Heavy Menstrual Bleeding: A Comprehensive Overview
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A
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Consultant Gynaecologist
Sheffield Teaching Hospitals
NHS FT
Disclosures
•
Honoraria for teaching, travel expenses
and consultancy fees received from:
Medtronic
Hologic Inc
Learning outcomes
1.
Know initial investigations when a
woman first presents with HMB
2.
Know initial treatments when a woman
first presents with HMB
3.
Know when referral to secondary care
is indicated
Why focus on HMB?
•
Affects 1:5 women of reproductive age
•
With 1:20 women contacting their GP
each year
•
Affects a woman’s physical,
psychological and social health and
wellbeing
•
4% experience anxiety
•
67% suffer with depression
Why focus on HMB?
•
HMB in women with obesity or condition
causing unopposed estrogen excess at
risk of endometrial hyperplasia and
cancer
•
Rates of obesity, and therefore
endometrial pathology, are rising
NICE HMB
2018
Where to start
NICE Quality Standards for
HMB QS47
Focused history
•
nature of bleeding
•
duration
•
heaviness
•
frequency
•
regularity/irregularity of periods
•
related symptoms
•
pain
•
tiredness
Focused history
•
impact on quality of life
•
soiling of clothes or bedding
•
quantity of sanitary protection at a time
•
disruption to daily life (unable to go out,
need to leave classroom)
•
other factors that may affect treatment
•
comorbidities
•
previous treatment for HMB
•
fertility requirements
Focused history
Establish symptoms that may indicate
uterine cavity or histological abnormality,
adenomyosis or fibroids
•
intermenstrual bleeding
•
postcoital bleeding
•
pelvic pain
•
pelvic pressure
Investigations
•
F
B
C
•
test for coagulation disorders if HMB
since menarche, personal/FH of
coagulation disorders
•
consider sexual health screening
•
Cytology if due
•
No
indication for TFT, ferritin unless
additional symptoms
NICE HMB
2018
•
No
further
need to
examine or investigate
if no additional
symptoms and low risk
for endometrial
pathology
•
May offer treatment at
this stage
NICE HMB
2018
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enlarged uterus on
examination
•
pelvic mass on
examination
•
pressure symptoms
•
significant dysmenorrhoea
•
unable to otherwise assess
NICE Quality Standards for
HMB QS47
Role of cyclical progestogens
Long course progestogens
•
MPA (10–20 mg daily) or
NET (5 mg tds)
•
days 5–26/month
•
reduced MBL, may be less
effective than TXA, cocp,
LNG-IUS
•
No studies on satisfaction
or QoL
Summary - dose regimes
•
Long cycle regimes definitely better
than short cycle for reducing MBL, so
ignore the BNF!
•
Compliance seems better with
continuous treatment than cyclical
•
NET more effective than MPA at
reducing MBL
Summary - dose regimes
•
LNG-IUS more effective at reducing
overall blood loss than oral treatment
•
IMB less troublesome with long cycles
of oral progestogens than LNG-IUS
Referral to
Secondary
Care
1.
When Hysteroscopy
indicated
2.
Abnormal TVS or TAS
•
endometria polyps
•
submucosal fibroids
<3cm
3.
When pain a significant
factor
4.
Excessive bleeding
5.
Severe anaemia
NICE Quality Standards for
HMB QS47
NICE HMB
2018
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persistent IMB
•
persistent irregular
bleeding
•
infrequent bleeding and
•
obese
•
PCOS
•
Lynch syndrome
•
unsuccessful HMB
treatment
Referral to Secondary Care
Learning outcomes
1.
Know initial investigations when a
woman first presents with HMB
2.
Know initial treatments when a woman
first presents with HMB
3.
Know when referral to secondary care
is indicated
Sources of information
Thank you!
A
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ThermoChoice Sep 05-MG
A detailed exploration of heavy menstrual bleeding (HMB) by Consultant Gynaecologist Mary Connor, highlighting its impact on women's health and well-being. The importance of early investigations, treatments, and referrals, as well as key considerations for women with obesity or estrogen imbalances. Insights from NICE guidelines and the significance of a focused medical history in assessing HMB are also discussed.
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Presentation Transcript
Heavy menstrual bleeding An overview Mary Connor Consultant Gynaecologist Sheffield Teaching Hospitals NHS FT
Disclosures Honoraria for teaching, travel expenses and consultancy fees received from: Medtronic Hologic Inc
Learning outcomes 1. Know initial investigations when a woman first presents with HMB 2. Know initial treatments when a woman first presents with HMB 3. Know when referral to secondary care is indicated
Why focus on HMB? Affects 1:5 women of reproductive age With 1:20 women contacting their GP each year Affects a woman s physical, psychological and social health and wellbeing 4% experience anxiety 67% suffer with depression
Why focus on HMB? HMB in women with obesity or condition causing unopposed estrogen excess at risk of endometrial hyperplasia and cancer Rates of obesity, and therefore endometrial pathology, are rising
NICE HMB 2018 Where to start
NICE Quality Standards for HMB QS47
Focused history nature of bleeding duration heaviness frequency regularity/irregularity of periods related symptoms pain tiredness
Focused history impact on quality of life soiling of clothes or bedding quantity of sanitary protection at a time disruption to daily life (unable to go out, need to leave classroom) other factors that may affect treatment comorbidities previous treatment for HMB fertility requirements
Focused history Establish symptoms that may indicate uterine cavity or histological abnormality, adenomyosis or fibroids intermenstrual bleeding postcoital bleeding pelvic pain pelvic pressure
Investigations FBC test for coagulation disorders if HMB since menarche, personal/FH of coagulation disorders consider sexual health screening Cytology if due No indication for TFT, ferritin unless additional symptoms
NICE HMB 2018 No further need to examine or investigate if no additional symptoms and low risk for endometrial pathology May offer treatment at this stage
NICE HMB 2018 Pelvic ultrasound scan (preferably TVS) enlarged uterus on examination pelvic mass on examination pressure symptoms significant dysmenorrhoea unable to otherwise assess
NICE Quality Standards for HMB QS47
Role of cyclical progestogens Long course progestogens MPA (10 20 mg daily) or NET (5 mg tds) days 5 26/month reduced MBL, may be less effective than TXA, cocp, LNG-IUS No studies on satisfaction or QoL
Summary - dose regimes Long cycle regimes definitely better than short cycle for reducing MBL, so ignore the BNF! Compliance seems better with continuous treatment than cyclical NET more effective than MPA at reducing MBL
Summary - dose regimes LNG-IUS more effective at reducing overall blood loss than oral treatment IMB less troublesome with long cycles of oral progestogens than LNG-IUS
Referral to Secondary Care 1. When Hysteroscopy indicated 2. Abnormal TVS or TAS endometria polyps submucosal fibroids <3cm 3. When pain a significant factor 4. Excessive bleeding 5. Severe anaemia
NICE Quality Standards for HMB QS47
NICE HMB 2018 Hysteroscopy for women at high risk of endometrial pathology persistent IMB persistent irregular bleeding infrequent bleeding and obese PCOS Lynch syndrome unsuccessful HMB treatment
Learning outcomes 1. Know initial investigations when a woman first presents with HMB 2. Know initial treatments when a woman first presents with HMB 3. Know when referral to secondary care is indicated
Thank you! Any questions?
