Heavy menstrual bleeding (HMB), previously known as menorrhagia or hematomunia, is a

menstrual period The menstrual cycle is a series of natural changes in hormone production and the structures of the uterus and ovaries of the female reproductive system that makes pregnancy possible. The ovarian cycle controls the production and release of eg ...

with excessively heavy flow. It is a type of

abnormal uterine bleeding Abnormal uterine bleeding is vaginal bleeding from the uterus that is abnormally frequent, lasts excessively long, is heavier than normal, or is irregular. The term "dysfunctional uterine bleeding" was used when no underlying cause was presen ...

(AUB). Abnormal uterine bleeding can be caused by structural abnormalities in the

reproductive tract The reproductive system of an organism, also known as the genital system, is the biological system made up of all the anatomical organs involved in sexual reproduction. Many non-living substances such as fluids, hormones, and pheromones are als ...

, skipping ovulation (

anovulation Anovulation is when the ovaries do not release an oocyte during a menstrual cycle. Therefore, ovulation does not take place. However, a woman who does not ovulate at each menstrual cycle is not necessarily going through menopause. Chronic anovulat ...

), bleeding disorders, hormonal issues (such as

hypothyroidism Hypothyroidism is an endocrine disease in which the thyroid gland does not produce enough thyroid hormones. It can cause a number of symptoms, such as cold intolerance, poor ability to tolerate cold, fatigue, extreme fatigue, muscle aches, co ...

) or cancer of the reproductive tract. Initial evaluation during diagnosis aims at determining pregnancy status, menopausal status, and the source of bleeding. One definition for diagnosing the condition is bleeding lasting more than 7 days or the loss of more than 80 mL of blood. Treatment depends on the cause, severity, and interference with

quality of life Quality of life (QOL) is defined by the World Health Organization as "an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards ...

. Initial treatments often involve

birth control pills Oral contraceptives, abbreviated OCPs, also known as birth control pills, are medications taken by mouth for the purpose of birth control. The introduction of the birth control pill ("the Pill") in 1960 revolutionized the options for contraception, ...

tranexamic acid Tranexamic acid is a medication used to treat or prevent excessive blood loss from major trauma, postpartum bleeding, surgery, tooth removal, nosebleeds, and heavy menstruation. It is also used for hereditary angioedema. It is taken eithe ...

danazol Danazol, sold as Danocrine and other brand names, is a medication used in the treatment of endometriosis, fibrocystic breast disease, hereditary angioedema and other conditions. It is taken oral administration, by mouth. The use of danazol is ...

and

hormonal intrauterine device A hormonal intrauterine device (IUD), also known as an intrauterine system (IUS) with progestogen and sold under the brand name Mirena among others, is an intrauterine device that releases a progestogenic hormonal agent such as levonorgest ...

. Painkillers ( NSAIDs) are also helpful. Surgery can be effective for those whose symptoms are not well-controlled with other treatments. Approximately 53 in 1000 women are affected by AUB.

Signs and symptoms

A normal menstrual cycle is 21–35 days in duration, with bleeding lasting an average of 5 days and total blood flow between 25 and 80 mL. Heavy menstrual bleeding is defined as total menstrual flow >80ml per cycle, soaking a pad/tampon at least every 2 hours, changing a pad/tampon in the middle of the night, or bleeding lasting for >7 days. Deviations in terms of frequency of menses, duration of menses, or volume of menses qualifies as abnormal uterine bleeding. Bleeding in between menses, outside reproductive age, or after sex is also abnormal uterine bleeding and thus requires further evaluation.

Causes

Usually, no causative abnormality can be identified and treatment is directed at the symptom, rather than a specific mechanism. However, there are known causes of abnormal uterine bleeding that need to be ruled out. Most common causes based on the nature of bleeding is listed below followed by the rare causes of bleeding (i.e. disorders of coagulation). * Excessive menses but normal cycle: ** Painless: *** Fibroids (leiomyoma) — fibroids in the wall of the uterus cause increased menstrual loss if they protrude into the central cavity and thereby increase endometrial surface area. *** Coagulation defects (rare) — with the shedding of an endometrial lining's blood vessels, normal

coagulation Coagulation, also known as clotting, is the process by which blood changes from a liquid to a gel, forming a thrombus, blood clot. It results in hemostasis, the cessation of blood loss from a damaged vessel, followed by repair. The process of co ...

process must occur to limit and eventually stop the blood flow. Blood disorders of

platelets Platelets or thrombocytes () are a part of blood whose function (along with the coagulation factors) is to react to bleeding from blood vessel injury by clumping to form a blood clot. Platelets have no cell nucleus; they are fragments of cyto ...

(such as ITP) or

(such as

von Willebrand disease Von Willebrand disease (VWD) is the most common heredity, hereditary coagulopathy, blood-clotting disorder in humans. An acquired form can sometimes result from other medical conditions. It arises from a deficiency in the quality or quantity of ...

) or use of

anticoagulant An anticoagulant, commonly known as a blood thinner, is a chemical substance that prevents or reduces the coagulation of blood, prolonging the clotting time. Some occur naturally in blood-eating animals, such as leeches and mosquitoes, which ...

medication (such as

warfarin Warfarin, sold under the brand name Coumadin among others. It is used as an anticoagulant, anticoagulant medication. It is commonly used to prevent deep vein thrombosis and pulmonary embolism, and to protect against stroke in people who ha ...

) are therefore possible causes, although a rare minority of cases. Platelet function studies can also be used to ascertain platelet function abnormalities ***

Endometrial cancer Endometrial cancer is a cancer that arises from the endometrium (the epithelium, lining of the uterus or womb). It is the result of the abnormal growth of cells (biology), cells that can invade or spread to other parts of the body. The first s ...

(cancer of the uterine lining) — bleeding can also be irregular, in between periods, or after the menopause (

post-menopausal bleeding Vaginal bleeding is any expulsion of blood from the vagina. This bleeding may originate from the uterus, vaginal wall, or cervix. Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductiv ...

or PMB) ***

Endometrial polyp An endometrial polyp or uterine polyp is a tumor, mass in the inner lining of the uterus. They may have a large flat base (Sessility (medicine), sessile) or be attached to the uterus by an elongated wikt:pedicle, pedicle (pedunculated). Peduncul ...

** Painful (i.e. associated with dysmenorrhea): ***

Pelvic inflammatory disease Pelvic inflammatory disease (PID), also known as pelvic inflammatory disorder, is an infection of the upper part of the female reproductive system, mainly the uterus, fallopian tubes, and ovaries, and inside of the pelvis. Often, there may be no ...

***

Adenomyosis Adenomyosis is a medical condition characterized by the growth of cells that proliferate on the inside of the uterus (endometrium) atypically located among the cells of the uterine wall (myometrium), as a result, thickening of the uterus occurs. ...

- extension of the endometrial tissue into the outer muscular wall of the uterus which can cause pain and abnormal bleeds when the endometrium sheds *** Pregnancy related complication (i.e. miscarriage) ***

Endometriosis Endometriosis is a disease in which Tissue (biology), tissue similar to the endometrium, the lining of the uterus, grows in other places in the body, outside the uterus. It occurs in women and a limited number of other female mammals. Endomet ...

* Short cycle (less than 21 days) but normal menses. * Short cycle and excessive menses due to ovarian dysfunction and may be secondary to blockage of blood vessels by tumours. *

Polycystic ovary syndrome Polycystic ovary syndrome, or polycystic ovarian syndrome, (PCOS) is the most common endocrine disorder in women of reproductive age. The name is a misnomer, as not all women with this condition develop cysts on their ovaries. The name origin ...

. * Systemic causes: thyroid disease, excessive emotional/physical stress. *

Sexually transmitted infection A sexually transmitted infection (STI), also referred to as a sexually transmitted disease (STD) and the older term venereal disease (VD), is an infection that is Transmission (medicine), spread by Human sexual activity, sexual activity, e ...

. * Copper intrauterine device

Pathophysiology

HMB is associated with increased omega-6 AA in uterine tissues. The endometrium of people with HMB have higher levels of prostaglandin (E2, F2alpha and others) when compared with women with normal menses. It is thought that prostaglandins are a by product of omega 6 build up. Furthermore, prostaglandins have been found to trigger abnormal, painful uterine contractions, making it a source for targeted therapy.

Diagnosis

Diagnosis is largely achieved by obtaining a complete medical history followed by physical exam and

vaginal ultrasonography Vaginal ultrasonography is a medical ultrasonography that applies an ultrasound transducer (or "probe") in the vagina to visualize organs within the pelvic cavity. It is also called transvaginal ultrasonography because the ultrasound waves go ''a ...

. If need be, laboratory tests or

hysteroscopy Hysteroscopy is the inspection of the uterine cavity by endoscopy with access through the cervix. It allows for the diagnosis of intrauterine pathology and serves as a method for surgical intervention (operative hysteroscopy). Hysteroscope A hyst ...

may be used. The following are a list of diagnostic procedures that medical professionals may use to identify the cause of the abnormal uterine bleeding. * Pelvic and rectal examination to ensure that bleeding is not from lower reproductive tract (i.e. vagina, cervix) or rectum * Pap smear to rule out cervical neoplasia * Pelvic ultrasound scan is the first line diagnostic tool for identifying structural abnormalities. * Endometrial biopsy in those with high risk endometrial cancer or atypical hyperplasia or malignancy. * Sonohysterography to assess for abnormalities within the uterine lining *

Hysteroscopy Hysteroscopy is the inspection of the uterine cavity by endoscopy with access through the cervix. It allows for the diagnosis of intrauterine pathology and serves as a method for surgical intervention (operative hysteroscopy). Hysteroscope A hyst ...

(anaesthesia should be offered) * Thyroid-stimulating hormone and

thyrotropin-releasing hormone Thyrotropin-releasing hormone (TRH) is a hypophysiotropic hormone produced by neurons in the hypothalamus that stimulates the release of thyroid-stimulating hormone (TSH) as well as prolactin from the anterior pituitary. TRH has been used ...

dosage to rule out hypothyroidism In the UK, the

NICE Nice ( ; ) is a city in and the prefecture of the Alpes-Maritimes department in France. The Nice agglomeration extends far beyond the administrative city limits, with a population of nearly one million

Treatment

Treatment depends on identified underlying cause and varies between medication, radiation, and surgery. Heavy periods at

menarche Menarche ( ; ) is the first menstrual cycle, or first menstruation, menstrual bleeding, in female humans. From both social and medical perspectives, it is often considered the central event of female puberty, as it signals the possibility of fe ...

and

menopause Menopause, also known as the climacteric, is the time when Menstruation, menstrual periods permanently stop, marking the end of the Human reproduction, reproductive stage for the female human. It typically occurs between the ages of 45 and 5 ...

may settle spontaneously (the menarche being the start and menopause being the cessation of periods). If the degree of bleeding is mild, all that may be sought is the reassurance that there is no sinister underlying cause. If anemia occurs due to bleeding then

iron Iron is a chemical element; it has symbol Fe () and atomic number 26. It is a metal that belongs to the first transition series and group 8 of the periodic table. It is, by mass, the most common element on Earth, forming much of Earth's o ...

tablets may be used to help restore normal

hemoglobin Hemoglobin (haemoglobin, Hb or Hgb) is a protein containing iron that facilitates the transportation of oxygen in red blood cells. Almost all vertebrates contain hemoglobin, with the sole exception of the fish family Channichthyidae. Hemoglobin ...

levels.

The first line treatment option for those with HMB and no identified pathology, fibroids less than 3 cm in diameter, and/or suspected or confirmed adenomyosis is the levonorgestrel-releasing intrauterine system (LNG-IUS). Clinical trial evidence suggests that the LNG-IUS may be better than other medical therapy in terms of HMB and quality of life. Usually, oral combined contraceptive or progesterone only pills may be taken for a few months, but for longer-term treatment the alternatives of injected Depo Provera or the more recent

progesterone Progesterone (; P4) is an endogenous steroid and progestogen sex hormone involved in the menstrual cycle, pregnancy, and embryogenesis of humans and other species. It belongs to a group of steroid hormones called the progestogens and is the ma ...

releasing

IntraUterine System A hormonal intrauterine device (IUD), also known as an intrauterine system (IUS) with progestogen and sold under the brand name Mirena among others, is an intrauterine device that releases a progestogenic hormonal agent such as levonorgestrel ...

(IUS) may be used. In particular, an oral contraceptive containing estradiol valerate and dienogest may be more effective than tranexamic acid, NSAIDs and IUDs. Fibroids may respond to hormonal treatment, and if they do not, then radiation or surgical removal may be required. In the UK, regarding hormonal treatment, the NICE guidelines states that: "No evidence was found on MRI-guided transcutaneous focused ultrasound for uterine fibroids nor for the progestogen-only pill, injectable progestogens, or progestogen implants." Progestogen pills, independently if taken in a short or long course, are not as effective at reducing menstrual blood loss as LNG-IUS or tranexamic acid. Tranexamic acid treatments, which reduce bleeding by inhibiting the clot-dissolving enzymes, appear to be more effective than

anti-inflammatory Anti-inflammatory is the property of a substance or treatment that reduces inflammation, fever or swelling. Anti-inflammatory drugs, also called anti-inflammatories, make up about half of analgesics. These drugs reduce pain by inhibiting mechan ...

treatment like NSAIDs, but are less effective than LNG-IUS.

Tranexamic acid Tranexamic acid is a medication used to treat or prevent excessive blood loss from major trauma, postpartum bleeding, surgery, tooth removal, nosebleeds, and heavy menstruation. It is also used for hereditary angioedema. It is taken eithe ...

tablets may reduce loss by up to 50%. This may be combined with hormonal medication previously mentioned. NSAIDs are also used to reduce heavy menstrual bleeding by an average of 20-46% through inhibiting the production of prostaglandins. For this purpose, NSAIDs are taken for only 5 days of the menstrual cycle, limiting their most common adverse effect of

dyspepsia Indigestion, also known as dyspepsia or upset stomach, is a condition of impaired digestion. Symptoms may include upper abdominal fullness, heartburn, nausea, belching, or upper abdominal pain. People may also experience feeling full earlier ...

In the UK, NICE guidelines says that for individuals with HMB and no identified pathology or fibroids less than 3 cm in diameter who do not wish to have pharmacological treatment and who do not want to conserve their fertility, surgical options could be considered as a first-line treatment option. Options include a hysterectomy and second generation endometrial ablation, with hysterectomy being more effective than second generation endometrial ablation. A definitive treatment for heavy menstrual bleeding is to perform

hysterectomy Hysterectomy is the surgical removal of the uterus and cervix. Supracervical hysterectomy refers to removal of the uterus while the cervix is spared. These procedures may also involve removal of the ovaries (oophorectomy), fallopian tubes ( salpi ...

(removal of the uterus). The risks of the procedure have been reduced with measures to minimize the risk of

deep vein thrombosis Deep vein thrombosis (DVT) is a type of venous thrombosis involving the formation of a blood clot in a deep vein, most commonly in the legs or pelvis. A minority of DVTs occur in the arms. Symptoms can include pain, swelling, redness, and enl ...

after surgery, and the switch from the front abdominal to vaginal approach greatly minimizing the discomfort and recuperation time for the patient; however extensive fibroids may make the womb too large for removal by the vaginal approach. Small fibroids may be dealt with by local removal (

myomectomy Myomectomy, sometimes also called fibroidectomy, refers to the surgical removal of uterine leiomyomas, also known as fibroids. In contrast to a hysterectomy, the uterus remains preserved and the woman retains her reproductive potential. It still ...

). A further surgical technique is

endometrial ablation Endometrial ablation is a surgical procedure that is used to remove ( ablate) or destroy the endometrial lining of the uterus. The goal of the procedure is to decrease the amount of blood loss during menstruation (periods). Endometrial ablation i ...

(destruction) by the use of applied heat ( thermoablation). The effectiveness of endometrial ablation is probably similar to that of LNG‐IUS but the evidence is uncertain if hysterectomy is better or worse than LNG-IUS for improving HMB.

Medications

These have been ranked by the UK's

National Institute for Health and Clinical Excellence The National Institute for Health and Care Excellence (NICE) is an executive non-departmental public body of the Department of Health and Social Care. As the national health technology assessment body of England, it is responsible for j ...

: * First line ** Intrauterine device with progesterone * Second Line **

an antifibrinolytic agent **

Nonsteroidal anti-inflammatory drugs A nonsteroidal compound is a drug that is not a steroid nor a steroid derivative. Nonsteroidal anti-inflammatory drugs (NSAIDs) are distinguished from corticosteroids as a class of anti-inflammatory agents. List of nonsteroidal steroid receptor mod ...

(NSAIDs). **

Combined oral contraceptive pill The combined oral contraceptive pill (COCP), often referred to as the birth control pill or colloquially as "the pill", is a type of birth control that is designed to be Oral administration, taken orally by women. It is the oral form of combi ...

s to prevent proliferation of the endometrium * Third line ** Oral progestogen (e.g.

norethisterone Norethisterone, also known as norethindrone and sold under the brand name Norlutin among others, is a progestin medication used in birth control pills, menopausal hormone therapy, and for the treatment of gynecological disorders. The medicatio ...

), to prevent proliferation of the endometrium ** Injected progestogen (e.g. Depo provera) * Other options ** CancerRisks

Gonadotropin-releasing hormone agonist A gonadotropin-releasing hormone agonist (GnRH agonist) is a type of medication which affects gonadotropins and sex hormones. They are used for a variety of indications including in fertility medicine and to lower sex hormone levels in the tre ...

Surgery

Dilation and curettage Dilation (or dilatation) may refer to: Physiology or medicine * Cervical dilation, the widening of the cervix in childbirth, miscarriage etc. * Coronary dilation, or coronary reflex * Dilation and curettage, the opening of the cervix and s ...

(D&C) is not recommended for cases of simple heavy menstrual bleeding, having a reserved role if a spontaneous abortion is incomplete *

Endometrial ablation Endometrial ablation is a surgical procedure that is used to remove ( ablate) or destroy the endometrial lining of the uterus. The goal of the procedure is to decrease the amount of blood loss during menstruation (periods). Endometrial ablation i ...

is not recommended for women with active or recent genital or pelvic infection, known or suspected endometrial hyperplasia or malignancy. *

Uterine artery embolization Uterine artery embolization (UAE, uterine fibroid embolization, or UFE) is a procedure in which an interventional radiologist uses a catheter to deliver small particles that block the blood supply to the uterine body. The procedure is primarily do ...

(UAE) is a common treatment with the etiology of a leiomyoma. The rate of serious complications is comparable to that of

; however, UAE presents an increased risk of minor complications and requiring surgery within two to five years. * Hysteroscopic

is a minimally invasive surgical procedure to remove leiomyomas (otherwise known a
fibroids
. Though a safe and effective mode of treating for menstrual disorders but it is unclear whether or not it is beneficial for treating infertility. *

Hysterectomy Hysterectomy is the surgical removal of the uterus and cervix. Supracervical hysterectomy refers to removal of the uterus while the cervix is spared. These procedures may also involve removal of the ovaries (oophorectomy), fallopian tubes ( salpi ...

is a surgical procedure consisting of the full removal of the

uterus The uterus (from Latin ''uterus'', : uteri or uteruses) or womb () is the hollow organ, organ in the reproductive system of most female mammals, including humans, that accommodates the embryonic development, embryonic and prenatal development, f ...

, and can include the removal of fallopian tubes (otherwise known as the uterine tubes), cervix and ovaries. In the UK the use of hysterectomy for heavy menstrual bleeding has been almost halved between 1989 and 2003. This has a number of causes: better medical management, endometrial ablation and particularly the introduction of IUS which may be inserted in the community and avoid the need for specialist referral; in one study up to 64% of women cancelled surgery.

Complications

Previous studies have suggested a nontrivial reduction in the quality of life in individuals with HMB; however, there is no single metric that has been shown to be specific enough to measure health-related quality of life in individuals with HMB. HMB can take a significant toll on the physical, psychological, and social aspects of individuals' lives. For example, a large, cross-sectional study in the United States identified significant associations between HMB and lower employment rates, lost earnings, and a lower self-rating of overall health compared to the general population. Physical and social issues, including performance of house work, life causing embarrassment, and social life, have also been identified as significant reasons why individuals with HMB seek help. While the main impacts of HMB are primarily physical and social, previous studies have also identified an inverse relationship between HMB and psychological scores. Aside from the social distress of dealing with a prolonged and heavy period, over time the blood loss may prove to be greater than the body iron reserves or the rate of blood replenishment, leading to

anemia Anemia (also spelt anaemia in British English) is a blood disorder in which the blood has a reduced ability to carry oxygen. This can be due to a lower than normal number of red blood cells, a reduction in the amount of hemoglobin availabl ...

. Symptoms attributable to the anemia may include shortness of breath, tiredness, weakness, tingling and numbness in fingers and toes, headaches, depression, becoming cold more easily, and poor concentration.

Research

Both the levonorgestrel-releasing intrauterine system and medications (tranexamic acid, mefenamic acid, contraceptive pill with combined oestrogen–progestogen or progesterone alone) seem to be equally effective in reducing the impact of HMB.

References

External links

{{Authority control Menstrual disorders