Heavy menstrual bleeding

{{short description|Menstrual period with excessive blood flow}} {{distinguish|Metrorrhagia}} {{cs1 config|name-list-style=vanc}} {{Infobox medical condition (new) | name = Heavy menstrual bleeding | synonyms = Hypermenorrhea, menorrhagia | image = | caption = | pronounce = | field = Gynecology | symptoms = bleeding more than usual | complications = Anemia, severe pain | onset = | duration = | types = | causes = | risks = family history, anovulation, fibroids, polyps, and adenomyosis | diagnosis = based on physical examination | differential = Irregular menstruation | prevention = | treatment = | medication = tranexamic acid | prognosis = | frequency = | deaths = }}

'''Heavy menstrual bleeding''' ('''HMB'''), previously known as '''menorrhagia''' or '''hematomunia''', is a menstrual period with excessively heavy flow. It is a type of abnormal uterine bleeding (AUB).<ref name="Munro 3–13"/><ref name=Bac2017>{{cite journal | vauthors = Bacon JL | title = Abnormal Uterine Bleeding: Current Classification and Clinical Management | journal = Obstetrics and Gynecology Clinics of North America | volume = 44 | issue = 2 | pages = 179–193 | date = June 2017 | pmid = 28499529 | doi = 10.1016/j.ogc.2017.02.012 }}</ref>

Abnormal uterine bleeding can be caused by structural abnormalities in the reproductive tract, skipping ovulation (anovulation), bleeding disorders, hormonal issues (such as hypothyroidism) or cancer of the reproductive tract.<ref name="HMBH2018" />

Initial evaluation during diagnosis aims at determining pregnancy status, menopausal status, and the source of bleeding. One definition for diagnosing the condition is bleeding lasting more than 7 days or the loss of more than 80 mL of blood.<ref name="HMBH2018">{{cite journal |vauthors=O'Brien SH |title=Evaluation and management of heavy menstrual bleeding in adolescents: the role of the hematologist |journal=Hematology |volume=30 |issue=1 |pages=390–398 |date=2018 |pmid=30504337 |pmc=6246024 |doi=10.1182/asheducation-2018.1.390}}</ref>

Treatment depends on the cause, severity, and interference with quality of life.<ref name="ncbi.nlm.nih.gov">{{cite journal | title = Practice bulletin no. 136: management of abnormal uterine bleeding associated with ovulatory dysfunction | journal = Obstetrics and Gynecology | volume = 122 | issue = 1 | pages = 176–85 | date = July 2013 | pmid = 23787936 | doi = 10.1097/01.AOG.0000431815.52679.bb | author1 = Committee on Practice Bulletins—Gynecology | s2cid = 2796244 }}</ref> Initial treatments often involve birth control pills, tranexamic acid, danazol and hormonal intrauterine device. Painkillers (NSAIDs) are also helpful.<ref name="BofillRodriguez_2019" /> Surgery can be effective for those whose symptoms are not well-controlled with other treatments.<ref>{{cite journal | vauthors = Marjoribanks J, Lethaby A, Farquhar C | title = Surgery versus medical therapy for heavy menstrual bleeding | journal = The Cochrane Database of Systematic Reviews | issue = 1 | article-number = CD003855 | date = January 2016 | volume = 2016 | pmid = 26820670 | doi = 10.1002/14651858.CD003855.pub3 | pmc = 7104515 }}</ref> Approximately 53 in 1000 women are affected by AUB.<ref>{{cite journal | vauthors = Kjerulff KH, Erickson BA, Langenberg PW | title = Chronic gynecological conditions reported by US women: findings from the National Health Interview Survey, 1984 to 1992 | journal = American Journal of Public Health | volume = 86 | issue = 2 | pages = 195–9 | date = February 1996 | pmid = 8633735 | pmc = 1380327 | doi = 10.2105/ajph.86.2.195 }}</ref>

==Signs and symptoms== thumb|300x300px|Symptoms of heavy menstrual bleeding, according to the decision aid from NHS England.<ref name=":1">{{Cite web |title=NHS England » Decision support tool: making a decision about managing heavy periods |url=https://www.england.nhs.uk/publication/decision-support-tool-making-a-decision-about-managing-heavy-periods/ |access-date=2024-09-16 |website=www.england.nhs.uk}}</ref> A normal menstrual cycle is 21–35 days in duration, with bleeding lasting an average of 5 days and total blood flow between 25 and 80 mL. Heavy menstrual bleeding is defined as total menstrual flow >80ml per cycle, soaking a pad/tampon at least every 2 hours, changing a pad/tampon in the middle of the night, or bleeding lasting for >7 days.<ref name=HMBH2018/><ref name="Munro 3–13">{{cite journal | vauthors = Munro MG, Critchley HO, Broder MS, Fraser IS | title = FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age | journal = International Journal of Gynaecology and Obstetrics | volume = 113 | issue = 1 | pages = 3–13 | date = April 2011 | pmid = 21345435 | doi = 10.1016/j.ijgo.2010.11.011 | s2cid = 205260568 | doi-access = free }}</ref><ref>{{Cite web |title=Menorrhagia (heavy menstrual bleeding) - Symptoms and causes |url=https://www.mayoclinic.org/diseases-conditions/menorrhagia/symptoms-causes/syc-20352829 |access-date=2022-09-10 |website=Mayo Clinic }}</ref> Deviations in terms of frequency of menses, duration of menses, or volume of menses qualifies as abnormal uterine bleeding. Bleeding in between menses, outside reproductive age, or after sex is also abnormal uterine bleeding and thus requires further evaluation.<ref name="Abnormal Uterine Bleeding">{{Cite web |title=Abnormal Uterine Bleeding |url=https://www.acog.org/en/womens-health/faqs/abnormal-uterine-bleeding |access-date=2022-09-10 |website=www.acog.org }}</ref>

== Causes == Usually, no causative abnormality can be identified and treatment is directed at the symptom, rather than a specific mechanism. However, there are known causes of abnormal uterine bleeding that need to be ruled out. Most common causes based on the nature of bleeding is listed below followed by the rare causes of bleeding (i.e. disorders of coagulation).

* Excessive menses but normal cycle: ** Painless: *** Fibroids (leiomyoma) — fibroids in the wall of the uterus cause increased menstrual loss if they protrude into the central cavity and thereby increase endometrial surface area. *** Coagulation defects (rare) — with the shedding of an endometrial lining's blood vessels, normal coagulation process must occur to limit and eventually stop the blood flow. Blood disorders of platelets (such as ITP) or coagulation (such as von Willebrand disease) or use of anticoagulant medication (such as warfarin) are therefore possible causes, although a rare minority of cases. Platelet function studies can also be used to ascertain platelet function abnormalities *** Endometrial cancer (cancer of the uterine lining) — bleeding can also be irregular, in between periods, or after the menopause (post-menopausal bleeding or PMB) *** Endometrial polyp ** Painful (i.e. associated with dysmenorrhea): *** Pelvic inflammatory disease *** Adenomyosis - extension of the endometrial tissue into the outer muscular wall of the uterus which can cause pain and abnormal bleeds when the endometrium sheds *** Pregnancy related complication (i.e. miscarriage) *** Endometriosis * Short cycle (less than 21 days) but normal menses. * Short cycle and excessive menses due to ovarian dysfunction and may be secondary to blockage of blood vessels by tumours. * Polycystic ovary syndrome.<ref name=HMBH2018/> * Systemic causes: thyroid disease, excessive emotional/physical stress.<ref name=HMBH2018/> * Sexually transmitted infection.<ref name=HMBH2018/> * Copper intrauterine device

==Pathophysiology== HMB is associated with increased omega-6 AA in uterine tissues.<ref name=HMBbook2015>{{cite book |author1=Joseph E. Pizzorno |author2=Michael T. Murray |author3=Herb Joiner-Bey |title=The Clinician's Handbook of Natural Medicine |date=2015 |doi=10.1016/C2010-0-67298-1|isbn=978-0-7020-5514-0 }}</ref> The endometrium of people with HMB have higher levels of prostaglandin (E2, F2alpha and others) when compared with women with normal menses.<ref name="BofillRodriguez_2019"/> It is thought that prostaglandins are a by product of omega 6 build up.<ref name="Harel 2006">{{cite journal | vauthors = Harel Z | title = Dysmenorrhea in adolescents and young adults: etiology and management | journal = Journal of Pediatric and Adolescent Gynecology | volume = 19 | issue = 6 | pages = 363–71 | date = December 2006 | pmid = 17174824 | doi = 10.1016/j.jpag.2006.09.001 }}</ref> Furthermore, prostaglandins have been found to trigger abnormal, painful uterine contractions, making it a source for targeted therapy.<ref>{{Cite book |url=https://link.springer.com/book/10.1007/978-3-319-71964-1 |title=Dysmenorrhea and Menorrhagia |year=2018 |doi=10.1007/978-3-319-71964-1|last1=Smith |first1=Roger P. |isbn=978-3-319-71963-4 |s2cid=10078385 }}</ref>

==Diagnosis== thumb|300x300px|Prevalence of heavy menstrual bleeding, amongst people of child-bearing age, and the proportion who seek medical help.<ref>{{Cite book |url=https://www.hqip.org.uk/wp-content/uploads/2018/02/HwNYNM.pdf |title=National Heavy Menstrual Bleeding Audit |date=2014 |publisher=Royal College of Obstetricians and Gynaecologists |location=London, UK |pages=Table 4.1}}</ref> Diagnosis is largely achieved by obtaining a complete medical history followed by physical exam and vaginal ultrasonography. If need be, laboratory tests or hysteroscopy may be used. The following are a list of diagnostic procedures that medical professionals may use to identify the cause of the abnormal uterine bleeding. * Pelvic and rectal examination to ensure that bleeding is not from lower reproductive tract (i.e. vagina, cervix) or rectum * Pap smear to rule out cervical neoplasia * Pelvic ultrasound scan is the first line diagnostic tool for identifying structural abnormalities.<ref name="NICE44-2007"/> * Endometrial biopsy in those with high risk endometrial cancer or atypical hyperplasia or malignancy.<ref name="NICE2018">{{cite book |title=Heavy menstrual bleeding (update) |date=2018 |publisher=National Institute for Health and Care Excellence}}</ref> * Sonohysterography to assess for abnormalities within the uterine lining<ref>{{Cite web |title=Menorrhagia (heavy menstrual bleeding) - Diagnosis and treatment - Mayo Clinic |url=https://www.mayoclinic.org/diseases-conditions/menorrhagia/diagnosis-treatment/drc-20352834 |access-date=2022-09-10 |website=www.mayoclinic.org}}</ref> * Hysteroscopy (anaesthesia should be offered)<ref name=NICE2018/> * Thyroid-stimulating hormone and thyrotropin-releasing hormone dosage to rule out hypothyroidism <ref>{{cite journal | vauthors = Weeks AD | title = Menorrhagia and hypothyroidism. Evidence supports association between hypothyroidism and menorrhagia | journal = BMJ | volume = 320 | issue = 7235 | page = 649 | date = March 2000 | pmid = 10698899 | pmc = 1117669 | doi = 10.1136/bmj.320.7235.649 }}</ref> In the UK, the NICE guidelines states that: "Many women presenting to primary care with symptoms of HMB can be offered treatment without the need for further examination or investigation. However, investigation via a diagnostic technique might be warranted for women for whom history or examination suggests a structural or endometrial pathology or for whom the initial treatment has failed."<ref name="NICE2018" />

==Treatment== thumb|Heavy Menstrual Bleeding - Treatment Workflow<ref>{{Cite journal |date=2019-01-17 |title=NICE Guideline - Renal and ureteric stones: assessment and management |journal=BJU International |volume=123 |issue=2 |pages=220–232 |doi=10.1111/bju.14654 |pmid=30656839 |issn=1464-4096|doi-access=free }}</ref> Treatment depends on identified underlying cause and varies between medication, radiation, and surgery. Heavy periods at menarche and menopause may settle spontaneously (the menarche being the start and menopause being the cessation of periods).

If the degree of bleeding is mild, all that may be sought is the reassurance that there is no sinister underlying cause. If anemia occurs due to bleeding then iron tablets may be used to help restore normal hemoglobin levels.<ref name="Munro 3–13"/> thumb|The treatment choices of those referred to hospital in the UK for heavy menstrual bleeding.<ref>{{Cite book |url=https://www.hqip.org.uk/wp-content/uploads/2018/02/HwNYNM.pdf |title=National Heavy Menstrual Bleeding Audit |date=July 2014 |publisher=Royal College of Obstetricians and Gynaecologist |location=London, UK |pages=Table 4.1}}</ref> The first line treatment option for those with HMB and no identified pathology, fibroids less than 3 cm in diameter, and/or suspected or confirmed adenomyosis is the levonorgestrel-releasing intrauterine system (LNG-IUS).<ref name="NICE2018" /> Clinical trial evidence suggests that the LNG-IUS may be better than other medical therapy in terms of HMB and quality of life.<ref name="Bofill2020">{{cite journal |last1=Bofill Rodriguez |first1=M |last2=Lethaby |first2=A |last3=Jordan |first3=V |title=Progestogen-releasing intrauterine systems for heavy menstrual bleeding. |journal=The Cochrane Database of Systematic Reviews |date=12 June 2020 |volume=2020 |issue=6 |article-number=CD002126 |doi=10.1002/14651858.CD002126.pub4 |pmid=32529637|pmc=7388184 }}</ref>

Usually, oral combined contraceptive or progesterone only pills may be taken for a few months, but for longer-term treatment the alternatives of injected Depo Provera or the more recent progesterone releasing IntraUterine System (IUS) may be used. In particular, an oral contraceptive containing estradiol valerate and dienogest may be more effective than tranexamic acid, NSAIDs and IUDs.<ref>{{cite journal | vauthors = Kaunitz AM, Meredith S, Inki P, Kubba A, Sanchez-Ramos L | title = Levonorgestrel-releasing intrauterine system and endometrial ablation in heavy menstrual bleeding: a systematic review and meta-analysis | journal = Obstetrics and Gynecology | volume = 113 | issue = 5 | pages = 1104–16 | date = May 2009 | pmid = 19384127 | doi = 10.1097/AOG.0b013e3181a1d3ce | s2cid = 25599471 }}</ref><ref>{{cite journal | vauthors = Jensen JT, Parke S, Mellinger U, Machlitt A, Fraser IS | title = Effective treatment of heavy menstrual bleeding with estradiol valerate and dienogest: a randomized controlled trial | journal = Obstetrics and Gynecology | volume = 117 | issue = 4 | pages = 777–87 | date = April 2011 | pmid = 21422847 | doi = 10.1097/AOG.0b013e3182118ac3 | s2cid = 40164050 }}</ref> Fibroids may respond to hormonal treatment, and if they do not, then radiation or surgical removal may be required. In the UK, regarding hormonal treatment, the NICE guidelines states that: "No evidence was found on MRI-guided transcutaneous focused ultrasound for uterine fibroids nor for the progestogen-only pill, injectable progestogens, or progestogen implants."<ref name=NICE2018/> Progestogen pills, independently if taken in a short or long course, are not as effective at reducing menstrual blood loss as LNG-IUS or tranexamic acid.<ref>{{Cite journal|vauthors=Bofill Rodriguez M, Lethaby A, Low C, Cameron IT|date=14 August 2019|title=Cyclical progestogens for heavy menstrual bleeding|url=|journal=Cochrane Database Syst Rev|volume=8|issue=8 |article-number=CD001016|doi=10.1002/14651858.CD001016.pub3|pmid=31425626|pmc=6699663}}</ref>

Tranexamic acid treatments, which reduce bleeding by inhibiting the clot-dissolving enzymes, appear to be more effective than anti-inflammatory treatment like NSAIDs, but are less effective than LNG-IUS.<ref>{{Cite journal|vauthors=Bryant-Smith AC, Lethaby A, Farquhar C, Hickey M|date=15 April 2018|title=Antifibrinolytics for heavy menstrual bleeding|url=|journal=Cochrane Database Syst Rev|volume=2018|issue=6|article-number=CD000249|doi=10.1002/14651858.CD000249.pub2|pmid=29656433|pmc=6494516}}</ref> Tranexamic acid tablets may reduce loss by up to 50%.<ref name="BonnarSheppard">{{cite journal | vauthors = Bonnar J, Sheppard BL | title = Treatment of menorrhagia during menstruation: randomised controlled trial of ethamsylate, mefenamic acid, and tranexamic acid | journal = BMJ | volume = 313 | issue = 7057 | pages = 579–82 | date = September 1996 | pmid = 8806245 | pmc = 2352023 | doi = 10.1136/bmj.313.7057.579 }}</ref> This may be combined with hormonal medication previously mentioned.<ref>{{cite journal | vauthors = Lukes AS, Moore KA, Muse KN, Gersten JK, Hecht BR, Edlund M, Richter HE, Eder SE, Attia GR, Patrick DL, Rubin A, Shangold GA | title = Tranexamic acid treatment for heavy menstrual bleeding: a randomized controlled trial | journal = Obstetrics and Gynecology | volume = 116 | issue = 4 | pages = 865–75 | date = October 2010 | pmid = 20859150 | doi = 10.1097/AOG.0b013e3181f20177 | s2cid = 6977827 }}</ref>

NSAIDs are also used to reduce heavy menstrual bleeding by an average of 20-46% through inhibiting the production of prostaglandins.<ref name="BofillRodriguez_2019">{{cite journal |last1=Bofill Rodriguez |first1=M |last2=Lethaby |first2=A |last3=Farquhar |first3=C |title=Non-steroidal anti-inflammatory drugs for heavy menstrual bleeding. |journal=The Cochrane Database of Systematic Reviews |date=19 September 2019 |volume=2019 |issue=9 |article-number=CD000400 |doi=10.1002/14651858.CD000400.pub4 |pmid=31535715|pmc=6751587 }}</ref> For this purpose, NSAIDs are taken for only 5 days of the menstrual cycle, limiting their most common adverse effect of dyspepsia.<ref name="Shaw">{{cite web |url=http://emedicine.medscape.com/article/255540-treatment |title=Menorrhagia Treatment & Management |last1=A Shaw |first1=Julia |date=2014-09-29 |website=Medscape |access-date=2015-01-04}}</ref> none|thumb|656x656px|The efficacy of different treatments for heavy menstrual bleeding.<ref name=":5">{{Cite journal |last1=Khajehei |first1=Marjan |last2=Abdali |first2=Khadijeh |last3=Tabatabaee |first3=Hamidreza |date=2013-04-23 |title=The effect of mefenamic acid and naproxen on heavy menstrual bleeding: A placebo-controlled study |url=http://hmpg.co.za/index.php/sajog/article/view/1546 |journal=South African Journal of Obstetrics and Gynaecology |volume=19 |issue=2 |doi=10.7196/sajog.587 |doi-broken-date=12 July 2025 |issn=2305-8862|url-access=subscription |doi-access=free }}</ref><ref>{{Cite journal |last1=Preston |first1=J. 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|last2=Wajszczuk |first2=Charles J. |last3=Kaunitz |first3=Andrew M. |date=December 2000 |title=Bleeding patterns of women using Lunelle™ monthly contraceptive injections (medroxyprogesterone acetate and estradiol cypionate injectable suspension) compared with those of women using Ortho-Novum® 7/7/7 (norethindrone/ethinyl estradiol triphasic) or other oral contraceptives |url=https://linkinghub.elsevier.com/retrieve/pii/S0010782400001839 |journal=Contraception |volume=62 |issue=6 |pages=289–295 |doi=10.1016/s0010-7824(00)00183-9 |pmid=11239615 |issn=0010-7824|url-access=subscription }}</ref><ref>{{Cite journal |last1=Dahiya |first1=Pushpa |last2=Dalal |first2=Monika |last3=Yadav |first3=Anu |last4=Dahiya |first4=Krishna |last5=Jain |first5=Shaveta |last6=Silan |first6=Vijay |date=August 2016 |title=Efficacy of combined hormonal vaginal ring in comparison to combined hormonal pills in heavy menstrual bleeding |url=https://linkinghub.elsevier.com/retrieve/pii/S0301211516302238 |journal=European Journal of Obstetrics & Gynecology and Reproductive Biology |volume=203 |pages=147–151 |doi=10.1016/j.ejogrb.2016.05.009 |pmid=27285306 |issn=0301-2115|url-access=subscription }}</ref><ref>{{Cite journal |last1=Cooper |first1=Kevin G. |last2=Parkin |first2=David E. |last3=Garratt |first3=Andrew M. |last4=Grant |first4=Adrian M. |date=December 1997 |title=A randomised comparison of medical and hysteroscopic management in women consulting a gynaecologist for treatment of heavy menstrual loss |url=https://obgyn.onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.1997.tb11004.x |journal=BJOG: An International Journal of Obstetrics & Gynaecology |volume=104 |issue=12 |pages=1360–1366 |doi=10.1111/j.1471-0528.1997.tb11004.x |pmid=9422013 |issn=1470-0328|url-access=subscription }}</ref><ref>{{Cite journal |last1=Benagiano |first1=Giuseppe |last2=Primiero |first2=Francesco Maria |date=November 2003 |title=Seventy-Five Microgram Desogestrel Minipill, A New Perspective in Estrogen-Free Contraception |url=https://nyaspubs.onlinelibrary.wiley.com/doi/10.1196/annals.1290.019 |journal=Annals of the New York Academy of Sciences |volume=997 |issue=1 |pages=163–173 |doi=10.1196/annals.1290.019 |pmid=14644823 |bibcode=2003NYASA.997..163B |issn=0077-8923|url-access=subscription }}</ref><ref name=":11">{{Cite journal |last1=Kriplani |first1=A. |last2=Kulshrestha |first2=V. |last3=Agarwal |first3=N. |last4=Diwakar |first4=S. |date=January 2006 |title=Role of tranexamic acid in management of dysfunctional uterine bleeding in comparison with medroxyprogesterone acetate |url=http://www.tandfonline.com/doi/full/10.1080/01443610600913932 |journal=Journal of Obstetrics and Gynaecology |volume=26 |issue=7 |pages=673–678 |doi=10.1080/01443610600913932 |pmid=17071438 |issn=0144-3615|url-access=subscription }}</ref><ref>{{Cite journal |last1=Goshtasebi |first1=Azita |last2=Moukhah |first2=Somayeh |last3=Gandevani |first3=Samira Behboudi |date=2013-11-01 |title=Treatment of heavy menstrual bleeding of endometrial origin: randomized controlled trial of medroxyprogesterone acetate and tranexamic acid |url=https://link.springer.com/article/10.1007/s00404-013-2839-3 |journal=Archives of Gynecology and Obstetrics |volume=288 |issue=5 |pages=1055–1060 |doi=10.1007/s00404-013-2839-3 |pmid=23595582 |issn=1432-0711|url-access=subscription }}</ref><ref>{{Cite journal |last1=Grover |first1=Vimal |last2=Usha |first2=R. |last3=Gupta |first3=Usha |last4=Kalra |first4=S. |date=September 1990 |title=Management of Cyclical Menorrhagia with Prostaglandin Synthetase Inhibitor |url=https://obgyn.onlinelibrary.wiley.com/doi/10.1111/j.1447-0756.1990.tb00235.x |journal=Asia-Oceania Journal of Obstetrics and Gynaecology |volume=16 |issue=3 |pages=255–259 |doi=10.1111/j.1447-0756.1990.tb00235.x |pmid=2088249 |issn=0389-2328|url-access=subscription }}</ref><ref>{{Cite journal |last=Bülent Ergün |first=Oğuzhan Kuru |title=Comparison between roller-ball endometrial ablation and levonorgestrel intrauterine system (LNG-IUS) in the treatment of abnormal uterine bleeding |url=https://tjoddergisi.org/articles/doi/tjod.2011.75768 |access-date=2024-09-16 |journal=Journal of Turkish Society of Obstetric and Gynecology |date=2011 |volume=8 |issue=4 |pages=259–263 |doi=10.5505/tjod.2011.75768|url-access=subscription }}</ref><ref>{{Cite journal |last1=Vihko |first1=Kimmo K. |last2=Raitala |first2=Reijo |last3=Taina |first3=Esko |date=January 2003 |title=Endometrial thermoablation for treatment of menorrhagia: comparison of two methods in outpatient setting |url=http://doi.wiley.com/10.1080/j.1600-0412.2003.00110.x |journal=Acta Obstetricia et Gynecologica Scandinavica |volume=82 |issue=3 |pages=269–274 |doi=10.1080/j.1600-0412.2003.00110.x |pmid=12694124 |issn=0001-6349|url-access=subscription }}</ref><ref>{{Cite journal |last1=Dwyer |first1=Nuala |last2=Hutton |first2=John |last3=Stirrat |first3=Gordon M. |date=March 1993 |title=Randomised controlled trial comparing endometrial resection with abdominal hysterectomy for the surgical treatment of menorrhagia |url=https://obgyn.onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.1993.tb15237.x |journal=BJOG: An International Journal of Obstetrics & Gynaecology |volume=100 |issue=3 |pages=237–243 |doi=10.1111/j.1471-0528.1993.tb15237.x |pmid=8476829 |issn=1470-0328|url-access=subscription }}</ref><ref name=":3">{{Cite journal |last1=O'Connor |first1=Hugh |last2=Broadbent |first2=J A Mark |last3=Magos |first3=Adam L |last4=McPherson |first4=K |date=March 1997 |title=Medical Research Council randomised trial of endometrial resection versus hysterectomy in management of menorrhagia |url=https://linkinghub.elsevier.com/retrieve/pii/S0140673696072856 |journal=The Lancet |volume=349 |issue=9056 |pages=897–901 |doi=10.1016/s0140-6736(96)07285-6 |pmid=9093249 |issn=0140-6736|url-access=subscription }}</ref> Graphic from NHS decision aid (purple colour indicates hormonal medications, pale green indicates surgical procedures).<ref name=":1" />thumb|300x300px|The side effects of surgical approaches to heavy menstrual bleeding.<ref>{{Cite journal |last1=Pellicano |first1=Massimiliano |last2=Guida |first2=Maurizio |last3=Acunzo |first3=Giuseppe |last4=Cirillo |first4=Domenico |last5=Bifulco |first5=Giuseppe |last6=Nappi |first6=Carmine |date=September 2002 |title=Hysteroscopic transcervical endometrial resection versus thermal destruction for menorrhagia: A prospective randomized trial on satisfaction rate |url=https://linkinghub.elsevier.com/retrieve/pii/S0002937802001655 |journal=American Journal of Obstetrics and Gynecology |volume=187 |issue=3 |pages=545–550 |doi=10.1067/mob.2002.124958 |pmid=12237625 |issn=0002-9378|url-access=subscription }}</ref><ref>{{Cite journal |last1=Vihko |first1=Kimmo K. |last2=Raitala |first2=Reijo |last3=Taina |first3=Esko |date=January 2003 |title=Endometrial thermoablation for treatment of menorrhagia: comparison of two methods in outpatient setting |url=http://doi.wiley.com/10.1080/j.1600-0412.2003.00110.x |journal=Acta Obstetricia et Gynecologica Scandinavica |language=en |volume=82 |issue=3 |pages=269–274 |doi=10.1080/j.1600-0412.2003.00110.x |pmid=12694124 |issn=0001-6349|url-access=subscription }}</ref><ref name=":2" /><ref name=":3" /><ref name=":4" />In the UK, NICE guidelines says that for individuals with HMB and no identified pathology or fibroids less than 3 cm in diameter who do not wish to have pharmacological treatment and who do not want to conserve their fertility, surgical options could be considered as a first-line treatment option. Options include a hysterectomy and second generation endometrial ablation, with hysterectomy being more effective than second generation endometrial ablation.<ref name="NICE2018" /> A definitive treatment for heavy menstrual bleeding is to perform hysterectomy (removal of the uterus). The risks of the procedure have been reduced with measures to minimize the risk of deep vein thrombosis after surgery, and the switch from the front abdominal to vaginal approach greatly minimizing the discomfort and recuperation time for the patient; however extensive fibroids may make the womb too large for removal by the vaginal approach. Small fibroids may be dealt with by local removal (myomectomy). A further surgical technique is endometrial ablation (destruction) by the use of applied heat (thermoablation).<ref>{{cite journal |last1=Bofill Rodriguez |first1=M |last2=Lethaby |first2=A |last3=Grigore |first3=M |last4=Brown |first4=J |last5=Hickey |first5=M |last6=Farquhar |first6=C |title=Endometrial resection and ablation techniques for heavy menstrual bleeding. |journal=The Cochrane Database of Systematic Reviews |date=22 January 2019 |volume=1 |issue=1 |article-number=CD001501 |doi=10.1002/14651858.CD001501.pub5 |pmid=30667064|pmc=7057272 }}</ref> The effectiveness of endometrial ablation is probably similar to that of LNG‐IUS but the evidence is uncertain if hysterectomy is better or worse than LNG-IUS for improving HMB.<ref name="Bofill2020" />

===Medications=== thumb|374x374px|Side effects of medications used for heavy menstrual bleeding.<ref name=":4" /><ref name=":10" /><ref name=":8" /><ref name=":9" /><ref name=":7" /><ref name="Kaunitz 625" /><ref name=":6" /><ref>{{Cite journal |last1=Fraser |first1=Ian S. |last2=McCarron |first2=Gay |date=February 1991 |title=Randomized Trial of 2 Hormonal and 2 Prostaglandin-inhibiting Agents in Women with a Complaint of Menorrhagia |url=https://obgyn.onlinelibrary.wiley.com/doi/10.1111/j.1479-828X.1991.tb02769.x |journal=Australian and New Zealand Journal of Obstetrics and Gynaecology |language=en |volume=31 |issue=1 |pages=66–70 |doi=10.1111/j.1479-828X.1991.tb02769.x |pmid=1872778 |issn=0004-8666|url-access=subscription }}</ref><ref name=":11" /><ref name=":5" /><ref>{{Cite book |url=https://www.fsrh.org/Public/Documents/ceu-guidance-intrauterine-contraception.aspx |title=FSRH Clinical Guideline: Intrauterine contraception |orig-date=March 2023 |date=July 2023 |publisher=Faculty of Sexual and Reproductive Healthcare |location=London, UK |page=97}}</ref><ref>{{Cite book |url=https://www.fsrh.org/Public/Documents/fsrh-guideline-combined-hormonal-contraception.aspx |title=FSRH Clinical Guideline: Combined Hormonal Contraception |orig-date=January 2019 |date=October 2023 |publisher=Faculty of Sexual and Reproductive Healthcare |location=London, UK}}</ref><ref>{{Cite book |url=https://www.accessdata.fda.gov/drugsatfda_docs/label/2007/011839s071lbl.pdf |title=Federal Drug Administration data: Provera |date=September 2007 |publisher=FDA |pages=Table 4}}</ref> These have been ranked by the UK's National Institute for Health and Clinical Excellence:<ref name="NICE44-2007">{{cite web | title=CG44 Heavy menstrual bleeding: Understanding NICE guidance | url=http://www.nice.org.uk/guidance/cg44 | format=PDF | date=24 January 2007 | publisher=National Institute for Health and Clinical Excellence (UK)}}</ref> * First line ** Intrauterine device with progesterone * Second Line ** Tranexamic acid an antifibrinolytic agent ** Nonsteroidal anti-inflammatory drugs (NSAIDs). ** Combined oral contraceptive pills to prevent proliferation of the endometrium * Third line ** Oral progestogen (e.g. norethisterone), to prevent proliferation of the endometrium ** Injected progestogen (e.g. Depo provera) * Other options ** thumb|300x300px|The effects of long term hormonal medication use on cancer risks (in women of child-bearing age).<ref>{{Cite journal |last1=Fitzpatrick |first1=Danielle |last2=Pirie |first2=Kirstin |last3=Reeves |first3=Gillian |last4=Green |first4=Jane |last5=Beral |first5=Valerie |date=2023-03-21 |title=Combined and progestagen-only hormonal contraceptives and breast cancer risk: A UK nested case–control study and meta-analysis |journal=PLOS Medicine |language=en |volume=20 |issue=3 |article-number=e1004188 |doi=10.1371/journal.pmed.1004188 |doi-access=free |issn=1549-1676 |pmc=10030023 |pmid=36943819}}</ref>Gonadotropin-releasing hormone agonist

===Surgery=== * Dilation and curettage (D&C) is not recommended for cases of simple heavy menstrual bleeding, having a reserved role if a spontaneous abortion is incomplete<ref>{{cite journal | vauthors = Duckitt K | title = Menorrhagia | journal = BMJ Clinical Evidence | volume = 2015 | date = September 2015 | pmid = 26382038 | pmc = 4574688 }}</ref> * Endometrial ablation is not recommended for women with active or recent genital or pelvic infection, known or suspected endometrial hyperplasia or malignancy.<ref name=EA2018>{{cite journal |vauthors=Louie M, Wright K, Siedhoff MT | title = The case against endometrial ablation for treatment of heavy menstrual bleeding. | journal = Curr Opin Obstet Gynecol | volume = 30 | issue = 4 | pages = 287–292 | date = 2018 | pmid = 29708902 | doi=10.1097/GCO.0000000000000463| s2cid = 13671197 }}</ref> * Uterine artery embolization (UAE) is a common treatment with the etiology of a leiomyoma. The rate of serious complications is comparable to that of myomectomy or hysterectomy; however, UAE presents an increased risk of minor complications and requiring surgery within two to five years.<ref name=":0">{{Cite journal|last1=Gupta|first1=Janesh K.|last2=Sinha|first2=Anju|last3=Lumsden|first3=M. A.|last4=Hickey|first4=Martha|date=2014-12-26|title=Uterine artery embolization for symptomatic uterine fibroids|journal=The Cochrane Database of Systematic Reviews|issue=12|article-number=CD005073|doi=10.1002/14651858.CD005073.pub4|issn=1469-493X|pmid=25541260|pmc=11285296}}</ref><ref>{{Cite journal |last1=Spies |first1=James B |last2=Ascher |first2=Susan A |last3=Roth |first3=Antoinette R |last4=Kim |first4=Joon |last5=Levy |first5=Elliot B |last6=Gomez-Jorge |first6=Jackeline |date=2001-07-01 |title=Uterine artery embolization for leiomyomata |url=https://www.sciencedirect.com/science/article/pii/S0029784401013825 |journal=Obstetrics & Gynecology |volume=98 |issue=1 |pages=29–34 |doi=10.1016/S0029-7844(01)01382-5 |pmid=11430952 |issn=0029-7844|url-access=subscription }}</ref> * Hysteroscopic myomectomy is a minimally invasive surgical procedure to remove leiomyomas (otherwise known as [https://www.sciencedirect.com/science/article/abs/pii/S0140673600036229 fibroids]). Though a safe and effective mode of treating for menstrual disorders but it is unclear whether or not it is beneficial for treating infertility.<ref>{{Cite journal |last=Stewart |first=Elizabeth A |date=January 2001 |title=Uterine fibroids |journal=The Lancet |volume=357 |issue=9252 |pages=293–298 |doi=10.1016/s0140-6736(00)03622-9 |pmid=11214143 |s2cid=12675635 |issn=0140-6736}}</ref> * Hysterectomy is a surgical procedure consisting of the full removal of the uterus, and can include the removal of fallopian tubes (otherwise known as the uterine tubes), cervix and ovaries.<ref>{{Cite journal |last=Clayton |first=R.D. |date=February 2006 |title=Hysterectomy |journal=Best Practice & Research Clinical Obstetrics & Gynaecology |volume=20 |issue=1 |pages=73–87 |doi=10.1016/j.bpobgyn.2005.09.007 |pmid=16275095 |issn=1521-6934}}</ref>

In the UK the use of hysterectomy for heavy menstrual bleeding has been almost halved between 1989 and 2003.<ref name="BMJ2005">{{cite journal | vauthors = Reid PC, Mukri F | title = Trends in number of hysterectomies performed in England for menorrhagia: examination of health episode statistics, 1989 to 2002-3 | journal = BMJ | volume = 330 | issue = 7497 | pages = 938–9 | date = April 2005 | pmid = 15695496 | pmc = 556338 | doi = 10.1136/bmj.38376.505382.AE | url = http://bmj.com/cgi/content/full/330/7497/938 }}</ref> This has a number of causes: better medical management, endometrial ablation and particularly the introduction of IUS<ref name="JAMA-5yr">{{cite journal | vauthors = Hurskainen R, Teperi J, Rissanen P, Aalto AM, Grenman S, Kivelä A, Kujansuu E, Vuorma S, Yliskoski M, Paavonen J | title = Clinical outcomes and costs with the levonorgestrel-releasing intrauterine system or hysterectomy for treatment of menorrhagia: randomized trial 5-year follow-up | journal = JAMA | volume = 291 | issue = 12 | pages = 1456–63 | date = March 2004 | pmid = 15039412 | doi = 10.1001/jama.291.12.1456 | doi-access = }}</ref><ref name="FertSteril">{{cite journal | vauthors = Istre O, Trolle B | title = Treatment of menorrhagia with the levonorgestrel intrauterine system versus endometrial resection | journal = Fertility and Sterility | volume = 76 | issue = 2 | pages = 304–9 | date = August 2001 | pmid = 11476777 | doi = 10.1016/S0015-0282(01)01909-4 | doi-access = free }}</ref> which may be inserted in the community and avoid the need for specialist referral; in one study up to 64% of women cancelled surgery.<ref name="BJOG">{{cite journal | vauthors = Stewart A, Cummins C, Gold L, Jordan R, Phillips W | title = The effectiveness of the levonorgestrel-releasing intrauterine system in menorrhagia: a systematic review | journal = BJOG | volume = 108 | issue = 1 | pages = 74–86 | date = January 2001 | pmid = 11213008 | doi = 10.1016/S0306-5456(00)00020-6 }}</ref>

==Complications== Previous studies have suggested a nontrivial reduction in the quality of life in individuals with HMB; however, there is no single metric that has been shown to be specific enough to measure health-related quality of life in individuals with HMB.<ref>{{Cite journal |last1=Clark |first1=T. Justin |last2=Khan |first2=Khalid S. |last3=Foon |first3=Richard |last4=Pattison |first4=Helen |last5=Bryan |first5=Stirling |last6=Gupta |first6=Janesh K. |date=2002-09-10 |title=Quality of life instruments in studies of menorrhagia: a systematic review |journal=European Journal of Obstetrics, Gynecology, and Reproductive Biology |volume=104 |issue=2 |pages=96–104 |doi=10.1016/s0301-2115(02)00076-3 |issn=0301-2115 |pmid=12206918}}</ref> HMB can take a significant toll on the physical, psychological, and social aspects of individuals' lives. For example, a large, cross-sectional study in the United States identified significant associations between HMB and lower employment rates, lost earnings, and a lower self-rating of overall health compared to the general population.<ref>{{Cite journal |last1=Côté |first1=Isabelle |last2=Jacobs |first2=Philip |last3=Cumming |first3=David |date=October 2002 |title=Work loss associated with increased menstrual loss in the United States |journal=Obstetrics and Gynecology |volume=100 |issue=4 |pages=683–687 |doi=10.1016/s0029-7844(02)02094-x |issn=0029-7844 |pmid=12383534|s2cid=22526668 }}</ref> Physical and social issues, including performance of house work, life causing embarrassment, and social life, have also been identified as significant reasons why individuals with HMB seek help.<ref>{{Cite journal |last1=Shapley |first1=M. |last2=Jordan |first2=K. |last3=Croft |first3=P. R. |date=January 2003 |title=Increased vaginal bleeding: the reasons women give for consulting primary care |journal=Journal of Obstetrics and Gynaecology: The Journal of the Institute of Obstetrics and Gynaecology |volume=23 |issue=1 |pages=48–50 |doi=10.1080/0144361021000043245 |issn=0144-3615 |pmid=12623484|s2cid=22878317 }}</ref> While the main impacts of HMB are primarily physical and social, previous studies have also identified an inverse relationship between HMB and psychological scores.<ref name=":4">{{Cite journal |last1=Hurskainen |first1=R. |last2=Aalto |first2=A. M. |last3=Teperi |first3=J. |last4=Grenman |first4=S. |last5=Kivelä |first5=A. |last6=Kujansuu |first6=E. |last7=Vuorma |first7=S. |last8=Yliskoski |first8=M. |last9=Paavonen |first9=J. |date=March 2001 |title=Psychosocial and other characteristics of women complaining of menorrhagia, with and without actual increased menstrual blood loss |journal=BJOG: An International Journal of Obstetrics and Gynaecology |volume=108 |issue=3 |pages=281–285 |doi=10.1111/j.1471-0528.2001.00040.x |issn=1470-0328 |pmid=11281469|s2cid=750120 |doi-access=free }}</ref>

Aside from the social distress of dealing with a prolonged and heavy period, over time the blood loss may prove to be greater than the body iron reserves or the rate of blood replenishment, leading to anemia.<ref name="ncbi.nlm.nih.gov" /> Symptoms attributable to the anemia may include shortness of breath, tiredness, weakness, tingling and numbness in fingers and toes, headaches, depression, becoming cold more easily, and poor concentration.

== Research == Both the levonorgestrel-releasing intrauterine system and medications (tranexamic acid, mefenamic acid, contraceptive pill with combined oestrogen–progestogen or progesterone alone) seem to be equally effective in reducing the impact of HMB.<ref>{{Cite journal |last1=Kai |first1=Joe |last2=Dutton |first2=Brittany |last3=Vinogradova |first3=Yana |last4=Hilken |first4=Nicholas |last5=Gupta |first5=Janesh |last6=Daniels |first6=Jane |date=2023-10-24 |title=Rates of medical or surgical treatment for women with heavy menstrual bleeding: the ECLIPSE trial 10-year observational follow-up study |url=https://www.journalslibrary.nihr.ac.uk/hta/jhsw0174/ |journal=Health Technology Assessment |volume=27 |issue=17 |pages=1–50 |doi=10.3310/JHSW0174 |issn=2046-4924 |pmc=10641716 |pmid=37924269 |archive-date=2023-11-06 |access-date=2024-04-12 |archive-url=https://web.archive.org/web/20231106011541/https://www.journalslibrary.nihr.ac.uk/hta/JHSW0174 }}</ref><ref>{{Cite journal |date=8 March 2024 |title=The coil and medicines are both effective long-term treatments for heavy periods |url=https://evidence.nihr.ac.uk/alert/the-coil-and-medicines-are-both-effective-long-term-treatments-for-heavy-periods/ |journal=NIHR Evidence |doi=10.3310/nihrevidence_62335|url-access=subscription |doi-access=free }}</ref>

== References == {{Reflist}}

== External links == {{Medical resources | DiseasesDB = 22575 | ICD11 = {{ICD11|GA20.50}} | ICD10 = {{ICD10|N|92|0|n|80}} | ICD9 = {{ICD9|627.0}} | ICDO = | OMIM = | MedlinePlus = | eMedicineSubj = med | eMedicineTopic = 1449 | MeshID = D008595 }}

Category:Menstrual disorders