Heavy menstrual bleeding

A normal menstrual cycle is 21–35 days in duration, with bleeding lasting an average of 5 days and total blood flow between 25 and 80 mL. Heavy menstrual bleeding is defined as total menstrual flow >80ml per cycle, or soaking a pad/tampon every 2 hours or less.[1] Deviations in terms of frequency of menses, duration of menses, or volume of menses qualifies as abnormal uterine bleeding. Bleeding in between menses is also abnormal uterine bleeding and thus requires further evaluation.

Complications of heavy menstrual bleeding could also be the initial symptoms. Excessive bleeding can lead to anemia which presents as fatigue, shortness of breath, and weakness. Anemia can be diagnosed with a blood test.

Usually no causative abnormality can be identified and treatment is directed at the symptom, rather than a specific mechanism. However, there are known causes of abnormal uterine bleeding that need to be ruled out. Most common causes based on the nature of bleeding is listed below followed by the rare causes of bleeding (i.e. disorders of coagulation).

Diagnosis is largely achieved by obtaining a complete medical history followed by physical exam and ultrasound. If need be, laboratory tests or hysteroscopy may be used. The following are a list of diagnostic procedures that medical professionals may use to identify the cause of the abnormal uterine bleeding.

• Pelvic and rectal examination to ensure that bleeding is not from lower reproductive tract (i.e. vagina, cervix) or rectum
• Pap smear to rule out cervical neoplasia
• Pelvic ultrasound scan is the first line diagnostic tool for identifying structural abnormalities.[7]
• Endometrial biopsy to exclude endometrial cancer or atypical hyperplasia
• Hysteroscopy
• TSH and T4 dosage to rule out hypothyroidism [8]

Where an underlying cause can be identified, treatment may be directed at this. Clearly heavy periods at menarche and menopause may settle spontaneously (the menarche being the start and menopause being the cessation of periods).

If the degree of bleeding is mild, all that may be sought by the woman is the reassurance that there is no sinister underlying cause. If anemia occurs due to bleeding then iron tablets may be used to help restore normal hemoglobin levels.[1]

The condition is often treated with hormones, particularly as abnormal uterine bleeding commonly occurs in the early and late menstrual years when contraception is also sought. Usually, oral combined contraceptive or progesterone only pills may be taken for a few months, but for longer-term treatment the alternatives of injected Depo Provera or the more recent progesterone releasing IntraUterine System (IUS) may be used.[9][10] Fibroids may respond to hormonal treatment, and if they do not, then surgical removal may be required.

Tranexamic acid tablets that may also reduce loss by up to 50%.[11] This may be combined with hormonal medication previously mentioned.[12]

Anti-inflammatory medication like NSAIDs may also be used. NSAIDs are the first-line medications in ovulatory heavy menstrual bleeding, resulting in an average reduction of 20-46% in menstrual blood flow.[13] For this purpose, NSAIDs are ingested for only 5 days of the menstrual cycle, limiting their most common adverse effect of dyspepsia.[14]

A definitive treatment for heavy menstrual bleeding is to perform hysterectomy (removal of the uterus). The risks of the procedure have been reduced with measures to reduce the risk of deep vein thrombosis after surgery, and the switch from the front abdominal to vaginal approach greatly minimizing the discomfort and recuperation time for the patient; however extensive fibroids may make the womb too large for removal by the vaginal approach. Small fibroids may be dealt with by local removal (myomectomy). A further surgical technique is endometrial ablation (destruction) by the use of applied heat (thermoablation).[15]

In the UK the use of hysterectomy for heavy menstrual bleeding has been almost halved between 1989 and 2003.[16] This has a number of causes: better medical management, endometrial ablation and particularly the introduction of IUS[17][18] which may be inserted in the community and avoid the need for specialist referral; in one study up to 64% of women cancelled surgery.[19]

Aside from the social distress of dealing with a prolonged and heavy period, over time the blood loss may prove to be greater than the body iron reserves or the rate of blood replenishment, leading to anemia.[3] Symptoms attributable to the anemia may include shortness of breath, tiredness, weakness, tingling and numbness in fingers and toes, headaches, depression, becoming cold more easily, and poor concentration.

• Menometrorrhagia