CPD: Casebook – heavy menstrual bleeding

In this case-based module, Dr Toni Hazell discusses how to manage consultations about heavy menstrual bleeding.

Complete the full module on Pulse 365 today

Learning objectives

This module will support your knowledge and understanding of:

• How to take a history from a patient with heavy menstrual bleeding (HMB).
• The risk factors for endometrial pathology.
• Which patients need examination and investigating.
• How to treat idiopathic HMB.

Case 1: Teenager with HMB. Part 1 – clinical assessment

Ngozi is 15 and comes in with her mother to talk about her heavy periods. Her mother starts the consultation and tells you that Ngozi is missing several days of school each month; her teachers are concerned, especially with GCSEs looming next year.

1. What do you want to know about her bleeding?

HMB is often defined in research terms as the loss of more than 80ml of blood per month,¹ but that isn’t terribly useful in a clinical consultation. The box below contains some useful questions to ask about the heaviness of the periods, but the fact that she is missing school is already a red flag. It’s important to find out if the periods have been heavy from her menarche, or if the heaviness developed later – the former might suggest a coagulation disorder such as von Willebrand disease.²

2. Many teenagers won’t have an underlying cause for their HMB, but it’s still important to ask the questions. What would you want to know, to help you exclude treatable pathology, before treating the HMB as idiopathic?   

You’ll need your diplomatic skills to get the mother out of the room at some point, as you need to know whether Ngozi is sexually active. A simple statement of ‘I always see teenagers alone as well as with their parent, would you mind having a seat in the waiting room and I’ll come and get you in 5 minutes’ usually works.

Symptoms which might suggest a uterine cavity abnormality include persistent intermenstrual bleeding, pelvic pain and pressure symptoms such as frequency of urine.² If she is sexually active then you should ask about symptoms of a sexually transmitted infection (pain, discharge, intermenstrual or postcoital bleeding), about whether she uses contraception (barrier or hormonal or both) and if there is any chance that she could be pregnant. On the holistic front, while you have her alone it’s worth checking that there is nothing else going on which is causing her to avoid school, such as bullying.

It is also important to know about past medical history and drug history, as well as family history which might be relevant in terms of suitability for combined hormonal contraception, which is often used to treat HMB. HMB can rarely be a presentation of hypothyroidism, so it is useful also to enquire about any other symptoms of thyroid dysfunction.

3. Having taken a history, you determine Ngozi clearly has HMB, as she is having to change single protection every 1-2 hours, and is using double protection at night, but still sometimes wakes up having flooded. She isn’t sexually active, there’s no medical history, drug history or family history of note, and no symptoms to suggest a structural cause. Do you need to examine her?  

It’s always important to think about why we’re doing any medical intervention – an examination or a test – how will what I find out here change my management, and why am I doing it? For women with no related symptoms, it’s fine to treat HMB without examination.² If there were red flags such as intermenstrual or postcoital bleeding, then it’s sensible to look at the cervix (though this may not be possible in a woman who has not been sexually active), but there is no reason to examine Ngozi.

Dr Toni Hazell is a GP in north London

References

1. Warner P et al. Menorrhagia II: is the 80-mL blood loss criterion useful in management of complaint of menorrhagia? Am J Obstet Gynecol 2004 May;190(5):1224-9
2. NICE. Heavy menstrual bleeding: assessment and management. [NG88] May 2021