Menorrhagia

Tool

Heavy Menstrual Bleed - Jean Hailes

History

Gynae history

• Menstrual

  • Menarche

  • Date of LMP

  • Cycle length, number of bleeding days, note heaviest days

  • Volume

    • Hourly change of tampons, pads, cups

    • Tampons and pads together

    • Flooding through clothing

    • Unable to leave house of heaviest days

    • Large >3cm clots

  • Impact on daily life

  • Associated dysmenorrhoea

• Other gynae issues

  • IMB / PCB

  • Abnormal vaginal discharge

  • Dyspareunia

• Pregnancy possibility

• STI risk

• Reproductive history

• Cervical screening history

• Contraceptive methods

Medications

• Anticoagulants

• Antidepressants

• Hormonal contraceptives

• Tamoxifen

• Antipsychotics

• Corticosteroids

Symptoms of anaemia

Symptoms of underlying medical issue:

• thyroid disorder

• Androgen excess

• Malignancy

• Bleeding disorders

Family history of bleeding disorder or gynae cancers

Desire for pregnancy

Diagnoses

• Anovulatory cycles or PCOS

• Contraceptive problems

• Pregnancy-related

• Medication-related

• Fibroids

• Endometriosis

• Adenomyosis

• Cancer

• Thyroid disease

• Haematological

• Hypothalamic

Investigations

• Consider Urine BHCG

• FBC and Ferritin

• TSH

• Testosterone, FAI, SHBG

• Consider coags

• Consider STII screen

• Pelvic ultrasound on day 5 to 10 of cycle if

  • Abnormal pelvic exam

  • Risk factors for endometrial cancer

  • Persistent IMB

  • Heavy menstrual bleeding with IMB or PCB

Treatment

• ED if acute and haemodynamic compromise

• Antifibrinolytic e.g. tranexamic acid

• Oral progestogens

  • Norethisterone 5 to 10 mg Q4h

  • Medroxyprogesterone 10mg orally Q4h and taper

• If suspicious for malignancy on exam or ultrasound then Gynae review

• Treat iron deficiency anaemia

• Non-hormonal treatment options

  • Tranexamic acid – reduced bleeding by 40%. Give 500 mg orally (2 or 3 tablets every 6 to 8 hours, for 3 to 4 days), and/or

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) – reduces bleeding by 30%:

    • Start at the onset of menses and continue for the first 3 to 4 days of the cycle.

    • Do not use NSAIDs in patients with an allergy to aspirin, or bleeding problems.

    • Consider concomitant proton pump inhibitor in women at risk of gastrointestinal bleeding.

    • Do not use more than one type of NSAID concomitantly – options include:

      • Ibuprofen – give 200 to 400 mg orally 3 to 4 times a day. Maximum daily dose 1600 mg, or

      • Mefenamic acid – give 500 mg orally 3 times a day, or

      • Naproxen – give 500 mg orally initially then 250 mg every 6 to 8 hours. Maximum daily dose 1250 mg.

    • NSAIDs can be combined with hormonal treatment or tranexamic acid.

• Hormonal treatment options

  • Combined oral contraceptive pill (COCP)

    • Reduces bleeding by 40%. 3

    • Can use 20 to 50 micrograms of oestrogen. If breakthrough bleeding occurs, change the COCP formulation to one containing a higher dose of oestrogen.

    • Causes ovarian suppression.

    • Medical risks are no greater for adolescent females after menarche than for young adults. (Consider MEC criteria)

    • Trial for at least 3 months, and continue if effective.

    • Consider tri‑cycling or continuous use to reduce the number of withdrawal bleeds, helping to regulate bleeds and pain.

  • Oral progestogen (contraceptive) – levonorgestrel (Microlut™). Reduces bleeding by 85%. Give 30 micrograms daily.

  • Oral progestogen (non-contraceptive)

    Use for 10 to 14 days during second half of cycle. Options include:

    • Norethisterone (Primolut N™) – start at 5 mg and give orally, 3 times a day

    • Medroxyprogesterone (Provera™):

      • Give 5 to 10 mg daily in one or two doses

      • Note that if heavy menstrual bleeding is occurring in ovulatory cycles, it can be used from day 5 to day 25 of the cycle.

    • Generally use for a short term (1 to 2 months). Treatment should not usually continue for longer than 6 months due to the risk of hypo-estrogenism.

    • If spotting occurs, double the dose.

    • If spotting ceases and the patient experiences progestogenic side‑effects, consider reducing back to the starting dose.

  • Depo-Provera™

    • Injectable contraceptive progestogen which suppresses ovulation.

    • When starting Depo-Provera™, it may take a few injections to achieve infrequent bleeding or amenorrhoea. Bleeding and spotting may occur in the first few months.

    • Dose:

      • 150 mg intramuscularly (IM) within first 5 days of cycle, or within first 5 days after childbirth.

      • Delay until 6 weeks after childbirth if breastfeeding.

      • For long-term contraception, repeat every 12 weeks.

      • If more than 12 weeks and 5 days, rule out pregnancy before the next injection and advise the patient to use additional contraceptive measures e.g., barrier for 14 days after the injection.

    • Reduced bone density can occur while on Depo‑Provera™. Advise patients to ensure other factors contributing to bone density are maximised:

      • Calcium intake

      • Regular weight-bearing exercises

      • BMI > 20 kg/m2

      • Not smoking

    • If at significant risk of osteoporosis, use alternative regimes.

    • See also – Contraceptive Injection.

  • Mirena™ – levonorgestrel intrauterine device (IUD)

    • Reduces bleeding by 95% after at least 3 months use.

    • Irregular light bleeding is a possible side effect, usually in the first 3 months. May take up to 6 months for full benefit is seen.

    • PBS restricted benefit available for idiopathic menorrhagia where oral treatments are ineffective or contraindicated.

    • See also – Intra-uterine System or Device (IUD) Insertion.