Roughly 25% of women of reproductive age experience heavy menstrual bleeding (HMB), which refers to menstrual blood loss that is excessive enough to affect their physical, social or emotional quality of life.
That’s according to Dr Yasmin Tan, a gynaecologist with the Women’s Health and Research Institute of Australia, who receives many referrals for these patients.
“I get asked to review patients when they are low in iron and anaemic, for not responding to simple measures, [and for] whether they need further investigations like hysteroscopy or D&C,” she says.
Work up for HMB depends on the associated symptoms, but usually involves bloods and an ultrasound. Checking iron levels and haemoglobin is important.
Pelvic ultrasound should be both transabdominal and transvaginal, and is best done just after the period to ensure you see baseline endometrial thickness.
Heavy bleeding is not always a cause for concern. For example, it’s common for women to “hit their 40s and every now and then get a run of heavy bleeding” as they approach menopause, Dr Tan says, but prolonged or recurrent episodes need appropriate investigation.
When to refer?
In most cases, GPs should refer promptly when pathology is seen on ultrasound. However, Dr Tan notes that “adenomyosis may not need to be reviewed by a specialist if it’s asymptomatic”, that is, not painful, and “only incidental on ultrasound”.
In the absence of pathology on ultrasound or any other red flags for cancer, Dr Tan feels it is reasonable for GPs to treat for a few months before referring refractory cases. She says this is particularly important so as she has unfortunately seen patients with HMB go for a year without referral before ultimately being diagnosed with a malignancy.
“If they are bleeding heavily for a long time, they should be referred so we don’t miss cancer,” Dr Tan says. “I’ve seen patients on months and months of high dose progesterone—12 months later they see me and it’s cancer.”
Treatment options
Treatment options for HMB may be hormonal or non-hormonal, depending on factors including the patient’s age, comorbid risk factors, and their preferences.
“NSAID with or without tranexamic acid is often adequate,” Dr Tan says.
She adds that although high dose progesterone (for example, Primolut) may decrease heavy bleeding in the short term, it should not be used for months and months due to its side effect profile.
The Mirena intrauterine system remains the treatment of choice for many women, although for those preferring an oral option, the new drospirenone pill has recently entered the market. Dr Tan says it is particularly useful for women in their 40s in whom an oestrogen-containing pill is not recommended. It provides ovulation suppression and decreases blood loss whilst still being a lower dose progestogen without the cardiovascular thrombotic side effects of oestrogen.
To learn more about managing HMB, register to attend Healthed’s FREE webcast on Tuesday, 4 April, where Dr Yasmin Tan will be speaking.
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