HEAVY MENSTRUAL BLEEDING

Presented by:
Amal Zahra 04
Ambreen Ayub 06
Basic Anatomy
What is normal
1. Frequency: 24-35 days cycle
2. Regularity: Variation of +- 4 days
3. Duration: 3-7 days
4. Quantity: Doesn’t interfere with quality of life
 DEFINITION and OVERVIEW
 Heavy menstrual bleeding (HMB) is defined as blood loss greater than 80 ml
per period
 Methods to quantify this blood loss are both inaccurate and impractical so
clinical diagnosis based on patient’s perception of blood loss preferred
 Of women of reproductive age, 20-30 % suffer from HMB
 HMB is one of the types of abnormal uterine bleeding (AUB), other types
include intermenstrual bleeding (IMB), Post-coital bleeding (PCB) and post-
menopausal bleeding (PMB)
 A commonly used classification system for AUB that can also apply to HMB is
‘PALM-COEIN system’
PALM represents visually objective structural criteria: Polyps, Adenomyosis,
Leiomyoma, Malignancy
COEIN represents Coagulopathy, Ovulatory disorders, Endometrial, Iatrogenic
and Not-classified causes
 ETIOLOGY
 The etiology of HMB may be hormonal or structural with common causes
listed:
1. Fibroids – 30 % of HMB associated with fibroids
2. Adenomyosis: 70 % of women will have AUB/HMB
3. Endometrial polyps
4. Coagulation disorders (e.g. von Willerbrand disease)
5. PID
6. Thyroid disease
7. Drug therapy e.g. warfarin
8. IUDs
9. Endometrial/cervical carcinoma
 ENDOMETRIAL POLYPS
 Benign growth of endometrial glands, stroma and blood vessels protruding into
the uterine cavity
 Causes include unopposed estrogen, obesity, late menopause, HRT etc.
 Can vary in size from a few millimeters to several centimeters
 May occur as single or multiple polyps and can be sessile or pedunculated
 Common symptoms include HMB, IMB, PMB, pelvic pain or discomfort
 Presence of polyps within the uterine cavity can disrupt the normal
architecture of uterine lining interfering with menstrual blood flow
 Leads to an increased surface area for bleeding
 Fragile blood vessels in polyps prone to bleeding
Diagnosis and Treatment:

 Treatment options include watchful waiting or polypectomy for larger

polyps under the guidance of hysteroscopy
 ADENOMYOSIS
 Presence of ectopic endometrial tissue in the myometrium of the uterus
 Can be diffuse and scattered or focal
Causes
1. Mechanical disruption of interface between endometrium and myometrium
- Uterine trauma especially during D&C and C-sections
2. Hormonal changes – high estrogen levels

Signs and symptoms include severe dysmenorrhea, heavy and prolonged

menstrual bleeding, and chronic pelvic pain (HMB occurs due to disruption of
normal uterine architecture leading to increased uterine contractions during
menstruation and providing a larger surface area for bleeding)

Clinical findings include pallor and diffusely enlarged and boggy uterus

Definitive diagnosis made by histologic examination and imaging studies such

as trans-abdominal ultrasound and MRI
Diagnostic hysteroscopy and myometrial biopsy can be done too
Treatment options
 Leiomyoma (Fibroids)
Defined as benign noncancerous growths of smooth muscle cells that develop in
the myometrium of uterus
Variable in sizes i.e. from small, barely noticeable nodules to large masses that
can distort shape of uterus
 Growth of fibroids is mainly dependent on circulating estrogen as they
enlarge during pregnancy and shrink after menopause
 Fibroids start as a single smooth muscle cell that deviates from normal
signaling pathways
 Risk factors of fibroids include early menarche, late menopause, obesity,
positive family history, and nulliparity
Amongst the three types of fibroids, submucosal fibroids are most likely to cause
HMB, because
- Grow just beneath the inner lining of endometrium likely disrupting their
lining the most
- Providing larger surface area for heavy and prolonged bleeding
- Interfere with uterine contractility
Clinical findings of fibroids include heavy menstrual bleeding, IMB, pelvic pain
and pressure, frequent urination and bowel dysfunction
Diagnosis can be made by certain imaging studies such as
- TVUSS: Good for detecting and locating submucosal and intramural
fibroids
- TAUSS: Good for detecting large intramural and subserosal fibroids
- Hysteroscopy: Good for detecting and locating submucosal fibroids
and planning subsequent surgical treatment
Treatment for symptomatic fibroids:
Medical therapy – injectable GnRH agonists
Surgical therapy:
 Malignancy
 Endometrial cancer – originates in the lining of endometrium
Presents as AUB, HMB and PMB because of disruption of normal menstrual
cycle
AUB also caused due to
1. Endometrial hyperplasia
2. Abnormal fragile blood vessel formation within the endometrial tissue
3. Altered hormone production
Remaining pathologies that can cause HMB
1. Coagulopathy (bleeding disorders) – include Von Willebrand disease,
platelet function disorders and clotting factor deficiencies. Clinical
presentation includes HMB, irregular bleeding/spotting, and bleeding after
minor trauma or surgery
2. Ovulatory dysfunction – associated with anovulation (imbalance between
estrogen and progesterone) and PCOS
3. Use of blood thinning or anticoagulant drugs like warfarin
4. Copper IUD
5. Hypothyroidism
 HISTORY AND EXAMINATION

Useful questions to ask in history ;

 In younger women ,it is important to ask whether HMB
started at menarche –this is less likely to be associated with
pathology.
 -ask about the regularity of menstrual cycle.
 -How often does soaked sanitary wear need to be
changed?
 Is there presence of clots?
 Is the bleeding so heavy that it spills over your
towel/tampon and on to your pants, clothes or bedding?
 Have you had to take any time off work due to this bleeding?
 After examining the patient for signs of anemia, it is
important to perform an abdominal and pelvic
examination in all women complaining of HMB. This
enables;
• any pelvic masses to be palpated
• The cervix to be visualized for polyps/carcinoma
• Swabs to be taken if pelvic infection is suspected
• Or cervical smear to be taken
 INVESTIGATIONS
THE NICE GUIDELINES FOR HMB INDICATE THE FOLLOWING
INVESTIGATIONS.THESE ARE USEFUL GUIDE FOR
CLINICIANS;

 Full blood count (FBC) should be performed in all

women
 Coagulation screen only if coagulation HMB since
menarche or family history of coagulation defects
 Hormone testing shall not be performed
 Pelvic ultrasound scan( USS) if history suggests
structural or histological abnormality such as PCB, IMB, or
pain/pressure symptoms and when a pelvic mass is palpable on
examination(suggestive of fibroids)
✔ High vaginal and endocervical swabs should be
taken when unusual vaginal discharge is reported or
observed on examination and when there are risk
factors for PID
✔ EB should be considered if risk factors such
as age over 45, treatment failure, if irregular or IMB
or risk factors for endometrial pathology.
✔ Thyroid function tests should only be carried
out when the history is suggestive of a thyroid
disorder.
Outpatient hysteroscopy with guided
biopsy:
 EB biopsy attempt fails.
 EB biopsy sample is insufficient.
 TVUSS is inconclusive
 If patient fails to tolerate an outpatient procedure , if cervix needs
to be dilated or for treatment of large polyps or submucosal fibroids
then hysteroscopy would be done under anesthesia.
 MANAGEMENT
When selecting appropriate management for the
patient, it is important to consider and discuss;
▪ The patient preference of treatment;
▪ Risks/benefits of each option
▪ Contraceptive requirements;
1.family complete?
2.current contraception?
▪ Past medical history;
1.any contraindication to medical therapies for
HMB?
2.suitability for an anesthetic. Previous
surgical history?
▪ Previous surgical history on uterus
 MEDICAL TREATMENT
Initial management of HMB in the absence of
structural or histological abnormality should be
medical.
The NICE guidelines suggest the following order;
1. Levonorgestrel intrauterine system (LNG-IUS,
Mirena)
• Mean reductions in mean blood loss of around 95%are
achieved by 1 year after LNG-IUS insertion
• It provides highly effective alternative to surgical
treatment with few sideffects
• CONTRAINDICATED : for women who are wishing to
concieve
THE LEVONORGESTR INTRAUTERINE
DEVICE
 2. TRANEXAMIC ACID
 Anti fibrinolytic agent
 Reduces the blood loss by 50% by blocking the breakdown of blood
clots
 Taken during menstruation

3. NORETHISTERONE:
This cyclical progesterone is effective taken in a cyclical pattern from day
6 to day 26 of the menstrual cycle.
 4.GNRH
AGONISTS

• Drugs act on the pituitary to stop the production of

estrogen which results in amenorrhea.
• These are only used in the short term due to the
resulting hypo estrogenic state which predisposes to
osteoporosis.

BENEFITS:

1. They can be used preoperatively to shrink fibroids

2. Endometrial suppression to enhance visualisation at
hysteroscopy
3. In severe HMB they can allow the patient the oppurnity to
improve their hemoglobin by providing a respite from bleeding
 SURGICAL TREATMENT:

 Surgical treatments is normally restricted to women for whom

medical treatments have failed.
 Women contemplating surgical treatment for HMB must be certain
that their family is complete. Whilst this is obvious for women
contemplating hysterectomy , in which the uterus will be removed,
it also applies to women contemplating endometrial ablation.
 Therefore women wishing to preserve their fertility for future
attempts at childbearing should be advised to use medical
methods of treatment.
The risk of a pregnancy after an ablation procedure theoretically
include prematurity and morbidly adherent placenta.
 1. ENDOMETRIAL
ABLATION
• All endometrial destructive procedures employ the
principle that ablation of the endometrial lining of the
uterus to sufficient depth prevents regeneration of
the endometrium.
• Ablation is suitable for women with a uterus no
bigger than 10 weeks size and with fibroids less
than 3 cm.
• Some authorities have suggested that endometrial
ablation is so successful that all women with HMB
should be encouraged to consider it before opting for
hysterectomy.
 FIRST GENERATION ; OLDER
Second generation; newer
TECHNIQUE
technique

After treatment, 40% will become amenorrhoeic, 40% will have

markedly reduced menstrual periods and 20% will have no
difference in their bleeding.
 HYSTERECTOMY:

 Surgical removal of uterus

 First line treatment in women who have HMB associated with large
fibroids who also have pressure symptoms or who have smaller
uterus and associated uterine prolapse
 It can be necessary to control HMB in women who have not
responded to medical and ablation procedures
 OTHER SURGICAL OPTIONS:

1. UMBILICAL ARTERY EMBOLIZATION: HMB associated with fibroids

2. MYOMECTOMY: women with HMB secondary to large fibroids with
pressure symptoms who wish to conceive
3. TRANSCERVICAL RESECTION OF FIBROID: large sub mucosal fibroid
,appropriate in women who wish to conceive