1. Heavy Menstrual Bleeding for Undergraduates Max Brinsmead MB BS PhD May 2015

2. A Few Definitions Menorrhagia –Excessive menstrual loss at regular intervals Metrorrhagia –Excessive menstrual loss without evidence of any cycling –Typical of anovulatory bleeding at the extremes of reproductive life Intermenstrual bleeding (IMB) –Episodes of bleeding between menstrual periods –Postcoital bleeding is a type of IMB The generic modern terms are Heavy Menstrual Bleeding (HMB) & Abnormal Uterine Bleeding (AUB)

3. Heavy menstrual bleeding is defined as: Excessive menstrual blood loss which interferes with a woman’s… –physical –emotional –social or –material quality of life This implies that the woman herself is the primary judge of severity And there can be substantial variation in tolerance to this dis - ease

4. While a pathological description is impractical: That is, the menstrual loss of an amount of blood loss that is likely to lead to health sequelae Because treatment options have risk & cost implications, a health provider is obliged to indicate to patients some criteria for diagnosis My criteria: –Sufficient to cause iron deficiency (exclude other causes) –Escapes from accepted menstrual protection –Requires changes > 4 hourly –Up at night more than once –Passage of large clots –Lasts for >7 days (full flow)

5. Incidence of Heavy Menstrual Bleeding The Impact on Women Cross sectional studies indicate that 5 – 50% of women will complain of “heavy periods” Quantified studies show that ≈ 10% of women will have menstrual losses that ≥ 80 ml Many studies indicate that the condition is associated with… –Reduced employment options –Work absences –Decreased earning capacity that for women are more important than such psychological effects as… –Depression and anxiety –Mood changes, irritability –As well as effects on social life, hobbies etc Can be summarised in “Quality of Life” measures

6. Fibroids Adenomyosis Endometriosis & Chronic PID Endometrial cancer Bleeding disorders – Idiopathic and acquired thrombocytopenia – Other known & undiagnosable disorders of coagulation Physiological – Includes dysfunctional uterine bleeding – All studies show >50% have no identified pathology Some Causes of Heavy Menstrual Bleeding

7. How many days does your period last for How many heavy days? What do you mean by heavy What do you use for menstrual protection How often do you change? Why do you change so often What do you use at night Do you change at night? How many nights Do you pass clots? How big are the clots? How often Any accidents (escape from menstrual protection) What do you mean by flooding Do you have to modify your life when you have your periods What do you do for contraception in your relationship Do you experience any other bleeding or bruising Are you taking iron tablets Some History-taking Tips

8. Consider the cultural context Explore parity, fertility requirements etc Consider occupation and activities The extent of examination and investigations will depend on –Age >45 –Intermenstrual bleeding –Any pelvic pain or pressure symptoms Details of any previous gynaecological interventions Other illnesses or conditions may influence treatment options Other symptoms may influence treatment choices –Infertility –Prolapse –Urinary incontinence Family History Other History-taking Essentials

9. A general examination of all patients –Height & weight –Signs of anaemia –Signs of endocrinopathy Thyroid Androgen excess Abdominal examination –For significant uterine enlargement Only rewarding in slim patients A palpable uterus is >12w size A vaginal examination is not required in primary care if there is no palpable uterus & a Pap smear is not required Unless a Mirena is planned And patients should not be sent for US without prior VE Examination

10. A Full Blood Count (FBC) for all patients –Look for iron-deficiency anaemia –Check the platelet count S Ferritin –Is the most sensitive indicator of Iron deficiency –But it is an acute phase reactant Thyroid function tests –Only when clinically indicated Female hormones –Have no role –Even when the diagnosis is dysfunctional uterine bleeding Laboratory Tests in Primary Care

11. Symptoms from menarche Positive Family History Other personal bleeding or bruising There is thrombocytopenia Tests to do: – Renal and Liver Function Tests – Bleeding time and Coagulation time – Seek specialist haematological advice The most commonly identified abnormality is von Willebrands Disease Indications for Tests of Coagulation Disorders

12. Ultrasound is the imaging of choice –But is not required unless the uterus is enlarged –Required for uncertainty after pelvic examination –Required after a failure of primary medical treatment Required information from this examination include: –Uterine size including length of the endometrial cavity –Myometrial abnormalities –Any adnexal pathology Considerable caution is required when... –Comments about endometrial thickness are reported as abnormal –Fibroids <4 cm in size are reported –Multiple fibroids are reported but there is no clinical evidence of an enlarged or irregular uterus –Adnexal cysts <5 cm diameter are reported Imaging in Primary Care

13. What is the risk of significant pathology? This is mostly about the risk of endometrial cancer There are many studies… –Most do not distinguish between HMB and AUB The risk of endometrial Ca is age dependent –For women <30 yrs age the risk is 1:10,000 –For those >45 years the risk is 8:10,000 –And the risk of endometrial hyperplasia is ≈ 4X higher Who is at risk of Endometrial Cancer? –Those with intermenstrual bleeding –Those with irregular cycles – PCO disorder –Infertility –Obesity –Positive Family History

14. Patient is >45 years of age There is irregular or intermenstrual bleeding The uterus is >10 weeks size There are symptoms or signs suggestive of such pelvic conditions as endometriosis, PID, adnexal pathology etc. Ultrasound suggests uterine fibroids >4 cm or distortion of the uterine cavity Failure of primary pharmaceutical treatment Patient request Indications for Referral

15. Hormonal Levonorgestrel IUS (“Mirena”) Combined COC Cyclical oral Progestins Injected Progestin (“Depo Provra”) Danazol GnRH analogues Non Hormonal NSAIDs Tranexamic Acid (“Cyclokapron”) Medical Options for the Treatment of Heavy Menstrual Bleeding

16. Endometrial Ablation Hysteroscopic endometrial resection 2 nd generation techniques – Thermal balloon endometrial ablation (TBEA) – Microwave endometrial ablation (MEA) Myomectomy Uterine Artery Embolisation Hysterectomy Abdominal, vaginal or laparoscopic Subtotal or total With or without bilateral oophorectomy Surgical Treatment Options for Heavy Menstrual Bleeding

17. The Mirena IUS for HMB Reduces mean menstrual loss by 71 – 96% Up to 50% of patients amenorrhoeic after 6m depending on age ≈ 85% patients are satisfied (continuation rate) ≈ 1% rate of troublesome hormonal side effects When compared to endometrial ablation (EA) –Mean reduction in blood loss is greater with EA –But overall satisfaction equal –And Mirena better in the longer term (1 small study) When compared to hysterectomy –Overall satisfaction rates are equal –But Mirena is half the cost even when up to 40% of patients go on to hysterectomy

18. Oral Hormones for HMB What is the Evidence? Mean blood loss (MBL) is reduced by ≈40% Risks in older women and smokers plus side effects limit use of COC (oestrogen) Progestin e.g. Norethisterone 5 mg TDS from Day 5 to 27 of a cycle is effective in reducing (MBL) Progestin not as effective as NSAIDs and Tranexamic acid Side effects are limiting – weight gain, headaches, acne, mood changes, mastalgia They are of most use in the short term treatment of DUB at the extremes of reproductive life

19. IM Depo Provera for HMB ≈10% of patients are amenorrhoic after 3m of 150 mg every 12w ≈50% amenorrhoic after 12m Continuation rates are low, however, presumably due to side effects And there is a small risk of bone mineral loss with long term use

20. GnRH analogues for HMB Most studies have been directed at the reduction of uterine size with these agents that induce a “reversible menopause” Reductions in uterine size up to 75% over 6m can occur And up to 90% of patients achieve amenorrhea This can be very useful prior to hysterectomy Oestrogen-deficiency symptoms i.e. hot flushes, vaginal atrophy and bone loss are limiting But these can be overcome with add-back therepy using small doses of oral oestrogen, COC, progestin or tibilone GnRH are currently very expensive drugs

21. Tranexamic Acid (Cyklokapron) for HMB Inhibits plasminogen activation but has no effect on blood clotting in healthy vessels Reduces fibrin breakdown in spiral arterioles Systematic reviews confirm that mean blood loss during menstruation is reduced by ≈ 50% 12% of women experience side effects Nausea, vomiting, dyspepsia Diarrhoea No apparent risk of thromboembolism Visual side effects are rare Dose 1G every 6 – 8 hours It is not contraceptive nor cycle regulating

22. NSAIDs for HMB Systematic reviews confirm that mean menstrual blood loss during menstruation is reduced by ≈ 30% Mefanamic acid e.g. Naprosyn better than Ibufren e.g. Indocid Side effects are well known but risk is reduced by intermittent use Dose 1 – 2 tablets 4 – 6 hourly Particularly useful when dysmenorrhoea is also a problem Not recommended if there is a known bleeding disorder loss

23. Information for Patients that compares Endometrial Ablation & Hysterectomy

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