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Heavy Menstrual Bleeding (Menorrhagia)

Scope of the guidance

This EGP Update item covers the medical management of menorrhagia and is based on the clinical guideline Heavy Menstrual Bleeding developed by the National Collaborating Centre for Women's and Children's Health and published by the National Institute for Health and Clinical Excellence (NICE).

Source

National Collaborating Centre for Women's and Children's Health. Heavy Menstrual Bleeding. Clinical Guideline. London: Royal College of Obstetricians and Gynaecologists; 2007. http://www.nice.org.uk/nicemedia/pdf/CG44FullGuideline.pdf

Key points

1. Symptoms and signs

• Menorrhagia is diagnosed when menstrual blood loss is considered excessive by the woman and is having a negative impact on her quality of life in terms of physical, emotional or social wellbeing. It is often accompanied by other symptoms such as menstrual pain (dysmenorrhoea).
• It can be defined as an objectively measured blood loss of 60–80 m or more per menstruation. However, objective measurements of menstrual blood loss are not practical in the clinical setting correlate poorly with a woman's subjective assessment of blood loss and its impact on quality of life.
• No underlying cause is found in around half of women complaing of menorrhagia,. These women are said to have dysfunctional uterine bleeding (unexplained menorrhagia)

2. Assessment

• Ask about the nature of the bleeding and related symptoms a pelvic examination if an abnormality is suspected (e.g. if there is intermenstrual or postcoital bleeding, or pelvic pain or sensation of pressure).
• Take a full blood count in all women, and treat anaemia if present.
• Arrange further investigations as indicated by the history and/or pelvic examination.
• A serum ferritin test should not be routinely carried out.
• Female hormone testing should not be carried out on women with heavy menstrual bleeding.
• Menorrhagia is diagnosed when both the woman and clinician agree menstrual bleeding is heavy from the history.

3. Treatment

Advice and counselling:

• discuss the natural variability and range of menstrual blood loss between women and reassure the woman (if appropriate).
• discuss the acceptabily and efeectiveness of the different treatment options, their adverse effects such as contraception, and implications of treatment on fertility

Pharmaceutical treatment is recommended as first-line for women with menorrhagia who:

• have no symptoms or signs suggestive of underlying pathology (that is, structural or histological uterine abnormalities).
• are awaiting the results of investigations.

 Treatments for menorrhagia should be considered in the following order:

•  levonorgestrel-releasing intrauterine system (LNG-IUS) (Mirena®) is the preferred first-choice, provided that long-term contraception with an intrauterine device is acceptable to the woman (the woman should anticipate using it for a minimum of 12 months).
• tranexamic acid, nonsteroidal anti-inflammatory drugs (NSAIDs), or the combined oral contraceptive pill (COC) should be considered second, if LNG-IUS is unsuitable.
• oral norethisterone or long-acting progestogens should be considered third choice if other treatments are unsuitable.

 If initial treatment fails to produce an adequate reduction in menstrual bleeding (and treatment was complied with), consider three options:

• Switch to an alternative pharmaceutical treatment. Oral norethisterone or depot medroxyprogesterone are often suitable if other initial treatment was ineffective.
• Add in an additional drug. Typically, tranexamic acid can be combined with a NSAID, or an NSAID can be combined with a COC.
• Refer to a specialist.

4. Referral

Refer urgently if there are alarm symptoms suggesting a possible malignancy (within 2 weeks). This might include :

•  visible tumour on the cervix
• visible tuomur on the vulva
• palpable pelvic mass
• suspious mass detected on ultrasound
• post-menopausal bleeding not related to taking hormone replacement therapy (HRT)
• post-coital bleeding which persists for more than a month

make a routine referral according to local protocols for persistent heavy bleeding that is negatively affecting the woman's quality of life, despite adequate trials of pharmaceutical treatment.

make a routine referral if the woman wishes to consider surgery rather than persist with medical treatment.

Refer if the woman has iron deficiency anaemia that has failed to respond to treatment and other causes have been excluded. The timing of referral should reflect clinical judgement.

Practical tips for the busy GP >>

EGP 1. May 2008