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CG44 Heavy Menstrual Bleeding
By Dr Michael Tombros
18.3.2009
Definition of Menorrhagia
Menstrual loss > 80mls per month
Heavy Menstrual Bleeding (HMB) = excessive
blood loss interfering with physical, emotional,
social and material QOL
Menorrhagia
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Up to 30% complain of this but only half have
menstrual loss > 80 mls
> 10 pads or tampons per day
Passage of clots
Assessment
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History and pattern of bleeding
Pain
Contraceptive needs
Family history of bleeding tendencies
Drug history
Examination
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Anaemia
Pelvic examination (chronic infection or
endometriosis)
Adnexal tenderness
Endometrial polyps
Abdominal examination (pelvic
masses/tenderness)
Investigation
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FBC
Clotting screen
TFTs (not recommended by NICE 2007)
Cervical smear
Endocervical swabs
Pelvic +/- transvaginal USS
Biopsy if appropriate (endometrial CA,
atypical hyperplasia): over 45, persistent
intermenstrual bleeding, ineffective treatment
Differential
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Physiological bleeding or dysfunctional uterine
bleeding (50%)
Fibroids
Bicornuate uterus
Pelvic infection
Endometriosis
Endometrial polyps
IUCD
Endometrial carcinoma
Coagulopathy (eg Von Willebrand's)
Management
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Pharmaceutical: hormonal or non-hormonal
Non-hysterectomy surgery: endometrial
ablation in women with uterus no bigger than
10/40 pregnancy
Hysterectomy
Management
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Very heavy bleeding:
Noresthisterone 10mg TDS
Reduce dose over 7-10 days
Check FBC
Refer gynae
Reasons to refer
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Age > 40
Uterus >10/40
Intermenstrual or poistcoital bleeding
Pelvic pain between periods
Failed medical treatment
History of tamoxifen/unopposed oestrogens
If doesn't want hormones or does
not require contraception
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Mefanemic acid 500mg TDS (NSAID) – can
also try ibuprofen and naproxen (indigestion,
asthma, PUD) – preferred over tranexamic
acid in dysmenorrhoea
Tranexamic acid 1g TDS (anti-fibrinolytic
agent), SE diarrhoea, indigestion, headache
(starting on 1st day of period for days of
heavy flow)
Use for 3 months if no improvement
Either continue indefinitely or REFER if not
controlled/side effects + try other drug while
waiting
Needs contraception also
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Progestogen IUD or Long-acting
progestogens (Levonogestrel-releasing
intrauterine system):
Review in 6 months +/- REFER
Combined pill:
Review after 3 months +/- add mefanemic
acid then review in 3 months +/- REFER
Progestogens
Has copper or non-hormonal IUD
in place
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Add tranexamic acid OR mefanemic acid
Change to Progestogen releasing IUS
If still unacceptable remove IUD and suggest
alternative contraception
Side effects of hormonal IUS = irregular
bleeding, breast tenderness, acne,
headaches, amenorrhoea, uterine perforation
Progestogens
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Prevent proliferation of endometrium
Oral luteal phase progestogens are
ineffective in reducing blood flow eg.
Femulen,Micronor, Microval, Neogest,
Norgeston, Noriday
Intrauterine progestogens are effective
Long acting progestogens (im)
Norethisterone (oral)
Weight gain, headache, depression, PMS,
acne, breast tenderness, amenorrhoea,
bloating
Summary of Evidence (data from
national collaborating centre for
women's and children's health, 2007)
Treatment
Reduction in blood loss (% )
Source of
evidence
Several highquailty RCTs
Levonorgestrel-releasing
intrauterine system
71–90
Tranexamic acid
29–58
Several highquality RCTs
Nonsteroidal antiinflammatory drugs
20–49
Several highquality RCTs
Additional comment
Compared favourably with other treatments in head-tohead trials in terms of effectiveness and patient
satisfaction
No long-term outcomes have been reported
Mefenamic acid most effective, ibuprofen significantly
less effectiveAlso effective treatment for menstrual pain
Combined oral contraceptive
43 One small RCT Other benefits including regulation of cycles and
(n = 45)
reduction in breast pain
High-dose oral
progestogen*
83 One small RCT Not as effective or preferred as the levonorgestrel(n = 44)
releasing intrauterine systemRequires long-term use
Long-acting progestogen
22–47†
No direct
Data extrapolated from large trials of women requiring
evidence from long-term contraception
RCTs
Danazol
About 50
Several highquality RCTs
Use limited by frequent, clinically significant adverse
effects
Etamsylate
About 13
Several highquality RCTs
Least effective treatment for menorrhagia
NICE, Jan
2007
Pharamceutical Treatments
according to NICE
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1st line = Levonorgestrel-releasing IUD
2nd line = tranexamic acid, NSAIDS,
combined oral contraceptive
3rd line = oral progestogen (norethisterone) or
injected progestogen
'other' = Gn-RH analogue injection, S/E =
menopausal symptoms (Stops oestrogen and
progesterone production)
NICE do not recommend:
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Luteal phase oral progestogens
Danazol
Etamsylate
Dilatation and Curettage
Investigations that are NOT
recommended
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Menstrual blood loss measurements
Serum ferritin
Female hormone testing
TFTs
Saline infusion USS
MRI
D and C
Summary
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First line treatment is IUS (Mirena) if
contraception needed or combined pill
(second line)
If contraception not needed then: NSAID,
tranexamic acid
3rd line treatments = progestogens
(noresthisterone or progestogen injection)