Heavy Menstrual Bleeding (HMB)
This is the commonest bleeding problem seen in women.
1 in 20 women aged 30-49 consult GPs yearly for heavy periods; menstrual disorders account for 12% of gynaecology referrals in the UK. Similar stats in USA.
It affects 38-78% of women in the reproductive age group across South Asia/sub-Saharan Africa
HMB is leading cause of iron deficiency anemia worldwide
Definition
• Excessive menstrual bleeding that interferes with a woman’s quality of life (physical, emotional, social, material).
• Diagnosis is based on the woman’s perception of heaviness, not only on quantified blood loss (>80 mL).
Causes
• Uterine structural abnormalities – fibroids, polyps, adenomyosis(presence of womb-lining tissues within the muscle of the womb)
• Endometrial pathology (problems with the lining of the womb) – hyperplasia, malignancy.
• Ovulatory dysfunction – anovulation (no ovulation), irregular ovulation
• Coagulation/bleeding disorders – e.g. von Willebrand disease.
• Iatrogenic – intrauterine devices, medications.
• Often no identifiable cause.
Symptoms & Signs
• Heavy/prolonged bleeding, clots, flooding.
• Intermenstrual or postcoital bleeding.
• Pelvic pain or pressure symptoms (fibroids, adenomyosis).
• Fatigue, pallor (anaemia).
• Impact on daily life, work, social or emotional wellbeing.
Red Flag Symptoms
• Intermenstrual bleeding.
• Postcoital bleeding.
• Persistent irregular bleeding in women ≥45.
• Postmenopausal bleeding.
• Pelvic mass or enlarged uterus.
• Suspicion of endometrial hyperplasia or cancer (risk factors: obesity, PCOS, tamoxifen, Lynch syndrome).
• Severe anaemia symptoms/signs.
• HMB since menarche + family history of bleeding disorder.
Investigations
• Full history: cycle, bleeding pattern, associated symptoms, impact on life.
• Physical exam if symptoms suggest structural abnormality.
• Full blood count – for all women with HMB (to check anaemia).
• Coagulation screen if HMB since menarche + family history of bleeding disorder.
• Pelvic ultrasound – if uterus palpable, mass suspected, or cavity distortion suspected.
• Outpatient hysteroscopy – if submucosal fibroids, polyps, endometrial pathology suspected.
• Endometrial biopsy – ≥45 with new symptoms, <45 with risk factors, or persistent IMB/irregular bleeding.
Treatment Options
• First-line medical management
• Levonorgestrel-releasing intrauterine system (LNG-IUS, Mirena)- commonly used Mirena Coil
• Tranexamic acid (taken during menses).
• NSAIDs (e.g. mefenamic acid) – reduces blood loss and pain.
• Combined hormonal contraception – regulates cycles, reduces loss.
• Oral progestogens – less effective, option if others unsuitable.
• If structural pathology (e.g. fibroids)
• UAE (uterine artery embolisation).
• Myomectomy- fibroid removal
• Ulipristal acetate in selected cases (with caution, liver monitoring)- Needs serious conversation with a consultant gynecologist- because of risk of LIVER DISEASE.
• Surgical options (if medical management fails / not suitable)
• Endometrial ablation(burning of the lining of the womb) – high satisfaction, but not for women desiring fertility.
• Hysterectomy(removal of your womb) – definitive cure, fertility lost.
• Supportive care
• Treat iron deficiency/anaemia.
• Reassess regularly, tailor to woman’s priorities (fertility, contraception, symptom control).
Always consult your Gynaecologist to discuss your case/options
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