Heavy Menstrual Bleeding- assessment and management
Evaluate impact- Heavy menstrual bleeding ( HMB ) is one of the commonest reason for gynecological referral and consultations About 1 in 20 women aged 30-49 yrs see GP/ year for HMB or menstrual problems Menstrual disorders comprise 12 % of all referral to gynecology service The guideline states that HMB has a major impact on a womens QOL and advises to ensure that any intervention should aim to improve this rather than focusing on blood loss
HMB -a report has shown- 74 % suffered anxiety 67 % depression 62 % reported impact on physical wellbeing
history Examination and Testing – Nature of bleeding Related symptoms as ○ persistent IMB ○ pelvic pain and / or pressure symptoms -may indicate uterine cavity abnormality - histological abnormality - adenomyosis or fibroids Impact on QOL Co-morbidities Previous treatment of HMB Take into account the range & natural variability in menstrual cycles and blood loss when diagnosing HMB -discuss the variation. Discuss care options if the women feels she does not fall within the normal range.
Physical examination HMB without other related symptoms – Consider pharmacological management without carrying out a physical examination. Undertake a physical examination-HMB with other related symptoms Before all investigations or LNG-IUS fittings
Lab tests – FBC – for all with HMB in parallel with any HMB treatment offered Coagulation disorders eg von Willerbrand’s disease if ○ have had HMB since their periods started and ○ have a personal or family hx suggestive of a coagulation disorder TFT not routinely indicated unless other signs and symptoms of thyroid illness
investigating the cause –History and or examination suggests a low risk of fibroids uterine cavity abnormality histological abnormality or adenomyosis. Consider starting pharmacological management without investigating the cause. Cancer suspected- USC.
Take into account history and examination to decide which first line to offer. Outpatient hysteroscopy. If hx suggests ○ submucosal fibroids ○ polyps or ○ endometrial pathology because they have ○ symptoms as persistent intermenstrual bleeding ○ risk factors for endometrial pathology. NICE clarifies further that these are women with - persistent intermenstrual or persistent irregular bleeding who are obese or have PCOS - women who are on tamoxifen - women for whom treatment for HMB has been unsuccessful NICE has set-out guidance for organization and standards for the OP hysteroscopy services NICE also contemplates that hysterocopy services could be offered by GPs Women should be offered hysterocopy under general anesthesia if she declines OP hysteroscpy If a women declines hysteroscopy- offer a pelvic US and explain the limitations of this technique for detecting uterine cavity causes of HMB.
ultrasound -women with possible larger fibroids Uterus is palpable abdominally Hx / Examination suggests a pelvic mass Examination inconclusive or difficult , for eg in obese women.
Women with suspected adenomyosis Offer transvaginal US if ○ significant dysmenorrhoea or ○ a bulky , tender uterus that suggests adenomysosis If she declines TV US or it is not suitable for her consider ○ Transabdominal US ○ MRI and Explain the limitations of these techniques. Beware that pain associated with HMB may be due to endometriosis rather than adenomysosis. NICE urges not to use saline infusion sonography , MRI or dilatation and curettage for diagnosis of HMB
informatio about HMB and treatments – Discuss all options Benefits , risks Suitable treatments if she is trying to conceive If she wants to retain her fertility and / or uterus
LUS-IUS-Levonorgestrel- releasing IUS-anticipated changes in bleeding pattern – particularly 1st few cycles and may persist longer than 6 months to wait atleast 6 cycles to see the benefits of the treatment. fertility and treatment -Explain the impact on fertility that any planned surgery or uterine artery embolisation may have and if a potential Rx ( eg hysterectomy or ablation ) involves loss of fertility Explain that uterine artery embolisation or myomectomy may potentially allow them to retain fertility
endometrial ablation –Advice to avoid subsequent pregnancy and use of effective contraception if needed after the procedure.
Hysterectomy- discuss – sexual feelings impact on fertility bladder function need for further treatment complications ○ ↑ ed risk of serious complications ( eg intraoperative haemorrhage or damage to other abdominal organs ) when uterine fibroids are present ○ risk of possible loss of ovarian function and its consequences , even if ovaries are retained during hysterectomy her expectations alternative surgery psychological impact
Management of HMB-Preferences Co-morbidities Fibroids ( incl size, number and location ) Polyps , endometrial pathology or adenomyosis-No identified pathology , fibroids less than 3 cm in diameter or suspected or diagnosed adenomyosis. Consider LNG-IUS as the 1st line if ○ no identified pathology OR ○ fibroids < 3 cm in dia , which are not causing distortion of the uterine cavity OR ○ suspected or diagnosed adenomyosis. LNG-IUS declined or not suitable- consider ○ non- hormonal - tranexemic acid - NSAID ○ hormonal - COCP - cyclical oral progestogens. POP may suppress menstruation which could be beneficial
If Rx unsuccessful ,she declines pharmacological treatment or symptoms are severe, consider referral for ○ investigations to diagnose the cause ○ alternative treatment choices including - pharmacological options not already tried - surgical options as 2nd generation endometrial ablation hysterectomy For women with submuscosal fibroids , consider hysteroscopic removal
Pretreatment with a GNRH analogue or ulipristal acetate before hysterectomy and myomectomy should be considered if uterine fibroids are causing an enlarged or distorted uterus
Treatment for women with fibroids 3 cm or more in diameter-Consider referring for additional investigations and discuss treatment options Offer tranexemic acid and / or NSAID while investigations and definitive treatment are being organised – advise to continue for as long as they are found to be beneficial.Fibroids- take into account size, location , number and severity of symptoms and consider the following treatments ○ pharmacological Non- hormonal -♦ tranexemic acid ♦ NSAID Hormonal – ♦ ulipristal acetate ( UPSA ) ♦ LNG-IUS ♦ COCP ♦ cyclical progestogens ○ uterine artery embolisation ○ surgical – ♦ myomectomy ♦ hysterectomy
Ulipristal acetate -can cause serious liver injury ○ discuss benefits/ harm and educate so she recognises signs and symptoms of liver injury ○ monitor LFT for the 1st 2 treatment courses and as clinically indicated in line with current prescribing guidance If ulipristal is used for intermittent Rx in women who are not eligible for surgery for eg where the risks of surgery outweigh the benefits or where she declines surgical treatment ○ offer 5 mg ( up to 4 courses ) for HMB and fobroids of 3 cm and Hb of 102 g/L or below ○ consider 5 mg ( upto 4 courses ) for HMB and fibroids of 3 cm or more and Hb above 102 g/L
Beware that the effectiveness of pharmacological treatments for HMB ( excluding UPSA ) may be limited if fibroids that are substantially greater than 3 cm or more in dia and a Hb above 102 g/L
References GPs should refer 10000 more women with heavy menstrual bleeding , says NICE Pulse March 2018 New NICE guideline on Heavy Menstrual Bleeding Published RCOG Heavy menstrual bleeding : assessment and management NICE guideline March 2018 NICE guidance on heavy menstrual bleeding highlights importance of patient choice GP Online