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Evidence Based Management of Heavy Menstrual Bleeding

Hello, everyone. Today, we’re going to talk about the management of heavy menstrual bleeding. We will start by clarifying our definition of heavy menstrual bleeding and talking a little bit about epidemiology. For the purposes of this video, we’ll skip history taking, physical examination, and investigations, and focus only on the management of heavy menstrual bleeding with a non-organic cause. The management will be broken down into medical and surgical treatments. There are two definitions for having menstrual bleeding– a technical definition and a clinical one. The technical definition found in many research papers, classifies heavy menstrual bleeding as a blood loss of more than 88 mls. Realistically, however, it is very difficult to accurately quantify the exact amount of menstrual blood lost for each woman. So clinically, having menstrual bleeding is a subjective matter that can be gauged by the extent to which the woman’s physical, social, and emotional quality of life is impacted. Heavy menstrual bleeding is a very common problem amongst women, and studies show that 10% to 35% of women report having heavy menstrual bleeding during some point of their lives. 5% of women aged 30 to 49 actually consult a physician for this problem. Heavy menstrual bleeding goes hand in hand with iron deficiency anemia, and it can develop in as many as 67% of all cases. Risk factors for heavy menstrual bleeding include being non-Caucasian, having advanced maternal age, having uterine fibroids, having endometriosis, having a coagulopathy, including von Willebrand disease, or having some lifestyle factors, including obesity, smoking, and drinking. Parity plays no role in heavy– [AUDIO OUT] For a hemodynamically stable patient, we would generally prefer to try medical treatment before offering surgery. Medical treatment can be broken down into non-hormonal and hormonal options. Non-hormonal treatment is generally considered to be first in line due to its low cause and relatively few side effects. This includes tranexamic acid and NSAIDs. When non-hormonal treatments fail to satisfactorily reduce menstrual blood loss, hormonal treatments can be tried, such as combined oral contraceptives, oral progestogens, injected progestogens, or progestogen releasing intrauterine device. Tanexamic acid is an oral anti-fibrinolytic agent. The idea is to reduce menstrual bleeding by inhibiting plasmin, a protein responsible for breaking down clots. It is given at the onset of menstrual bleeding for three to five days or during the duration of a patient’s hospital stay, as investigations are being performed. It’s been shown to be an effective way to reduce menstrual blood loss. It carries only mild side effects, including indigestion, diarrhea, and headache. And although it has been shown to be more cost-effective than NSAIDs or no treatment, it is less effective than an IUS, which I will discuss later. NSAIDs reduce menstrual blood loss by inhibiting the synthesis of prostaglandins that increase menstrual bleeding. There are many options, but a meta-analysis found that the most efficacious NSAID for heavy menstrual bleeding was mefenamic acid, which could reduce visceral blood loss by 29%. Compared with antifibrinolytics, NSAIDs are generally less effective at reducing blood loss and carry more severe side effects, like worsening of asthma and peptic ulceration. However, in the presence of dysmenorrhea, they are the preferred option for their ability to simultaneously treat both blood loss and dysmenorrhea. A 2004 study comparing different non-hormonal treatments showed that NSAIDs says were effective at reducing menstrual blood loss when compared to a placebo, but were actually inferior to either tranexamic acid or danazol. It should be noted the dentists danazol should not be used routinely due to its masculinizing side effects. In practice, NSAIDs and tranexamic acid are often prescribed together. What’s important to remember is that non-hormonal treatments are effective and are first line options for patients with heavy menstrual bleeding. The purpose of taking combined oral contraceptives for heavy menstrual bleeding is to prevent ovulation and to stabilize the end of the endometrium. COCs contain a mixture of estrogen and progestogen, and have been shown to reduce menstrual blood lost by around 43% when taken in a 21 day cycle. They do have some side effects, such as mood change, headache, nausea, food retention, breast tenderness, and then some rare more serious cardiovascular side effects, like DVT, stroke, and heart attack. Qlaira is a new oral contraceptive pill approved by the FDA in 2009 to treat menorrhagia. It uses estradiol valerate instead of ethanol estradiol. When combined with a progestogen, it has been shown to be effective at reducing menstrual blood loss. There’s even evidence to suggest that it compares favorably to other contraceptive pills, but more data is needed. As we can see on the graph, when compared to the placebo, Qlaira was able to reduce menstrual bleeding by 88%, compared to the placebo, which showed only a 20% reduction in menstrual blood loss. This table also compares Qlaira with the placebo. Notice that not only did Qlaira reduce the total volume of lost as compared to the placebo. It also decreased the mean number of bleeding days per cycle. Another hormonal treatment option to consider is oral progestogens. Progestogens work by thinning out the endometrial lining and/or causing amenorrhea. The NICE guidelines recommend taking a 21 day cycle of norethisterone to control menstrual bleeding. In one study, there was a reported 87% reduction in menstrual blood loss after taking or oral progestogens for three months. The side effects are generally less severe than that of combined oral contraceptives. And they include amenorrhea, which can actually be desirable in some women, also undesirable side effects such as weight gain, bloating, and breast tenderness. IM progestogens have the same mechanism of action as oral progestogens. The only difference between them is that IM progestogens are given as a depot injection every three months the patients. This method has been shown to be very effective in causing amenorrhea, but it also carries a similar side effect profile to that of oral progestogens. The IM option can be very useful for women who have trouble adhering to a pill regime. Levonorgestrel is a potent progestogen the causes endometrial thinning. The levonorgestrel releasing intrauterine system as a t-shaped device that is inserted into a woman’s uterus for long term birth control and bleeding control. It releases small 20 micrograms doses of levonorgestrel daily, and can remain inside a uterus for up to five years. A meta-analysis of efficacy rates shows that the LNG IUS can reduce menstrual blood loss by up to 71% to 96%. In studies that look at satisfaction, the LNG IUS consistently scores very highly. In addition to the progesterone specific side effects, the LNG IUS does come with several unique side effects also. These include intrauterine perforation, a higher risk of ectopic pregnancy, and secondary infection. It should be noted though that these additional side effects are very rare. When considering which hormonal treatments to use, it is important to take into consideration the patient’s individual preferences and tailor your treatment to her wishes. The NICE guidelines recommend LNG IUS as the most cost-effective and satisfying treatment. However, some women may object to such a device. In these cases, oral contraceptive pills or IM injections may be best. In cases where medical treatment fails or a very definitive measure is required to stop having menstrual bleeding, surgery can and should be considered. Indications for surgery are failure or contraindication of medical treatment, severe impact on the quality of life stemming from heavy menstrual bleeding, and patient specific factors, such as age, fertility concerns, and personal preference regarding surgery. Surgical options should not be offered to women who still wish to conceive. And surgical treatment for heavy menstrual bleeding in a perimenopausal woman should be carefully weighed with the option of simply waiting for her to reach menopause. Endometrial ablation is a very popular surgery that allows a woman to avoid a full out hysterectomy. It is useful for pre-menopausal women with ovulatory menorrhagia, who are also fit for surgery. There are several contraindications, however, and women with any of these contraindications should not undergo under endometrial ablation. Endometrial ablation is compared favorably to other forms of medical treatment in several trials in its ability to reduce menstrual blood loss and days of bleeding. [AUDIO OUT] A hysterectomy is the most definitive and permanent treatment for uterine bleeding. It is indicated for women who have failed other treatment options, have a desire for permanent amenorrhea, have no desire for future children, and who are fit for surgery. Each option should be carefully discussed with patients, as it is irreversible. Overall, several studies show that women who undergo this option are generally very satisfied with their resulting quality of life. This is the table of the different treatment options discussed in this presentation and the corresponding efficacy in reducing menstrual blood loss. When deciding on which option to select it is important to weigh a number of things, in addition to just a total reduction of menstrual blood loss. For example, desire to maintain fertility is a very important factor that will effectively rule out surgical options. Considerations like economic cause and compliance issues should also be weighed very carefully, as a patient has to both pay for and comply to the treatment that you prescribe. Thank you. Good luck. And I hope this presentation has helpful.

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