Heavy (or Prolonged) Menstrual Bleeding(HMB)

Menstruation (also known as a period) is the regular discharge of blood and mucosal tissue from the inner lining of the uterus through the vagina. The menstrual cycle is the result of rise and fall of hormones, estrogen and progesterone from ovaries which prepare the uterine lining for pregnancy. Menstruation is triggered by falling hormone levels and is a sign that pregnancy has not occurred.

The first period, a point in time known as menarche, usually begins between the ages of 12 and 15. With the onset of menstruation, the young girl becomes capable of reproduction. The typical length of time between the first day of one period and the first day of the next is 21 to 45 days in young women. In adults, the range is between 24 and 31 days with the average being 28 days. Bleeding usually lasts around 2 to 7 days. Periods stop during pregnancy and typically do not resume during the initial months of breastfeeding. Menstruation, and with it the possibility of pregnancy, ceases after menopause, which usually occurs between 45 and 55 years of age.

In a normal menstrual cycle, a person loses an average of 2 to 3 tablespoons (35 to 40 milliliters) of blood over four to eight days. If a woman loses more than 5 to 6 tablespoons (approximately 80 milliliters) of blood during her period, this is called heavy or prolonged menstrual bleeding. This can lead to a problem called anemia which can cause fatigue, weakness, and other symptoms.

Causes of HMB

The most common causes of excessive menstrual bleeding are:

• Not ovulating every month (called “anovulation”)
• Having abnormal tissue in the uterus, such as polyps, fibroids, or adenomyosis
• Having a condition that increases bleeding throughout the body (for example, a bleeding disorder)

Anovulation: Anovulation occurs when the ovaries do not produce and release an egg (ovulate) every month. This causes the menstrual period to be irregular or absent. Anovulation is common in adolescents soon after menstruation starts and in people who are near menopause (perimenopause). Most girls/women with polycystic ovary syndrome (PCOS) do not ovulate regularly.

Abnormal tissue in the uterus Noncancerous growths in the uterus can cause heavy menstrual bleeding. The most common noncancerous growths are:

• Polyps, which are small, grape-like growths of the lining (cavity) of the uterus
• Fibroids
• Adenomyosis, in which uterine lining tissue grows into the muscular wall of the uterus
• Overgrowth of the lining of the uterus (called endometrial hyperplasia), which can be a precursor to uterine cancer

Increased bleeding tendency due to deficiency of clotting factors such as Hemophilia and Von Willebrand disease, low platelet count(thrombocytopenia) or taking medications like anticoagulant (blood thinner), such as warfarin or apixaban or a related medication , aspirin, etc

Medical conditions like thyroid dysfunction, chronic kidney or liver dysfunction too may cause heavy menstruation.

Symptoms of Heavy Or Prolonged Menstrual Bleeding

People with heavy or prolonged menstrual bleeding typically have one or more of the following:

• Soak through a pad or tampon every one to three hours on the heaviest days of the period
• Have bleeding for more than seven days
• Need to use both pads and tampons at the same time due to heavy bleeding
• Need to change pads or tampons during the night
• Pass blood clots larger than 1 inch (approximately 2.5 centimeters)
• Iron deficiency anemia

Bleeding this heavily can be serious or even life threatening.

Diagnosis of HMB

If one has heavy menstrual bleeding, it is advisable to visit a gynaecologist for evaluation and appropriate management.

A physical examination, which may include a pelvic exam will be performed.

They might recommend tests based on the examination findings.

1.Blood tests to look for:

• Anemia like CBC, peripheral smear, iron profile,
• Thyroid disease(Thyroid function tests)
• Bleeding disorders like Prothrombin Time, APTT, Coagulation factor, etc
• Liver Function Tests and Renal Function Test
• Pregnancy test to rule out causes like miscarriage, ectopic pregnancy, molar pregnancy.

2.Abdomino: pelvic ultrasound scan: It can detect endometrial polyps and Fibroids.

3.Endometrial biopsy i.e. biopsy of inner lining of uterus.

4.Hysteroscopy This test uses a small scope(camera) to look inside the uterus.

This may be performed in the doctor’s office or in an operating room.

Medical Treatment fro HMB

The treatment will depend on:

• The cause of bleeding
• Patient preferences
• Whether one wants to prevent pregnancy
• Whether one desires pregnancy in future

Medical management will be tried first unless polyps or fibroids are detected during evaluation, in which case surgery will be indicated.

Medications include:

Hormonal birth control methods:

For women with HMB who do not want to get pregnant, hormonal birth control are a good option. Options include the pill, skin patch, vaginal ring, shot, and hormonal intrauterine device (IUD). These treatments reduce bleeding during menstrual period. They also reduce cramps and pain during your period. The pill, patch and ring provide hormone free week during which menstruation occurs but may be taken without a break week for 2—3 months to reduce bleeding and cramps. This strategy is called “continuous dosing.”

Progestin pills

Progestins like Norethindrone acetate or Medroxyprogesterone acetate pills are also an option for people who do not ovulate regularly. They may be prescribed for use 10 to 14 days each month or continuously. This treatment helps to make the lining of the uterus thinner, reducing or even eliminating bleeding.

Hormonal intrauterine device(MIRENA, LILETTA)

There are IUDs that slowly release a hormone, progestin, into the uterus. They do not contain estrogen. They can be used to both prevent pregnancy and reduce menstrual bleeding for up to eight years. The most common side effect of the hormonal IUD is irregular bleeding; this is usually light bleeding or spotting which improves after the first few months after IUD placement

Shot

Depot medroxyprogesterone acetate (Depo-Provera) is a long-acting form of a progesterone-like hormone, taken once every three months. This treatment prevents pregnancy and reduces heavy menstrual bleeding. The most common side effect of medroxyprogesterone acetate is bleeding and spotting, particularly during the first few months. Many people completely stop having bleeding after using this treatment for one year.

Antifibrinolytic medicines

Antifibrinolytic medicines, such as tranexamic acid can help to slow menstrual bleeding quickly. These medicines work by helping the blood clotting system. The advantages of over other medical treatments are:

• The medicine slows bleeding quickly (within two to three hours)
• Need to take the medicine only a few days each month
• The medicines do not affect chances of becoming pregnant

Hormonal birth control pills and antifibrinolytic medicines should not be taken together as the risk of blood clots, stroke, and heart attack is possibly increased when taken together.

Nonsteroidal anti-inflammatory drugs (NSAIDs)

NSAIDS such as ibuprofen, naproxen and mefenamic acid can help reduce menstrual bleeding and menstrual cramps. They are inexpensive, have few side effects, and reduce pain and bleeding, and need to be taken them only during the menstrual period. NSAIDs may be used in combination with any of the medical treatments discussed here. However, NSAIDs do not reduce bleeding as well as other medical treatments.

Gonadotropin-releasing hormone (GnRH) agonists

GnRH agonists work by “turning off” the ovaries and causing temporary menopause. This treatment might be recommended for people who are waiting to have surgical treatment or are approaching menopause in which case surgery may be avoided. The medicines can be taken for up to six months. Side effects may include hot flashes and vaginal dryness (common symptoms of natural menopause). GnRH agonists are not usually recommended for longer than six months in a row due to the risk of weakened bones when used for long periods of time.

In some cases, GnRH agonists are prescribed along with a combined (estrogen-progestin) birth control pill to limit the side effects such as hot flashes and weakening of the bones, while also reducing heavy bleeding. When used together, these medications can be taken for up to two years.

Surgery for HMB

Presence of polyps or fibroids will necessitate surgical treatment.

• Polypectomy can be performed during hysteroscopy.
• Myomectomy(removal of fibroids) may be performed by laparoscopy(key hole), laparotomy(open) or via hysteroscopy depending on the size and location in the uterus. Fibroids may also be treated by cutting off the blood supply(stream_context_get_defaultUterine Artery Embolization)
• Endometrial ablation: Endometrial ablation is a treatment that destroys or removes most of the lining of the uterus using rollerball, monopolar or bipolar loop electrode, thermal fluid, microwave or bipolar radiofrequency electrical energy, laser thermotherapy, and cryoablation. This can reduce heavy menstrual bleeding or stop menstrual bleeding altogether. It is not a good option if one desires pregnancy in the future. The treatment can be done in the office or as a day surgery. After the treatment, some cramping, vaginal discharge, and nausea may occur. One can go back to work or school the following day.
• Hysterectomy Hysterectomy is a major surgery that removes the uterus. It may be carried out by laparoscopy or laparotomy or through the vaginal route. This is a permanent treatment that cures heavy menstrual bleeding. It should be performed only when conservative treatments fail since it is associated with longer period of recovery, complications like injury to surrounding organs like urinary bladder, ureter, intestines etc. and psychological upset due to loss of an organ and sense of loss of feminity. Pregnancy is not possible after hysterectomy.

Which treatment is right for me?

In most cases, one may start with medications like Nonsteroidal anti-inflammatory or Antifibrinolytic medicines, especially in young girls and women desiring pregnancy and if HMB is associated with pain.

If pregnancy is not desired in near future, hormonal birth control method, hormonal IUD, progestin pills, or progestin shots are a good option.

If the woman has completed child bearing, she can use any of the medical treatments described above. Hormonal birth control (including the IUD) and antifibrinolytic medicines are probably the most effective medical treatments.

If medical management has failed or not suitable or compliance is an issue, surgery may be recommended.