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Independents' Day

Heavy menstrual bleeding

Gynaecology GPSI Dr Anne Connolly and colleagues answer questions from GP Dr Paul Watkins on when to treat and when to investigate non-hormonal treatments and which women might need a hysterectomy

Gynaecology GPSI Dr Anne Connolly and colleagues answer questions from GP Dr Paul Watkins on when to treat and when to investigate non-hormonal treatments and which women might need a hysterectomy

1. Which women with heavy menstrual bleeding (HMB) require investigation? Is there any logic in doing a PV exam if you're arranging a pelvic ultrasound anyway?


41239522If HMB – or menorraghia, as it used to be called – is the sole presenting symptom in a low-risk woman, pelvic or speculum examination may not be necessary as long as cervical screening is up to date.

Women complaining of pelvic pain or ‘pressure symptoms', dysmenorrhoea, dyspareunia or non-menstrual bleeding (inter-menstrual or postcoital bleeding) will need a pelvic examination to assess uterine size, adnexal tenderness or other pelvic pathology. They will also need a speculum examination to allow visualisation of the cervix, an endocervical swab, testing for chlamydia, and cervical cytology if due.

Transvaginal ultrasound scanning is the investigation of choice. If endometrial or other pelvic pathology is suspected this should be arranged for women with abnormal findings on examination and those at higher risk of endometrial disease:

• women over 45

• those who have failed medical management

• younger women with endometrial risk factors such as PCOS, obesity, diabetes or a family history of endometrial cancer.

An FBC should be performed on all women presenting with HMB. Other blood tests include:

• TFTs – only if there are symptoms of thyroid disease

• Ferritin – in those with an abnormal FBC.

Hormonal assessments, including FSH/LH, are not indicated.

Order a coagulation screen in adolescents with HMB or women with a lifelong problem or family history of bleeding disorder.

A ‘blind' histology sample can be taken by pipelle endometrial sampling but hysteroscopy allows direct visualisation and is the gold-standard investigation. This is indicated where there are abnormal endometrial findings on ultrasound scan, if medical management has failed in women with risk factors or for those needing preoperative assessment for hysteroscopic submucosal fibroid resection or endometrial ablation.

2. Obviously a fibroid uterus is one potential cause of HMB. Given that the Mirena intrauterine progestogen-only system (IUS) might still be an effective treatment choice, in which cases do you need to consider further investigations such as a pelvic ultrasound rather than simply proceeding to empirical treatment options?

Some 30% of premenopausal women have fibroids but only some will be symptomatic. Subserous and intramural fibroids are unlikely to cause increased menstrual loss whereas submucosal fibroids, which distort the endometrium, are likely to be symptomatic.

A pelvic examination will indicate uterine size. If the uterus feels normal in size, significant fibroids are unlikely. If the uterus is enlarged, pelvic ultrasound will give the position and size of any fibroids.

The UK medical eligibility criteria for contraceptive use (UKMEC) recommend that when uterine fibroids are present without endometrial distortion the IUS may be used, as the benefits of treatment outweigh the risks (UKMEC2)1. If fibroids cause significant endometrial distortion the IUS should not be used (UKMEC4). An IUS may be an option if there is minimal displacement, but these women must be counselled about the increased risk of malposition and expulsion of the device.

If an ultrasound scan suggests submucosal fibroids are present, the most reliable way of assessing endometrial involvement is by direct visualisation at hysteroscopy, which is widely available, or by saline infusion sonography, which is not. Hysteroscopic resection of the fibroid may be carried out with insertion of an IUS at the same procedure.

Data on what happens to fibroids when an IUS is fitted are conflicting. Some studies show regression and others growth.

3. NICE emphasises the role of the IUS as an effective treatment for menorrhagia, but are any other long-acting reversible forms of contraception effective, as they also usually reduce menstrual flow?

Many women are now opting to use the long-acting reversible contraceptives (LARC) for their menstrual benefits as well as their superior contraceptive actions.

Depot medroxyprogesterone (Depo-Provera) can be used to reduce menstrual loss but has an unpredictable action. Irregular bleeding is very common, particularly in the first three months.

One retrospective study investigating bleeding patterns in women using Depo-Provera found 15.3% complained of frequent bleeding in the first three months of use but this had reduced to 6.2% after 12 months2. Amenorrhoea was reported by 35% after three months' use and 70% after 12 months' use.

Implanon is an extremely reliable method of contraception but does not have a significant effect on the endometrium. It should not be recommended as a treatment for HMB as only 20% of women are likely to become amenorrhoeic with it.

The combined hormonal methods, whether used orally, topically as a patch (Evra) or vaginally, as a contraceptive ring (NuvaRing), will also reduce menstrual loss by more than 40%. These methods are only advised in women who may safely take oestrogens – refer to UKMEC guidance1.

Studies are under way to find out if Qlaira – a new contraceptive containing oestradiol valerate plus a novel progestogen, dienogest – is an effective treatment for dysfunctional uterine bleeding and dysmenorrhoea.

4. In women who prefer a non-hormonal approach, would you recommend tranexamic acid or mefenamic acid first line? Do they have a synergistic effect when used in combination? What about women for whom associated dysmenorrhoea is a problem?

I would start with tranexamic acid 1g three or four times daily, only during the heavy days of menses. This may reduce blood loss by as much as 50%. Remember tranexamic acid is contraindicated in women with a history of thromboembolic disease.

Mefenamic acid or any other NSAID can be used – especially if pain is a feature.

Different NSAIDs have similar efficacy for dysmenorrhoea and pain relief is achieved in most women. They work better if they are started before heavy bleeding starts. But of course they are not recommended in women with a history of peptic ulceration or GI bleeding.

The actions of tranexamic acid and NSAIDs are synergistic as the drugs work at different points of the menstrual pathway and so can be used in maximum doses together.

Some women who do not want a systemic hormone will consider the IUS as its hormonal action is mainly localised to the endometrium and is extremely effective for dysmenorrhoea as well as in reducing HMB.

5. In women who have developed anaemia because of HMB, how long do they need to take iron supplementation once you have treated the cause of their iron loss?

The most important part of management is to ensure excessive menstrual blood loss is reduced and that the anaemia is treated. Generally women with a normal diet do not become anaemic from their HMB until they are losing more than 80ml blood per month – average blood loss is 35ml to 70ml.

Once the cause of the anaemia is treated women should be treated with iron supplements until their iron levels are back to normal. I'd recommend continuing replacement with ferrous sulphate 200mg three times a day – or an equivalent – for three months after anaemia resolves.

6 Is there still any role for using oral progestogens in the second half of the menstrual cycle? There seem to be conflicting views as to whether this is an effective treatment.

A recent Cochrane review showed a significant reduction in menstrual blood loss with a 21-day course of norethisterone3. This involves taking norethisterone 5mg three times a day from day five to 26 of the cycle. Blood loss reduction of 50% to 80% has been found with this regimen, but was less effective than the IUS.

The review also confirmed there is no benefit from taking norethisterone in the luteal phase of the cycle only – days 19-26.

Oral progestogens are also useful for regulating irregular menses provided there is no abnormal endometrial pathology and the problem is purely dysfunctional bleeding. Progestogens may aggravate or cause PMT effects, causing bloating, weight gain, breast tenderness and irritability, but interestingly these were less noticeable in norethisterone (Depo Provera) studies than with the IUS.

Medroxyprogesterone acetate may also be used as a long-cycle regimen, as an alternative to norethisterone, as discussed in question 3.

7. When using the contraceptive pill for HMB but not for contraception, how likely is it that treatment can be stopped at some point? How often should an attempt be made to withdraw treatment?

There are no specific recommendations. Women who do not develop co-existing disease or risk factors that would compromise their safety with the combined hormonal products may continue to take these until the age of 50.

There are added benefits of doing this as they can reduce the vasomotor symptoms associated with the perimenopause, they reduce the risk of ovarian and endometrial cancer by at least 50% and this benefit is maintained for up to 15 years after discontinuation.

But if a woman decided to have a trial without hormonal control of her menstruation and the problem recurred she could always restart provided her risks were unchanged.

8. I'm assuming the number of hysterectomies has dropped as more women are successfully treated medically. But in which women would you still consider hysterectomy?

Hysterectomy rates are reducing because of a combination of IUS use and an increase in the number of second-generation endometrial ablations4. Newer techniques for the management of some symptomatic fibroids include uterine artery embolisation and hysteroscopic myomectomy.

In the early 1990s around 60% of women presenting with HMB would have a hysterectomy without discussion of alternative options. NICE guidance for management of HMB5 recommends that hysterectomy should be considered only when it has a severe effect on the woman's quality of life and other treatments are not suitable or not working – or for a woman wanting to stop her periods completely.

The IUS will fail to improve symptoms, expel or have intolerable side-effects in 20% of women. Endometrial ablation will fail in 5% to 15% of women, depending on the device used.

Some women will still opt for hysterectomy even after being counselled about the risks. These women should be offered a laparoscopic or vaginal hysterectomy if possible.

There are some women with HMB whose uterus is not suitable for the IUS or ablation – they may have a large uterine cavity, multiple fibroids, endometriosis, chronic pelvic infection, endometrial hyperplasia or cancer. Co-existent prolapse also makes vaginal hysterectomy a better option than the IUS or ablation.

9. The role of anticoagulation seems to be ever increasing and it is no longer uncommon for women of menstruating age to be on warfarin. Obviously keeping their INR at target remains important but even with close monitoring some of these women still suffer from menorrhagia as a result of anticoagulation. What would be the best treatment option that does not adversely affect their anticoagulation?

Whatever the reason for a woman being prescribed anticoagulation, neither tranexamic acid or any combined hormonal contraceptive are options for treatment because of their unacceptable clotting risks.

The UKMEC suggests that ‘current VTE' refers to a disease that is still being treated and puts the risks of using Depo-Provera or the IUS as category 3 – where the risks outweigh benefits.

But the risks are actually of bleeding and haematoma formation at the injection site or from the tenaculum used to aid insertion of the IUS, rather than any direct effect on the clotting mechanism.

Warfarin is teratogenic so the requirement for reliable contraception during treatment is extremely important and must be entered into the equation.

After careful counselling these methods are acceptable if other methods are not.

As the irregular bleeding pattern associated with use of the IUS may be more problematic for anticoagulated women, an additional option is to use a GnRH analogue such as triptorelin in the first few months to maximise the beneficial effects.

Endometrial ablation is an alternative choice but may be considered only for women whose families are complete. Stopping warfarin for surgery should be decided on a case-by-case basis.

Some centres are offering endometrial ablation as an out-patient procedure, which will reduce some of the anaesthetic risks.

It's extremely important to avoid major surgery as there is an increased morbidity and mortality.

10. Can you expand on the role of endometrial ablation? What are the second generation procedures?

Endometrial ablation reduces menstrual blood loss using a variety of energy sources to destroy the endometrium and superficial myometrium, preventing endometrial regrowth. These procedures improve the quality of life in 85-90% of women. NICE recommends that endometrial ablation can be offered after IUS has been considered and may be recommended only in women who have completed their families and who need reliable contraception. Compared with hysterectomy this cannot guarantee amenorrhoea, but gives less pain, morbidity, mortality and reduced costs.

First-generation transcervical resection of endometrium techniques are no longer first-line procedures because of the risk of uterine perforation and fluid overload. Newer second-generation techniques using different energy sources have been developed, including microwaves, impedance-controlled bipolar radiofrequency energy, or hot water via the thermal balloon.

These are all approved by NICE, producing similar results and improved safety features. They can all be performed as day case procedures and some in outpatients, under local anaesthesia.

11. When should you consider a bleeding disorder such as Von Willebrand disease as a cause of menorrhagia? How should it be investigated and will the diagnosis affect management?

A detailed history may suggest the HMB is part of a more generalised bleeding disorder:

• if periods have always been heavy since menarche

• if there any bleeding problems such as post-partum haemorrhage, extensive bruising with surgery, nose bleeds, easy bruising

• any concerns following dental extraction

• a family history of bleeding disorder.

The local haematologist will advise on which blood tests are required and where they should be taken if there are transport delays. Tests usually include a clotting screen and Von Willebrand screen.

Tranexamic acid is an excellent treatment for women with bleeding disorders as this will help with bleeding issues generally. The IUS will limit its beneficial effect to the endometrium only but is still likely to reduce menstrual blood loss. NSAIDs should be avoided in these women.

Dr Anne Connolly is a gynaecology GPSI and hysteroscopist for NHS Bradford and Airedale

Dr Sian Jones is a consultant in obstetrics and gynaecology, Bradford Teaching Hospital

Helen Ludkin is a nurse practitioner and hysteroscopist, Bradford Teaching Hospital

Competing interests: All three authors have received funding for lecturing from Bayer, Schering Plough and Johnson and Johnson

What I will do now What I will do now

Dr Watkins consider the answers to his questions

First, it's interesting to note another term that has fallen out of fashion – menorrhagia – to be replaced by heavy menstrual bleeding!
I'd always do an FBC in a woman with HMB but – if anything – the authors' advice means I'll probably order fewer tests in these women.
In my practice I'm able to offer the IUS to any woman who wants it – and it's certainly been a popular choice as both a contraceptive and as a treatment for HMB. But I appreciated the advice on other hormonal and non-hormonal treatments.
Mefenamic acid would certainly be my first choice NSAID for HMB with pain but it might be worth trying others – and it is reassuring to read I can use both an NSAID and tranexamic acid together at maximal doses.
I think I've seen more women suffering anaemia as a result of HMB than the authors suggest I should – but I'll take up the advice to continue iron supplementation for three months after blood levels return to normal.

Dr Paul Watkins is a GP in Bristol

thps Fibroids which distort the endometrium are most likley to cause bleeding Fibroids

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Readers' comments (1)

  • Useful, pragmatic
    Info on post ablation hrt is missing!

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