Managing Heavy Menstrual Bleeding By Dr. Rebecca Cox & Dr. Nabeela Hasan

Aims & Objectives Defining heavy menstrual bleeding Why is it important Causes Case Scenarios Familiarise new NICE guidelines

What is heavy menstrual bleeding? Heavy menstrual bleeding (HMB) can be defined as excessive menstrual blood loss which interferes with a woman’s physical, social, emotional and/or material quality of life. (NICE guidelines for Heavy Menstrual Bleeding : January 2007)

Why is it important ? 1 in 20 women aged 30-49 years consults her GP with HMB Once referred to gynaecologist, surgical intervention is highly likely 1 in 5 women in the UK will have a hysterectomy before age 60 In at least ½ of those who undergo hysterectomy, HMB is the main presenting problem About ½ of all women who have a hysterectomy for HMB have a normal uterus removed Only 58% of women receive medical therapy for HMB before referral to a specialist NICE issued new guidelines for HMB in Jan 2007 (www.doctorsnet.uk- menorrhagia module 2004/5)

Causes For HMB & Erratic Bleeding Benign: Fibroids DUB PID Endometriosis Polyps Malignant: Endometrial Ca Cervical Ca Ovarian Ca Systemic: thyroid disease coagulation disorders

Case 1 A 28 year old lady comes to see you as she is tired of having heavy periods. She says she has always had heavy and painful periods for a long time but is finally at the end of her tether with them. What do you do first?

History Frequency of bleeding: - Has to change tampon and pad every 2-3 hrs - has flooded several times and is always worried about this. - Bleeds heavily for 4 days. Menstrual cycle: regular 28 day cycle, bleeds for 6 days. Pelvic pain only when menstruating No IMB No dyspareunia, No PCB No discharge Married for 8 yrs, no other partners. Smear aged 25 - normal PMH: Nil significant, smoker FH: Nil signiicant.

Would you examine her? Abdominal examination – YES Pelvic exmination +/_ swabs – NO O/E: Abdomen soft, no tenderness or masses.

NICE guidelines Re: abdominal examination Abdominal examination is recommended for patients with: Abdominal pain Bloating Constipation Back pain Urinary symptoms

Nice Guidelines Re: pelvic examination Pelvic examination: If history suggests HMB without structural or histological abnormality, pharmaceutical therapy can be started without pelvic examination or further investigations unless choice of therapy is the IUCD. If history suggests HMB with structural or histological abnormality eg.IMB, post-coital bleeding, pelvic pain or pressure symptoms then pelvic examination and further investigations should be carried out.

What investigations would you request? FBC – indicated in all women with heavy menstrual bleeding Coagulation – only indicated if heavy bleeding since menarche, other symptoms or FH. TFT’s and Ferritin not required unless clinically indicated. What management options would you offer?

Nice Guidelines re: pharmaceutical options 1. Levonorgestrel-releasing intrauterine system. IUCD which slowly releases progesterone and prevents proliferation of the endometrium. Pelvic exam needed first Acts as contraceptive Side effects: Irregular bleeding, hormone related problems

2. Tranexamic Acid, NSAIDs or COCPs.. Can be used while investigations are being carried out. Stop tranexamic or NSAIDs after 3 cycles if no improvement. NSAIDs preferred if dysmenorrhoea Side effects- see hand out.

3. Oral progestogen (northisterone) or Injected progestogen. Prevent proliferation of the endometrium. 15mg daily for days 5-26 of the menstrual cycle or long acting injection. Contraceptive Side effects- irregular bleeding, hormonal symptoms, bone density loss

Case 2 A 30 year old woman had the mirena coil put in one month ago for heavy menstrual bleeding. Before this she was on the COC which did not control her periods. Unfortunately she presents today because the coil was expelled a few days ago. She said this was because her bleeding was so heavy. She is now on her fourth day of her heavy period & suffering mild discomfort. She goes through 10 pads per day & has passed a few small clots. She said she had to take 2 days off work because she had to change her pads so often, was fearful of accidents & had pain.

She wants something done about her periods. She is adamant that she does not want another mirena inserted as she feels it won’t work. What other treatments could you offer her?

Management options Tranexamic acid NSAIDs COC Oral progesterones Injected/implanted progesterones. Consider referral to a specialist.

She now decides that she does not want any further hormonal treatment as when she was on the pill, she noticed severe changes in her mood & breast tenderness. After discussion of all the options, you both agree a trial of tranexamic acid. You also organise a pelvic USS scan. She tries tranexamic acid for 3 months.

3 months later she comes back and says that tranexamic acid has made very little difference to her periods. Her USS was normal. She has been discussing matters with her mother who had a hysterectomy in her 30s. She says she would like to be referred for a hysterectomy.

What could you do next? Discuss another less invasive technique such as ablation Make a referral

NICE Guidelines When a 1st pharmaceutical treatment proves ineffective, a 2nd can be considered rather than immediate referral to surgery. However following 2 failed management options it is recommended that the patient is referred.

NICE guidelines re: imaging Imaging is recommended in the form of USS if pharmaceutical treatment fails VE examination reveals a pelvic mass of unknown origin the uterus is palpable abdominally

NICE guidelines: re endometrial ablation Endometrial ablation should be considered in women: where bleeding has a severe impact on QoL & they do not want to conceive in future with HMB who have a normal uterus & with small uterine fibroids(<3cm in diameter) preferentially to a hysterectomy alone when the uterus is no bigger than 10/40 & suffer from HMB alone Women must be advised to avoid subsequent pregnancy & the need to use effective contraception, if required

Case 3 A 41yr old lady comes to see you with a 12 month history of increasingly heavy and painful periods significantly affecting her quality of life. No dysuria, frequency or incontinence LMP 2 weeks ago, Menstrual cycle: 7/28 She has 2 children Her last smear was normal PMH: Nil significant FH: Grandmother had fibroids

What would you do next? Abdominal and pelvic examination Obtain swabs for infection O/E: Abdominal exam: Suprapubic uterine mass. Pelvic examination reveals a bulky uterus. You suspect she has uterine fibroids however cannot at this stage rule out anything more sinister.

Investigations Pregnancy Test – Negative Urine Dipstix - NAD FBC USS: first line investigation for detecting structural abnormalities Hysteroscopy – only if USS inconclusive

Results.. USS confirms large uterine fibroids, the largest being 3.6cm diameter.

Do you refer? Yes: “Women with fibroids that are palpable abdominally or who have intracavity fibroids and/or whose uterine length as measured at ultrasound or hysteroscopy is greater than 12 cm should be offered immediate referral to a specialist.”

What management should she be offered next? Endometrial Ablation? No, - This can be offered to women with small fibroids <3cm diameter

Management options Uterine Artery Embolisation - for women who want to preserve uterus and avoid surgery. May remain fertile. Myomectomy - for women who want to preserve uterus. May remain fertile.

Hysterectomy - if other treatments fail, if the women no longer wishes to retain her uterus or fertility - if she has been fully informed - if she wishes to have amenorrhoea

Case 4 A 58 year old lady has been menopausal for the past 5 years. She comes to the surgery because she has had 2 days of period like bleeding. She is concerned. What would you do next?

Obtain further history Degree of bleeding Confirm start of menopause Has it happened before Weight loss Pressure symptoms – esp. pelvic pain, urinary frequency/ incontinence, constipation, bloating Other GU & GI symptoms O&G hx esp.smears FHx of Ca PMH

The lady says that before this bleeding that she has no had a period for 5 years. This is the first time that this bleeding has happened. She has noticed some bloating for the past 2 days. No other symptoms She is nulliparous. Last smear 1yr ago-NAD No significant PMH or FHx.

Would you want to examine this patient? Yes

You perform a pelvic and abdominal examination. O/E: abdomen soft & non-tender. No masses. Normal bowel sounds. Pelvic exam shows an atrophic looking vaginal walls. Small cystocele. Normal cervix. No blood. You feel a small 5cm postmenopausal uterus. No masses. You take swabs for infection.

Would you refer this patient? Yes Why? To rule out endometrial ca/atypical hyperplasia by endometrial sampling and hysteroscopy Urgent/non-urgent referral? Urgent Would you do anything else? Consider USS

NICE guidelines re: urgent referrals PMB is endometrial Ca until proven otherwise Urgent referral is made within one working day Refer urgently patients with: Not on HRT with PMB ON HRT with persistent /unexplained PMB after cessation of HRT for 6 weeks Taking tamoxifen with PMB With clinical features suggestive of cervical Ca Unexplained vulval lump With vulval bleeding due to ulceration Consider urgent referral for persistent IMB & negative pelvic exam

NICE guidelines re: pelvic examination Full pelvic examination including speculum examination is recommended for the following symptoms: Alterations in menstrual cycle IMB PCB PMB Vaginal discharge

Endometrial biopsy Nice Guidelines for HMB recommend that biopsy is indicated for: Persistent IMB Women aged >45 Following treatment failure BUT When referring patients with a suspicion of endometrial cancer, it is highly likely that they will require an endometrial biopsy, usually via hysteroscopy in this trust.