Heavy Menstrual Bleeding – OSCE Case

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Introduction

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

UK Medical Licensing Assessment (UKMLA)

This clinical case maps to the following UKMLA presentations:

  • Menstrual problems

History

Presenting complaint

“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!”

History of presenting complaint

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 mini 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!”

Tip: Although heavy menstrual bleeding was historically defined as >80ml of blood loss per cycle, this is rarely measured. Heavy menstrual bleeding has also replaced the term menorrhagia. Heavy menstrual bleeding is menstrual bleeding the patient feels impacts their quality of life and may be causing complications (e.g. iron deficiency anaemia).Β 

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 heavy periods, 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)

Answer

“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 can be very painful too.”

Other areas of the history

In the context of heavy menstrual bleeding, key areas include contraceptionΒ (past and present),Β cervical screening and plans forΒ future pregnancies.Β 

Sexual and contraception history:

  • 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)?
  • Do you have any vaginal symptoms (e.g. discharge, itching)?
  • Do you have a regular partner? When was your last sexual health screen?
  • Do you experience any problems during sex (e.g. dyspareunia)?

Gynaecology history and cervical smears:

  • Have you had any gynaecological problems previously? Any problems which run in the family?
  • When was your last cervical smear? Are you up to date with your smears?
  • Any abnormal smears or treatment required?

Urinary symptoms:

  • Do you have any problems passing water (e.g. incontinence, frequency)?

Brief obstetric history:

  • Have you ever been pregnant? Can you tell me about the outcomes of those pregnancies?
  • Are you currently trying to conceive or have plans to try for a pregnancy soon? (this will have an impact on management)

For more information, see the Geeky Medics guide to gynaecological history taking.

Answer

“I am married to my husband of 3 years. We are not using any contraception currently, I stopped the mini pill about 4 months ago because we were hoping to conceive. I’ve never had an STI, we had tests before we got together and I’ve had no other partners. My most recent cervical smear was two and a half years ago, and they’ve all been normal. My waterworks are fine.”

Past medicalΒ history

  • Do you have any medical conditions? (relevant conditions include hypothyroidism, coagulopathies and PCOS)Β 

Drug history

  • Do you take any regular medications? (anticoagulants, tamoxifen)

Systems review focussing on:

  • Do you feel tired, short of breath or more short of breath on exertion? (screen for anaemia)
  • Do you know your BMI? (PCOS, obesity)
  • Have you been having any abdominal pain or bloating? (malignancy but also endometriosis/fibroids)
  • Any fever, lethargy, weight loss, or 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? (coagulopathy)

Answer

“It’s just this bleeding, I feel well otherwise and don’t have any other symptoms. I don’t feel particularly tired or short of breath. 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.”Β 


Clinical examination

The examination aims to identify any underlying structural causes of the heavy menstrual bleeding (e.g. fibroid, cervical pathology).Β 

Clinical findings

  • Normal colour, no conjunctival pallor
  • Uterus not palpable on abdominal examination
  • No discharge or bleeding is noted from the cervical os or vaginal walls
  • No lesions are apparent on the cervix or vaginal walls
  • No cervical excitation
  • No uterine tenderness or masses, with a normal anteverted uterus that is not enlarged
  • No adnexal masses or tenderness noted

Differential diagnoses

This patient has heavy menstrual bleeding, a symptom with a broad range of potential causes (including local structural causes and systemic conditions). She also describesΒ painful periods (dysmenorrhoea).Β 

The PALM-COEINΒ mnemonic can be used to remember the causes:

Structural causes:

  • Polyps
  • Adenomyosis
  • Leiomyomas (fibroids)
  • Malignancy and hyperplasia

Non-structural causes:

  • Coagulopathy (e.g. von Willebrand’s disease)
  • Ovulatory dysfunction (e.g. anovulation in PCOS)
  • Endometrial (e.g. endometriosis)
  • Iatrogenic (e.g. secondary to anticoagulant treatment)
  • Not otherwise classified (e.g. systemic causes such as hypothyroidism, liver or kidney disease)

There are noΒ obviousΒ red flags in the history. However, she does describe dysmenorrhoea. The clinical examination is normal, which is reassuring.Β 

Potential structural causes of heavy menstrual bleeding and dysmenorrhoea include leiomyomas (fibroids), endometriosis and adenomyosis.Β 

If no cause is identified, this would previously have been calledΒ dysfunctional uterine bleedingΒ (DUB). However, this term is rarely used now.Β 


Investigations

Pregnancy test

  • This should always be performed in a woman of childbearing age with menstrual bleeding irregularities.Β 
  • This test is negative.

Laboratory investigations

  • Full blood count: to exclude anaemia (should be performed in all women with heavy menstrual bleeding)
  • Given her long history of heavy periods, a thyroid function test and coagulation screen would be reasonable.Β 
  • Sarah has a normal Hb of 140 g/L, and her TFTs/coagulation screen are normal.Β 

Imaging

  • Refer for a transvaginal ultrasound (TV US) to exclude local structural causes (e.g. fibroids, polyps)
  • Sarah’s TV US 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):

  • Hysteroscopy: for direct visualisation of the uterine cavity
  • Endometrial biopsy for histological examination (e.g. if abnormal endometrial thickness, intermenstrual bleeding or postmenopausal bleeding)
  • Vaginal swabs (if considering STI)

Hysteroscopy and endometrial biopsy would require a referral to gynaecology.Β 


Diagnosis and management

The examination and investigations so far have not identified an obvious cause for Sarah’s heavy menstrual bleeding. In this instance, initial management can be offered in primary care to see if this improves symptoms.Β 

If Sarah’s symptoms do not improve despite initial treatment, a referral to gynaecology should be made.

First-line treatment

The recommended first-line treatment for heavy menstrual bleeding is usually the intrauterine system (Mirena coil).

This is a T-shaped device inserted into the uterus via the cervical os via a simple outpatient/community procedure. It secretes a progestin hormone (levonorgestrel) to thin the endometrial lining and keep it thin. In some women, it will also prevent ovulation. The IUS is licensed for use in heavy menstrual bleeding, contraception, and endometrial protection in patients using hormone replacement therapy.

The IUS may also help with Sarah’s dysmenorrhoea.

However, in Sarah’s case, she is actively trying to get pregnant. A Mirena will be unsuitable as it is contraceptive.Β 

Second-line treatment

  • Combined oral contraceptive pill (COCP): reduces menstrual bleeding and helps with dysmenorrhoea. The combined oral contraceptive pill can be taken continuously (without a break), so patients don’t have to experience monthly bleeding. This method also provides contraception. Not everyone may be eligible for it based on their medical history.
  • Tranexamic acid (anti-fibrinolytic): ~50% reduction in blood loss – is used before or just before the period.Β 
  • 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 and can be taken with tranexamic acid.Β 

Third line treatment

  • Norethisterone (15 mg) daily from days 5 to 26 of the menstrual cycle. Like the COCP and tranexamic acid, not all patients may be medically eligible to receive norethisterone. Norethisterone may interfere with the menstrual cycle and is not an appropriate option for Sarah, who hoping to conceive.

Combined hormonal contraception would not be suitable as Sarah wishes to conceive. This is also the case for mefenamic acid, as there is evidence NSAIDs may interfere with ovulation.

Therefore, tranexamic acid is an appropriate choice for Sarah.

If medical treatment of HMB has failed or co-morbidities make medical management inappropriate, the patient should be referred to secondary care. Further investigations and surgical management may be considered.

Surgical management of HMB depends on the underlying pathology, co-morbidities (including fitness for surgery) and desire for future pregnancies. Options include:

  • Hysteroscopy with polypectomy (to remove any polyps) or fibroidectomy (may be attempted if submuscosal)
  • Endometrial ablation
  • Uterine artery embolisation (UAE)
  • MyomectomyΒ 
  • Hysterectomy

Reviewer

Dr Ashley Jefferies

Community Sexual and Reproductive Health Registrar


References

  • NICE CKS. Menorrhagia (heavy menstrual bleeding). Published in 2023. Available from: [LINK]
  • NICE Guideline. Heavy menstrual bleeding: assessment and management. Published in 2018. Available from: [LINK]

 

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