Managing Heavy Menstrual Bleeding
Published: 22 February 2021
Published: 22 February 2021
Heavy menstrual bleeding is the most common type of abnormal uterine bleeding, affecting 25% of women at reproductive age (ACSQHC 2017).
Generally, about 30 to 40 ml (six to eight teaspoons) of blood is lost during each menstruation (RANZCOG 2018). However, what is considered ‘normal’ varies between individuals, making abnormalities difficult to quantify (NHS 2018).
Instead, heavy menstrual bleeding is defined by the Australian Commission on Safety and Quality in Health Care as:
‘Excessive menstrual blood loss which interferes with the woman's physical, emotional, social and material quality of life, and which can occur alone or in combination with other symptoms’ (2017).
Note: The terms ‘dysfunctional uterine bleeding’ and ‘menorrhagia’ are no longer recommended to describe heavy menstrual bleeding (ACSQHC 2017).
Symptoms that may indicate heavy menstrual bleeding include:
(ACSQHC 2017; RANZCOG 2018)
Many patients who experience heavy menstrual bleeding also suffer from severe dysmenorrhoea (period pain) (ACSQHC 2017).
Heavy menstrual bleeding has various causes. In some cases, there may be more than one (ACSQHC 2017).
The International Federation of Gynecology and Obstetrics (FIGO)’s PALM-COEIN system for classifying abnormal uterine bleeding categorises potential causes as either structural (i.e. measurable through imaging or histopathology) or non-structural:
|Structural causes (PALM)||Non-structural causes (COEIN)|
|P - Polyps (about 10% of cases)||C - Coagulopathy|
|A - Adenomyosis||O - Ovulatory|
|L - Leiomyoma (fibroids) (about 30% of cases)||E - Endometrial|
|M - Malignancy or hyperplasia||I - Iatrogenic|
|N - Not yet classified|
(Adapted from ACSQHC 2017; Munro, Critchley & Fraser 2011)
Other causes include:
(Better Health Channel 2017)
Depending on the patient, heavy menstrual bleeding may be diagnosed through:
(ACSQHC 2017; RANZCOG 2018)
Treatment options include:
A hysterectomy is a procedure in which the uterus is surgically removed, permanently stopping menstruation. The cervix, ovaries, fallopian tubes and surrounding tissue may or may not be removed as well (ACSQHC 2017).
Hysterectomy is not recommended as a first-line treatment for heavy menstrual bleeding unless less-invasive options are inappropriate (ACSQHC 2017).
This is because:
In 2017, the Australian Commission on Safety and Quality in Health Care released the Heavy Menstrual Bleeding Clinical Care Standard. This standard aims to ensure that patients experiencing heavy menstrual bleeding receive the least invasive and most effective treatment possible for their individual needs (ACSQHC 2017).
The standard contains eight quality statements:
Patients presenting with heavy menstrual bleeding should undergo a comprehensive assessment. The clinician should take into account:
If clinically appropriate, a bi-manual pelvic examination should be performed in order to identify any masses or an abnormal uterine size.
Depending on the assessment findings, the clinician may recommend additional investigations such as:
Patients should be comprehensively informed about their treatment options, along with their potential risks and benefits. Clinicians should ask patients about their preferences, take their individual situations into account (e.g. culture and religion) and provide information in a clear, understandable form.(ACSQHC 2017)
Pharmaceutical therapy should be offered before considering procedural or surgical interventions. In some cases, medicines are able to effectively treat symptoms on their own. The specific therapy chosen will depend on a variety of patient factors.
In cases where both hormonal and non-hormonal therapy are acceptable, it is recommended that treatments are tried in the following order:
If further investigations are required, patients should be prescribed oral treatment to relieve symptoms until the investigations can be performed.
Patients should receive a transvaginal ultrasound as first-line imaging if structural or histological causes are suspected, for example:
A transabdominal ultrasound is an acceptable but less-accurate alternative if transvaginal ultrasound is inappropriate, unavailable or unwanted by the patient.
Optimal ultrasound timing is between days 5 and 10 of the menstrual cycle, as this allows for the most accurate measurement of endometrial thickness.
The levonorgestrel intra-uterine system is the most effective pharmaceutical treatment for heavy menstrual bleeding and should be offered if clinically appropriate.
Clinical appropriateness is determined by taking into account:
Patients with suspicious clinical findings upon assessment or ultrasound should be referred to a specialist early. Those who should be referred include:
Patients considering surgical intervention should be offered the least invasive option that is clinically appropriate before considering a hysterectomy.
Uterine-preserving alternatives to hysterectomy include:
Hysterectomy may be considered if:
Patients must be provided with balanced information that addresses both the potential benefits and risks of the procedure. They should also be given adequate time to make a decision. Clinicians should ensure they are culturally sensitive when discussing this procedure.
Question 1 of 3
Which one of the following factors is a non-structural cause of heavy menstrual bleeding?
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