A lady with heavy menstrual bleeding


You are a junior doctor working in General Practice. Your next patient, Sarah Peters, is a 28-year-old nulliparous woman who is concerned about heavy periods. Work through the case to reach a diagnosis.


History

“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 two days, and I can’t afford to be taking so much time off work!”

How long has this been going on for? Were your periods normal before?

“My periods were heavier when I was younger, then they were better when I was on the pill. Since I stopped that a few months ago they’re worse again!”

 

How many pads or tampons do you use in a day? Do you need to wear both at the same time?

“I have to use pads and tampons at the same time, especially for the first couple of days. A heavy tampon will leak after a couple of hours.”

 

What colour is the blood? Have you noticed any clots or flooding (a sudden rush of heavy flow)?

“The blood is dark red. Sometimes I do get flooding and when it’s at its heaviest in the first couple of days I get clots too.”

 

Is there anything recently that’s prompted you to make an appointment today?

“I’ve had to have a meeting about taking time off at work, so I just want to get this sorted out. I’m so fed up of it.”

 

ICE – How is it affecting your life? Your job? Time off work? Is anything concerning you in particular?

“It’s affecting my job with having time off, and I’m fed up of being stuck in the house for the first couple of days. I’m hoping there’s some tablets or something that can help!”

The answers to the first set of questions form the basis of the diagnosis. Although menorrhagia is historically defined as >80ml of blood loss per cycle¹, 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 menstrual history

Menarche: How old were you when you started your period?

LMP: When was the first day of your last period?

Cycle: Are your cycles regular? How often do you get your period? How long does the bleeding last?

Other problems: Other than your periods being heavy, do you have any problems with them?

  • Painful periods (dysmenorrhoea can suggest endometriosis/fibroids)
  • Bleeding between cycles (intermenstrual bleeding can suggest STI/contraception problems/malignancy)
  • Bleeding after sex (post-coital bleeding can suggest ectropion/malignancy)
  • Long breaks between periods (amenorrhoea can be a feature of anorexia/hormonal problems such as hypothyroidism)

“I started my period when I was about 13, and they’ve always been regular. I bleed every 29 days on the dot and they always last about 6 days. The first day of my last period was 7 days ago. They’re not particularly painful and I’ve not had any other bleeding.”

Complete a full gynaecological history

Sexual and contraception history:

  • Are you sexually active at the moment? Do you have a regular partner? How many partners have you had in the past 6 months?
  • Have you had a sexual health screen in the past? When? Have you ever been treated for an STI?
  • Have you noticed any changes to your vaginal discharge?
  • Have you noticed any rashes or itching around your vulva?
  • Do you have pain when you’re having sex (dyspareunia)?
  • Are you using contraception at the moment? Have you used anything in the past?
  • Is there any chance you could be pregnant (e.g missed pills)?

 

Cervical smears:

  • When was your last cervical smear? Are you up to date with your smears?
  • Have you been vaccinated against HPV?
  • Any abnormal smears?
  • Any treatment required?

 

Urinary questions:

  • Any problems with going to the toilet?
  • Are you passing urine more often (frequency)?
  • Do you have any burning or stinging on passing urine (dysuria)?
  • Do you have any problems with incontinence?
  • So you have the sensation of “dragging” in your vagina (prolapse)?

 

Brief obstetric history:

  • Have you ever been pregnant? Any miscarriages or terminations?
  • Do you have any children? How old are they? Were they vaginal deliveries or c-sections? Any complications?
  • Are you currently trying to to get pregnant or have plans for a baby soon? (this will have an impact on management)

Answer

“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 pill about 6 months ago because we are trying for a baby. My most recent cervical smear was two and a half years ago, and they’ve all been normal. I’ve not had a letter for my next smear yet. I have no problems with my waterworks.”

Systems review with special focus on the below:

  • How are you otherwise? Are you in good health?
  • Are you more tired than usual, short of breath, noticeable heartbeats/palpitations, pale? (anaemia)
  • Have you been having any abdominal pain or bloating? (malignancy but also endometriosis/fibroids)
  • Any fever, lethargy, weight loss, night sweats? (malignancy)
  • Any excessive tiredness, weight gain, dry hair/hair loss, feeling cold when others are not? (hypothyroidism)
  • Have you had any bleeding problems in the past or does this run in the family?

Don’t forget the usual past medical, drug, family and social history.

Answer

“I don’t feel particularly tired or 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.” 

 


Differential Diagnoses

Dysfunctional uterine bleeding (DUB):

  • Because this patient has heavy menstrual bleeding as an isolated symptom (i.e. without pain, irregular cycles, a significant sexual history or intermenstrual bleeding), the most likely cause is DUB. However, this is a diagnosis of exclusion and further investigations must be performed before this diagnosis could be made. Her age makes fibroids less likely (typically present in women aged 30-50, rather than being symptomatic from menarche).
  • DUB is characterised by a lack of histological abnormality of the endometrium. Menorrhagia in these cases is likely due to subtle abnormalities of endometrial haemostasis and/or uterine prostaglandin levels.
  • Uterine fibroids
  • Endometriosis
  • Cervical or endometrial polyps
  • Adenomyosis
  • Pelvic inflammatory disease (PID)
  • Endometritis
  • Endometrial hyperplasia or carcinoma
  • Hypothyroidism
  • Bleeding disorders (e.g. Von Willebrand’s disease)
  • Iatrogenic (e.g. anticoagulant treatment; copper IUD)
  • Climacteric

Examination and Investigations

Clinical findings

  • No uterine tenderness or masses, with a normal anteverted uterus that is not enlarged
  • No adnexal masses or tenderness noted
  • No cervical excitation
  • No lesions apparent on the cervix
  • No discharge or bleeding is noted from the cervical os

Pregnancy test

  • This should form a part of the workup for almost all cases in which a woman of childbearing age is concerned. It is unlikely to be positive, but pregnancy would be unforgivable to miss!
  • This test is negative.

Bloods

  • Check FBC to rule out anaemia. If concerned, also perform iron studies (ferritin, transferrin, iron saturation).
  • Sarah has a normal Hb of 14.5 g/dL.

Imaging

  • Refer for a transvaginal ultrasound (TVUS) to exclude local organic causes (e.g. fibroids, polyps or adnexal masses)
  • Sarah’s TVUS results show a normal endometrial thickness and no abnormal masses.

Other investigations

Consider if appropriate based on the history (these investigations were not performed in this case):

  • Coagulation screen (bleeding disorder e.g. vWD)
  • TFTs (hypothyroidism)
  • Endometrial biopsy for histological examination (if worrying features e.g. endometrial thickness > 10mm on TVUS if premenopausal/intermenstrual bleeding)
  • Triple swabs (if considering STI)
  • Hormone profile if concerned about premature ovarian insufficiency (POI)

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. Referral to secondary care would be advised if two forms of management were to fail in primary care.

First-line treatment

  • Levonorgestrel intrauterine system (e.g. Mirena coil) provided that at least 12 months use is anticipated. This is the most effective management solution for heavy menstrual bleeding available in primary care. It can remain in situ for 5 years and also provides contraception.

Second-line treatment

  • Combined oral contraceptive pill (COCP) reduces menstrual bleeding by up to half. This also provides contraception but confers a higher side-effect profile compared to the IUS.
  • Tranexamic acid (anti-fibrinolytic) – ~50% reduction in blood loss and is used during or just before the period. Particularly effective in fibroids. Can be used alongside copper IUD.
  • Mefenamic acid (NSAID) – ~30% reduction in blood loss and is used during or just before the period; it is particularly useful if dysmenorrhoea is also present (not in this case), and it may be taken with the tranexamic acid.

Third line treatment

  • 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)
  • Medroxyprogesterone acetate injection every 12 weeks. This also provides contraception.

For Sarah, a non-hormonal treatment should be chosen as she is trying to get pregnant. Tranexamic acid would be an appropriate choice.

Surgical treatment of DUB

If medical treatment of DUB has failed, then the patient should be referred to secondary care where surgical management may be considered. Surgical management of DUB results in a loss of fertility and therefore may not be suitable for all patients.

  • Transcervical resection of the endometrium (TCRE): uses monopolar diathermy or microwave balloons to ablate the endometrium and superficial myometrium of the uterus, resulting in amenorrhoea or lighter periods.
  • Uterine artery embolisation (UAE): suitable for women who want to retain their uterus and avoid surgery.
  • Hysterectomy: often used as a last resort used for women who do not want further children.

References

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.


Editor

Dr Grace Farrington


 

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