Heavy menstrual bleeding

Diagnosis

The diagnosis of heavy menstrual bleeding usually involves a physical examination, a pelvic exam, inquiring about one’s medical history and menstrual cycles, possibly suggesting the maintenance of a diary to monitor bleeding patterns, flow intensity, and sanitary product usage.

The diagnosis of heavy menstrual bleeding or abnormal uterine bleeding is typically established only after ruling out other potential causes, including menstrual disorders, medical conditions, or medication-related factors.

Depending on the age and the severity of the symptoms, tests that may be required include:

  • Blood tests: Tests for illnesses like blood clotting issues or thyroid issues may be necessary. Blood test may also involve test for iron deficiency anemia.
  • Pap test: For women aged 25 and older, the cells are tested for the presence of the human papillomavirus (HPV). This examination involves gathering cells from the cervix, which are then analyzed for signs of inflammation or potential precancerous changes that might progress to cancer. (
  • Endometrial biopsy: This test look for indications of uterine cancer or precancerous growths. A tissue sample from the interior of the uterus is taken for laboratory analysis.
  • Imaging tests: Medical imaging techniques, such as magnetic resonance imaging (MRI) and ultrasound, are employed to see the structures inside the body. Ultrasound utilizes sound waves to generate images of the uterus, ovaries, and pelvis.

MRI is used to examine the interior of the uterus when ultrasound results are insufficient in providing detailed information about potential abnormalities. MRI is particularly useful in assessing structures within the uterus.

Additional tests that may be required depending on the initial results include:

  • Sonohysterography: This test, also known as saline-infusion sonography, is conducted to investigate issues within the uterine lining. Compared to a regular ultrasound, a sonohysterogram provides greater precision and sensitivity in identifying abnormalities within the uterine cavity. This procedure involves filling the uterus with saline to enable the healthcare provider to visualize its interior. The saline is injected via a tube into the uterus through the cervix and vagina.
  • Hysteroscopy: A hysteroscopy is performed to examine the presence of polyps, fibroids, or any irregular tissue in the uterus. Through the cervix and vagina, a small, lit device is placed into the uterus to visually inspect the vagina, cervix, and uterus. If any growths are identified as potential causes of bleeding, they can be removed during the hysteroscopy.

Treatment

The approach to treating heavy menstrual bleeding is contingent upon various factors including the root cause, severity, overall health, age, and medical history of the individual. Additionally, it takes into account the individual’s response to particular medications and personal preferences. For example, treatment may target either complete cessation of periods or reduction of bleeding, depending on the individual’s choice. Moreover, treatment decisions are influenced by the individual’s plans regarding pregnancy.

Treatment options include:

  • Medications: Individuals experiencing anemia resulting from excessive bleeding may receive prescriptions for iron supplements. Additionally, even in cases where iron levels are low without anemia, initiating iron supplements might be advised rather than waiting for anemia to develop. If heavy menstrual bleeding arises due to hormone medication, discontinuation or switching to an alternative medication may be necessary.

Medications that may be prescribed to treat heavy menstrual bleeding include:

    • Nonsteroidal anti-inflammatory drugs (NSAIDs):  These medications are effective in can providing relief from menstrual cramps and decrease bleeding. NSAIDs include ibuprofen or naproxen sodium.
    • Tranexamic acid: Antifibrinolytic medications, such as tranexamic acid, work by inhibiting the breakdown of clots, thus preventing excessive bleeding. One only need to take this medication when once they start bleeding.
    • Hormonal IUD: This thins the lining of the uterus and lessens discomfort and monthly blood flow. Levonorgestrel, a form of progestin released by IUDs
    • Oral contraceptives: These can help control irregular menstrual cycles and relieve heavy or extended menstrual bleeding.
    • Oral progesterone: The hormone progesterone, whether natural or in its synthetic form called progestin, can address hormone imbalances, and alleviate heavy menstrual bleeding.
    • Other medications: Gonadotropin-releasing hormone (GnRH) agonists are capable of temporarily halting or diminishing bleeding by inhibiting ovulation. On the other hand, GnRH antagonists, such as elagolix, are effective in managing heavy menstrual bleeding associated with fibroids. Additionally, desmopressin nasal spray can arrest bleeding linked to von Willebrand disease by aiding in blood clotting.
  • Procedures: Medication is typically the initial treatment option, followed by minor surgeries and surgical interventions. Many surgical procedures aimed at addressing heavy menstrual bleeding are often performed on an outpatient basis, enabling patients to return home the same day. While certain surgeries such as abdominal myomectomy or hysterectomy may require a short hospital stay, many are carried out under general anesthesia.

Surgical options include:

  • Dilation and curettage (D&C): This may be performed to identify the cause of abnormal uterine bleeding, such as polyps, fibroids, or uterine cancer. If one experienced a miscarriage, a D&C may be necessary to completely empty the uterus. In this procedure, the healthcare provider opens the cervix, known as dilating it, and then scrapes or suctions tissue from the uterine lining, called curettage. Hysteroscopy is often combined with D&C to help locate the source of bleeding in the uterus.
  • Hysterectomy: This is frequently employed for both the diagnosis and treatment of heavy menstrual bleeding. In an operative hysteroscopy, a slender, illuminated tube is inserted into the vagina, facilitating an examination of the uterine cavity. The hysteroscope serves as a precise surgical tool, enabling the removal of any growths that might be contributing to the bleeding.
  • Uterine artery embolization: During this procedure, a catheter is inserted into the major artery in the thigh. In order to stop the blood supply to the fibroid, tiny beads or sponges is inserted using a catheter that is guided to the uterine blood arteries. The purpose of uterine artery embolization is to obstruct blood flow to uterine fibroids. Reduced blood supply to fibroids aids in their shrinkage.
  • Focused ultrasound: This method, which does not require any incisions, reduces the size of fibroids by using ultrasound waves and radiofrequency energy to target and destroy them.
  • Myomectomy: This involves surgically removing uterine fibroids using different approaches. With hysteroscopic approach, a thin, flexible tube is inserted into the vagina and cervix to visualize and remove fibroids or polyps inside the uterus. With laparoscopic approach, several small incisions in the abdomen is done.
  • Endometrial ablation: Following endometrial ablation, periods are often significantly lighter. While pregnancy is unlikely, it is still possible and can be risky. It is advisable to use reliable or permanent birth control until menopause. Generally, endometrial ablation entails destroying the uterus lining, a process known as ablation, using methods like a laser, radio waves, or heat.
  • Endometrial resection: Pregnancy is not advised following this procedure. This usually employs an electrosurgical wire loop to eliminate the uterine lining.

In specific instances where excessive menstrual bleeding may signal an underlying condition, such as thyroid disease, addressing the root cause could result in a decrease in menstrual flow.