Heavy Menstural Bleeding (HMB)

 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.