Management of

Menorrhagia
(Heavy Menstrual
Bleeding)

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 Definition

 Heavy menstrual bleeding ( menorrhagia )

 is diagnosed when menstrual blood loss is

considered excessive by the woman , interferes with

women’s physical , social emotional , and/ or quality
of life
 Highly subjective and personal issue

 In
research studies-between 60ml and 80ml per
menstruation–not practical in the clinical setting
may be accompanied by other symptoms , such as
menstrual pain ( dysmenorrhoea )

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Normal Menstrual Cycle

•Cycle length
–average 29 days
–Range 21 - 35 days
•Duration of flow
–Average 4 days
–3 to 7 days
•Amount
–Average 35 mls
•Quality– Non-clotting blood , endometrial debris

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 Previously………….
 •In the early 1990s it was estimated that at

least 60% of women presenting with HMB

would have a hysterectomy to treat the
problem , often as a first line.
 •Emotive procedure
 womb and fertility often seen as being part of

a woman’s identity
 undesirable for some people

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 Now………….

 •Things have changed and the number of

hysterectomies is decreasing rapidly.
 •In the UK , aim to be managed by primary

health care
 •Never the less , clinically , hysterectomy Is

associated with a very high satisfaction rate by

those who have undergone the operation

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 Risk Factors

 •While HMB may occur in the presence of

histological abnormality , the association
does not necessarily imply causality

1•Uterine fibroids (30%)

 epidemiological study in the UK found that

site , size and number of fibroids are linked

to the level of MBL

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2•Polyps

3•Blood disorders
von Willebrand disease (vWD)
•13.0-15.4 % in women with menorrhagia
compared with the general population

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4•Thyroid disorders

5 •Endometriosis / Adenomyosis
-usually dysmenorrhoea but two studies have
found that HMB may be a significant
secondary symptom
6•Racial groups

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7•Uterine Pathology?
– Results of 20 observational and diagnostic
studies show that the majority of women with
HMB have no histological abnormality that can
be implicated in causing HMB
–Rare for a woman who has presented with HMB
and has undergone investigations to have an
underlying pre-malignant or malignant condition
-RCOG (Royal College of Obstetricians and Gynaecologists)
•women aged between 35 and 54 years , eight of
every 10,000 women who presented with HMB in
primary care would have endometrial carcinoma.

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8•Dysfunctional uterine bleeding ( bleeding of
endometrial origin )
–No organic cause
–Frequently due to an ovulation
9•Others
–PID
–Malignancy
–IUCD
–Medications ( Tamoxifen , Un apposed
oestrogen treatment )

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 What is our goal ?

 •Heavy menstrual bleeding (HMB) should be

recognized as having a major impact on a
woman’s quality of life , and any intervention
should aim to improve this rather than
focusing on menstrual blood loss.

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How should assess a woman with menorrhagia?

 History and Physical Examination

 •Nature of the bleeding ( flooding , clots

, double padding , etc ) and related

symptoms (anemia)
 •Directed to identify potential pathology
 •Explore women’s perspective , ideas ,

concerns
 .Previous treatments

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 Physical examination if an abnormality is
suspected (e.g. if there is intermenstrual or
postcoital bleeding, or pelvic pain or
pressure) -Recommended before all ;
 - LNG-IUS fittings (levonorgestrel intrauterine system)
 -investigations for structural abnormalities
 -investigations for histological abnormalities

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  Measurement of MBL
 Direct- alkaline haematin
 Accurate and precise
 Impractical
 Little impact on management
 Indirect- Pictorial Blood Loss Assessment
Chart (PBAC)
 Highly variable
 NOT RECOMMENDED ROUTINELY
 SHOULD BE DETERMINED BY PATIENT HERSELF

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 Investigations (Laboratory)

 FBC test - in all women with HMB

 Coagulation profile -if HMB since menarche/

family history
 Serum Ferritin - not routinely
 Hormone testing - not recommended
 Thyroid function test - when signs and

symptoms present

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 Investigations (Structural and Histological)

Ultrasound
 sensitivity 48 - 100%
 specificity 12 - 100%
 better at identifying fibroids than hysteroscopy
 less accurate for identifying polyps or endometrial disease
 should be undertaken in the following circumstances:

 uterus is palpable abdominally

 vaginal examination reveals a pelvic mass of

uncertain origin
 pharmaceutical treatment fails

Hysteroscopy
 when ultrasound results are inconclusive
 to determine the exact location of a fibroid or the exact

nature of the abnormality

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 Investigations (Structural and
Histological)
 Magnetic resonance imaging (MRI)
 Dilatation and curettage

alone should not be used as a diagnostic

tool
 Endometrial biopsy

o persistent intermenstrual bleeding

o in women aged 45 and over
o treatment failure or ineffective treatment

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What advice and counselling should I
give to a woman with menorrhagia?
 
 Discuss…….
 Natural variability and range of menstrual blood
loss and reassure the woman (if appropriate)
 Different treatment options :
 acceptability
 effectiveness of treatments
 adverse effects
 contraception
 implications of treatment on fertility

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 When should I prescribe
pharmaceutical treatment in
women presenting with
menorrhagia?

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Drug treatment

 Drug Treatment Pharmaceutical

treatment (recommended first-
line)
o no symptoms or signs suggestive of
underlying pathology (structural or
histological uterine abnormalities
o are awaiting the results of investigations

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Drug Treatment
If either hormonal or non-hormonal treatments
are acceptable (descending order) :
 levonorgestrel-releasing intrauterine system

(Mirena®) provided long-term (at least 12-

months) use is anticipated
 tranexamic acid or non-steroidal anti-

inflammatory drugs (NSAIDs) or combined oral

contraceptives
 norethisterone (15 mg) daily from days 5 to 26

of the menstrual cycle, or injected long-acting

progestogens ( Depo-Provera®) .

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Drug Treatment

•Levonorgestrel-releasing
intrauterine system (Mirena®)

RCTs reduction between 71%

and 96% -Full benefit of
treatment may not be seen
for 6 months
30% amenorrhoea

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 Drug Treatment
Tranexamic acid
o 1 g (2 X 500 mg tablets) three to

four times daily, from the onset of

bleeding for up to 4 days
o reductions in MBL (29% to 58%)

NSAIDs (mefenamic acid or naproxen)

oreductions in MBL (20% to 49%)
odysmenorrhoea

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Drug Treatment
 COCs
reduction of MBL of 43%
 Oral progestogen

used long-term reduces MBL by 83%

 Etonogestrel implant (Implanon ® )

no licence for the treatment of HMB

 Depot medroxyprogesterone acetate (DMPA)

No evidence
Amenorrhea is a side effect (NICE)

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Drug Treatment

 If
hormonal treatments are not
acceptable to the woman, then either
tranexamic acid or NSAIDs can be used
 GnRH analogue
o prior to surgery
o other treatment options for uterine fibroids,

including surgery or uterine artery embolisation

(UAE), are contraindicated
o ‘ add-back ’ therapy
o amenorrhea rates of 89%

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 What should I do if initial drug
treatment is ineffective in a
woman with menorrhagia? 
 A second pharmaceutical treatment
 Add on another drug rather than immediate

referral to surgery.
 Use of NSAIDs and/or tranexamic acid

should be stopped if it does not improve

symptoms within three menstrual cycles

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 How can I rapidly stop heavy
bleeding, if necessary? 
 Oralnorethisterone, 5 mg three
times daily (licensed use) or, in
very severe cases, 10 mg three
times daily (unlicensed use), then
tapering down to 5 mg three
times daily for a further week

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 Not Recommended 
 Oral progestogens in the luteal phase only
 Danazol (side effects)
 Etamsylate

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 When should I refer?
 Malignancy is suspected
refer urgently (within 2 weeks)
 Significant negative impact on her quality of

life despite adequate trials of pharmaceutical

treatment
 Anemia - not improved despite treatment

(other causes excluded)

make a routine referral.
 Wants to consider surgical options

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Surgical Treatment
 Used as the initial treatment for HMB?
o Unclear
o Endometrial ablation may be offered
o Hysterectomy should not be used as a first

-line treatment solely for HMB

 Whether a pharmaceutical intervention

should always be tried first ?

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Non-hysterectomy or
interventional radiology
 Endometrial ablation
o 1st generation (TCRE, Rollerball)
o 2nd generation (MEA, Inpedence-controlled
bipolar radiofrequency, balloon thermal)
o Affects fertility
o Use of effective contraception following
procedure
o 50% amenorrhoea, 95% satisfaction rate

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Non-hysterectomy or interventional
radiology

Uterine artery embolisation (UAE)

 Fertility is potentially retained

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Non-hysterectomy or interventional
radiology

 Hysteroscopic myomectomy

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Hysterectomy
 Fibroids >3cm + severe impact on QoL
 Desire for amenorrhoea
 Other treatments failed, contraindicated,

declined
 No desire to retain uterus or fertility
 Fully informed women request it

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Hysterectomy
   Route
o First line : Vaginal
o Second line : Abdominal
 Ovaries may also be removed
 100% amenorrhoea
 95% satisfaction rate

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Thank you

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