What is the workup and treatment for heavy menstrual bleeding?

Workup and Treatment for Heavy Menstrual Bleeding

The levonorgestrel-releasing intrauterine system (LNG-IUS) is the first-line medical therapy for heavy menstrual bleeding (HMB), followed by combined hormonal contraceptives as second choice for women not seeking pregnancy. 1

Initial Workup

History and Physical Examination

• Assess bleeding pattern: presence of clots ≥1 inch diameter, "flooding" (changing pad/tampon more frequently than hourly), duration of bleeding 2
• Evaluate for anemia symptoms: fatigue, shortness of breath, dizziness
• Review medication history: anticoagulants, hormonal therapies
• Family history of bleeding disorders
• Complete pelvic examination to identify:
  • Uterine size, shape, and mobility
  • Presence of fibroids or other pelvic masses
  • Cervical abnormalities

Laboratory Tests

• Complete blood count to assess for anemia
• Ferritin levels (low ferritin is predictive of HMB) 2
• Pregnancy test for reproductive-age women
• Coagulation studies if personal/family history of bleeding disorders
• Thyroid function tests to rule out thyroid dysfunction

Imaging

• Pelvic ultrasound (transvaginal and transabdominal) - first-line imaging to evaluate:
  • Endometrial thickness
  • Uterine fibroids
  • Adenomyosis
  • Endometrial polyps
• Sonohysterography or hysteroscopy for better visualization of endometrial polyps and submucosal fibroids 3
• Endometrial biopsy for women >40 years or with risk factors for endometrial hyperplasia/cancer 3

Treatment Algorithm

First-Line Medical Therapy

1. Levonorgestrel-releasing intrauterine system (LNG-IUS)

   • Most effective medical treatment, reducing menstrual blood loss by 71-95% 4, 1
   • Provides contraception while treating HMB
   • Effective for HMB due to endometrial dysfunction and some structural causes (fibroids, adenomyosis) 1

2. Combined hormonal contraceptives (oral or transvaginal)

   • Second-line option for women who cannot use or decline LNG-IUS 1
   • Reduces bleeding and provides contraception

3. Tranexamic acid

   • Nonhormonal option that reduces bleeding by inhibiting fibrinolysis
   • Taken only during menstruation
   • Reduces menstrual blood loss by 20-60% 3
   • Caution: avoid in women with history of thromboembolism

4. Nonsteroidal anti-inflammatory drugs (NSAIDs)

   • Reduces bleeding by 20-40% 3
   • Particularly useful for women with dysmenorrhea
   • Less effective than other options but may be sufficient for marginally increased blood loss 1

Second-Line Medical Therapy

1. Oral progestogens

   • Long-course (≥3 weeks per cycle) is more effective than short-course treatment 1
   • Cyclic progestogens are not significantly effective in ovulatory women 3

2. GnRH agonists and antagonists

   • Effective for reducing bleeding and fibroid volume 4
   • Associated with hypoestrogenic side effects (hot flashes, bone mineral density loss)
   • Usually used short-term or with add-back hormone therapy 4

Surgical Options (when medical management fails)

1. Hysteroscopic procedures

   • Hysteroscopic myomectomy for pedunculated submucosal fibroids <5cm 4
   • Endometrial ablation for women with completed childbearing

2. Uterine artery embolization (UAE)

   • Effective for fibroids causing HMB
   • Uterus-preserving option with 71-95% reduction in menstrual blood loss 4

3. Myomectomy (laparoscopic or open)

   • For women with symptomatic fibroids who wish to preserve fertility

4. Hysterectomy

   • Definitive treatment for HMB
   • Consider when other treatments have failed and fertility preservation is not desired

Special Considerations

Anticoagulant-Related HMB

• Reassess indication for anticoagulation and adjust dosage if appropriate 4
• LNG-IUS may be particularly beneficial in this population 4
• Avoid tranexamic acid in patients on anticoagulants due to thrombosis risk 4

Bleeding Disorders

• HMB with flooding and/or prolonged menses, especially with personal/family history of bleeding, warrants hematology referral 2
• Hemostatic therapy may be necessary alongside hormonal treatments 2

Fibroids

• Treatment depends on size, location, and number of fibroids
• Submucosal fibroids: hysteroscopic myomectomy is first-line treatment 4
• Multiple or large fibroids: consider UAE, myomectomy, or hysterectomy based on fertility desires 4

Common Pitfalls and Caveats

• Relying solely on patient's subjective assessment of blood loss is unreliable - objective measures should be used 3
• Short-course progestogens are commonly prescribed but have limited efficacy 1
• Delaying endometrial sampling in women >40 years with HMB may miss endometrial pathology 3
• Failing to screen for coagulation disorders in women with significant HMB may miss underlying conditions requiring specific management 2
• Tranexamic acid and NSAIDs should be avoided in women with history of thromboembolism or cardiovascular disease 4

By following this structured approach to diagnosis and treatment, most women with HMB can achieve significant improvement in symptoms and quality of life without resorting to major surgery.