Heavy Menstrual Bleeding : Management in Primary Care

Heavy Menstrual Bleeding – Management in Primary Care

Bim Williams

Consultant Gynaecologist

13th October 2015

Table of content

1. Definition

2. Causes/FIGO classification

3. History

4. Examination

5. Treatment

6. When to refer to secondary care

7. Reference

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Heavy Menstrual Bleeding

❑ Definition

❑ Causes

❑ Investigation

❑ Treatment

❑ When to refer

❑ Case Studies

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 What Is Normal Menstruation?

❑ Most menstrual cycles 22 – 35 days

❑ Normal menstrual flow 3 – 7 days

❑ Menstrual flow <  80ml

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Abnormal Uterine Bleeding

❑ Heavy menstrual bleeding (HMB)

❑ Inter – menstrual bleeding (IMB)

❑ Post – coital bleeding (PCB)

❑ Erratic / Irregular cycles

❑ Post-menopausal bleeding (PMB)

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 Heavy Menstrual Bleeding

❑ Excessive menstrual blood loss which interferes with a woman’s physical, social, emotional and / or material quality of life

❑ Can occur alone or in combination with other symptoms

❑ Major impact on a woman’s quality of life

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 Heavy Menstrual Bleeding

❑ Blood loss is subjective

❑ 30% women consider their bleeding excessive

❑ 1 in 20 GP visits  in women aged  30-49

❑ 12% of Gynaecology  referrals (80,000 per year)

❑ 30,000 treatments carried out per year

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 Abnormal Uterine Bleeding – FIGO classification

❑ P – Polyp

❑ A – Adenomyosis

❑ L – Leiomyoma

❑ M – & Hyperplasia

❑ C – Coagulopathy

❑ O – Ovulatory Dysfunction

❑ E – Endometrial Causes

❑ I – Iatrogenic

❑ N – Non classified

M.G. Munro, H.O. Critchley, M.S. Broder, I.S. Fraser

The FIGO classification system (“PALM-COEIN”) for causes of abnormal uterine bleeding in non-gravid women in the reproductive years, including guidelines for clinical investigation

Int J Gynaecol Obstet, 113 (2011), pp. 3–13

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 History

❑ Determine nature of the bleeding

❑ Duration of bleeding

❑ Related symptoms

❑ Impact on quality of life

❑ Other factors-comorbidity

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 Examination / Investigations

❑ Physical Examination

❑ Abdominal & Pelvic Exam

❑ FBC

❑ Clotting Screen**rule out coagulation disorders e.g. (von Willebrand disease) if having HMB since her period started or family history of coagulation disorders

❑ Pelvic Ultrasound Scan**

❑ Hysteroscopy – if history suggests submucosal fibroids, polyps and endometrial pathology

 

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 Treatment Options

 

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 Non-hormonal Treatment

❑ Tranexamic acid

❑ 1g  three to four times daily  for 3-4 days during her period

❑ From onset of heavy bleeding

❑ Stop after 3 cycles if no improvement

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 Non-hormonal Treatment

❑ NSAID’S – Mefenamic acid

❑ 500mg three times daily during heavy bleeding

❑ Relieves dysmenorrhea

❑ Stop after 3 cycles if no improvement

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 Hormonal Treatment

❑ Combined Oral Contraceptive Pill

❑ Oral Progesterone – Cyclical day 5-26 of cycle

❑ Injectable Progesterone-MPA

❑ Levenogesterol Intrauterine System

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 Other Treatments

❑ Esmya – check European Medicine Agency review on Esmya inculding full safety measures and performing liver function test prior to and during use of Esmya for treatment of HMB due to fibroid

 

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 When to refer to secondary care

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Reference