You are a junior doctor working in General Practice. Your next patient, Mrs Sarah Peters, is a 28-year-old nulliparous lady who is struggling to cope with heavy menstrual bleeding and wants something to be done to help reduce the amount of blood loss.
“Doctor, I’m really struggling with how heavy my periods are. It’s reached a point where I can’t even leave the house for the first 2 days, and I can’t afford to be taking so much time off work! And worse yet, the rest of the time I feel like I have no energy.”
How long has this been going on for? Were your periods previously normal?
“This has been going on since I first started my periods – but it’s just been getting worse and worse. I can’t cope with this anymore.”
How many pads/tampons do you use in a day? Do you wear both at the same time?
“I’m using 35 sanitary towels for each period.”
What colour is the blood? Have you noticed any clots? Any flooding or leaking?
“The blood is of a normal colour, and I have noticed clots during the first 3 days of getting my period.”
What triggered you to come in about this today?
“I feel that my heavy periods have caused me to have no energy and it’s really getting me down!”
ICE – How is it affecting your life? Your job? Time off work? Is anything concerning you in particular?
“I’m worried about leaking into my clothes and so I take 2 days off work when the period first begins, so that I can deal with it safely at home.”
The answers to the first set of questions form the basis of the diagnosis, as although menorrhagia is defined as >80ml of blood loss (1), this is rarely measured – thus, menorrhagia is diagnosed when both the patient and doctor agree the amount of blood loss is significant enough to affect the woman’s life.
Take a full menstrual history
At what age did you begin to have your periods? (Menarche)
“I started my periods when I was 14.”
Do you remember the first day of your last menstrual period (LMP)?
“I’ve just finished my period, so probably about 7 days ago.”
Are your cycles regular? After how many days do you get your next period? How long does the bleeding last?
“My menstrual cycle occurs every 29 days and my periods last for 6 days, with the presence of clots during the first 3 days.”
Other problems to consider asking about, depending on the history given so far, such as:
Painful periods (dysmenorrhoea)?
Bleeding between cycles (intermenstrual bleeding)?
Bleeding after sex (postcoital bleeding)?
Ever not had periods for some time (amenorrhoea)?
“I wouldn’t say my periods are painful, nor do I have bleeding between cycles or after sex.”
Sexual and contraception history:
Are you sexually active? Do you have a regular partner?
Any problems with sex (e.g. dyspareunia)?
Have you ever been treated for an STI?
Any other sexual partners in the past 3, 6 or 12 months?
Are you using contraception at the moment? What contraception did you last use? OR Any problems with your current contraception?
When was your last cervical smear?
Have you been attending regularly?
Any abnormal smears?
Any treatment required?
Any problems with your waterworks?
Are you passing urine more often (frequency)?
Pain on passing urine (dysuria)?
Any dragging sensation or mass in/at the vagina (prolapse)?
Brief obstetric history:
Do you have any children? Are you currently trying for a child?
Ascertain woman’s need for contraception or if trying for a child (determines subsequent management)
Have you ever been pregnant? Any miscarriages or terminations?
“I am married to my husband of 3 years. I am sexually active and have not had any other partners since I was married. I’ve never been treated for an STI. I stopped using the oral contraceptive pill about 9 months ago as I wanted to fall pregnant. My most recent cervical smear was 2 and a half years ago, and this was normal but I do have a reminder letter that I’m due another shortly as part of the 3-yearly screening. I have no problems with my waterworks. I do not have any children and really would like to fall pregnant in the next few months if possible.”
Systems review (to rule out any pathology that may cause menorrhagia):
And how are you otherwise? Are you in good health?
Any fever, lethargy, weight loss, night sweats? (malignancy)
Are you more tired than usual, short of breath, noticeable heartbeats/palpitations, pale? (anaemia)
Any excessive tiredness, weight gain, dry hair/hair loss, feeling cold when others are not? (hypothyroidism)
“Apart from feeling tired all the time, my husband does say I look quite pale. My weight hasn’t changed, and I haven’t had any fevers or night sweats. I wouldn’t say I’m particularly sensitive to the cold. I am otherwise well and haven’t had to see a doctor for any reason. I’m not on any medications, and I have no allergies. My family are well. I don’t smoke or drink alcohol.”
Don’t forget the usual past medical, drug, family and social history.
Dysfunctional uterine bleeding (DUB):
No histological abnormality
The menorrhagia is likely due to subtle abnormalities of endometrial haemostasis and/or uterine prostaglandin levels.
Cervical or endometrial polyps
Pelvic inflammatory disease (PID)
Endometrial hyperplasia or carcinoma
Bleeding disorders (e.g. von Willebrand’s disease)
Anticoagulant treatment (uncommon)
Climacteric (perimenopausal women)
Examination and Investigations
You have now performed a pelvic examination on Mrs Sarah Peters and the findings are shown below.
No uterine tenderness or masses, with a normal anteverted uterus that is not enlarged.
No adnexal masses or tenderness noted.
Cervix feels normal on palpation.
No masses apparent on the cervix.
No discharge or bleeding is noted from the cervical os.
Check FBC and ferritin levels for iron deficiency anaemia.
Mrs Peters has a low Hb of 10.5 g/dL and also a low ferritin level.
Refer for a transvaginal ultrasound (TVUS) to exclude local organic causes (e.g. fibroids, polyps or adnexal masses).
Mrs Peters TVUS results show a normal endometrial thickness and no abnormal masses.
Consider if appropriate based on the history (these investigations were not performed in this case):
Clotting tests (bleeding disorder e.g. vWD)
Endometrial biopsy for histological examination (if worrying features e.g. endometrial thickness > 10mm on TVUS if premenopausal or intermenstrual bleeding)
Triple swabs (if considering STI)
Diagnosis and Management
The examination and investigations confirm your diagnosis of dysfunctional uterine bleeding (DUB).
Dysfunctional uterine bleeding can be managed in primary care if there are no concerning features in the history, clinical examination and initial investigations (e.g. FBC, USS). Referral to secondary care would be advised if two types of treatment were to fail in primary care.
First line treatment
Tranexamic acid (anti-fibrinolytic) – ~50% reduction in blood loss and is used during or just before the period.
Mefenamic acid (NSAID) – ~30% reduction in blood loss and is used during or just before the period; it is particularly useful if dysmenorrhea is also present (not in this case), and it may be taken with the tranexamic acid.
First line treatment
Levonorgestrel intrauterine system (e.g. Mirena coil) provided long-term (at least 12 months) use is anticipated (this would not be appropriate for Mrs Peters as she is trying to conceive).
Combined oral contraceptive (COCP) is often used for women who are unable to take an NSAID (this would not be appropriate for Mrs Peters as she is trying to conceive).
Norethisterone (15 mg) daily from days 5 to 26 of the menstrual cycle (affects ovulation and has a contraceptive effect, so not appropriate for Mrs Peters)
Surgical treatment of DUB
None of the following treatments would be appropriate for Mrs Peters, as she wants to maintain her fertility.
Transcervical resection of the endometrium (TCRE): uses monopolar diathermy or microwave balloons to ablate the endometrium and superficial myometrium of the uterus, allowing amenorrhoea or lighter periods to follow.
Uterine artery embolisation (UAE): suitable for women who want to retain their uterus and avoid surgery.
Hysterectomy: often a last resort used for women who do not want further children.
1. Munro, Malcolm G.; Critchley, Hilary O. D.; Broder, Michael S.; Fraser, Ian S. (2011-04-01). “FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age”. International Journal of Gynecology & Obstetrics.
2. CG44 Heavy menstrual bleeding: Understanding NICE guidance” (PDF). National Institute for Health and Clinical Excellence (UK). 24 January 2007.