soaking through one or more sanitary pads or tampons every hour for several consecutive hours.
• Needing to use double sanitary protection to control your menstrual flow.
• Needing to wake up to change sanitary protection during the night.
• Bleeding for longer than a week.
• Passing blood clots larger than a quarter.
Investigations of HMB
The NICE guidelines for HMB indicate the following investigations:
• Full blood count (FBC).
• Coagulation screen .
• Hormone testing should not be performed.
• Pelvic ultrasound
• High vaginal and endocervical swabs.
• EB should be considered if risk factors such as age over 45, treatment failure or risk factors for endometrial pathology.
• Thyroid function tests .
• An outpatient hysteroscopy with guided biopsy may be indicated if:
• EB biopsy attempt fails.
• EB biopsy sample is insufficient for histopathology assessment.
• TVUSS is inconclusive.
• There is an abnormality on TVUSS amenable to treatment.
Management of HMB
Medical Treatment
• LNG-IUS.
• Transexmic acid/mefenamic acid or combined oral contraceptive pill (COCP).
• Progestogens.
Surgical Treatment
• Endometrial ablation.
• Hysterectomy or umbilical artery embolization (UAE) for fibroids.
Management of Acute HMB
• Admit.
• Pelvic examination.
• FBC, coagulopathy screen, biochemistry.
• Intravenous access and resuscitation or transfusion as required.
• Tranexamic acid oral or IV.
• TVUSS.
• High-dose progestogens to arrest bleeding.
• Consider suppression with GnRH or ulipristol acetate in the medium term.
• Longer-term plan when a diagnosis has been made.
