What is considered excessive uterine bleeding?

Excessive Uterine Bleeding Definition and Management

Excessive uterine bleeding, also known as heavy menstrual bleeding (HMB), is defined as menstrual blood loss exceeding 80 mL per cycle that interferes with a woman's physical, emotional, social wellbeing and quality of life. 1 This objective definition is often supplemented by subjective patient experience, as women frequently describe the loss or reduction of daily activities as more important than the actual volume of blood loss 2.

Clinical Characteristics of Excessive Uterine Bleeding

• Duration: Periods lasting more than 7 days 3
• Volume: Blood loss greater than 80 mL per cycle 3
• Impact: Interference with physical, emotional, and social wellbeing 1
• Prevalence: Affects up to 14% of women of reproductive age, with prevalence increasing to 24% in women aged 36-40 years 4, 3

Classification Using PALM-COEIN System

The American College of Obstetricians and Gynecologists (ACOG) recommends using the PALM-COEIN classification system to describe uterine bleeding abnormalities in women of reproductive age 5:

• Structural causes (PALM):

  • Polyp
  • Adenomyosis
  • Leiomyoma (submucosal or other myoma)
  • Malignancy and hyperplasia

• Non-structural causes (COEIN):

  • Coagulopathy
  • Ovulatory dysfunction
  • Endometrial
  • Iatrogenic
  • Not yet classified

Diagnostic Approach

1. Initial laboratory tests:

   • Complete blood count to assess for anemia
   • Pregnancy test (β-hCG)
   • Thyroid-stimulating hormone and prolactin levels 5

2. Imaging:

   • Transvaginal ultrasonography (first-line) 3
   • Saline infusion sonohysterography (96-100% sensitivity) for evaluating intracavitary lesions 5, 4
   • Hysteroscopy for direct visualization of endometrial cavity 5

3. Tissue sampling:

   • Endometrial biopsy for women ≥35 years with recurrent anovulation
   • Endometrial biopsy for women <35 years with risk factors for endometrial cancer
   • Endometrial biopsy for women with excessive bleeding unresponsive to medical therapy 4

Management Options

Medical Treatment

1. Hormonal options:

   • Levonorgestrel-releasing intrauterine system (LNG-IUS) - most effective medical treatment 6, 3
   • Combined hormonal contraceptives - regulate cycles and reduce blood loss 6, 4
   • Progestin-only contraceptives - effective for menorrhagia 6
   • Cyclic oral progestins (21 days per month) 4, 3

2. Non-hormonal options:

   • Tranexamic acid - FDA-approved for ovulatory bleeding 4
   • Nonsteroidal anti-inflammatory drugs (NSAIDs) during days of bleeding 6, 4
   • Iron supplementation for patients with iron-deficiency anemia 3

Surgical Treatment

When medical management fails or is contraindicated:

1. Uterine-preserving options:

   • Endometrial ablation techniques 4, 3
   • Polypectomy or fibroidectomy when structural causes are identified 4
   • Uterine artery embolization for fibroids 4

2. Definitive treatment:

   • Hysterectomy - provides highest satisfaction rates but has potential surgical morbidity 4, 2

Special Considerations

• Up to 20% of women with heavy menstrual bleeding may have an underlying inherited bleeding disorder 1
• Women with ovulatory dysfunction should be evaluated for potential causes including PCOS, diabetes, thyroid dysfunction, and hyperprolactinemia 5, 4
• Chronic anovulation increases risk of endometrial cancer due to prolonged unopposed estrogen stimulation 4

Treatment Algorithm

1. First-line: LNG-IUS or combined hormonal contraceptives (if contraception also desired) 6, 3
2. Alternative first-line: Tranexamic acid or NSAIDs (if hormonal methods contraindicated) 3
3. Second-line: Combination of hormonal and non-hormonal treatments 1
4. Third-line: Surgical management when medical therapy fails 5, 4

By understanding the definition and management options for excessive uterine bleeding, clinicians can provide appropriate care that improves patients' quality of life while addressing the underlying causes of this common condition.