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BASICS

DESCRIPTION
- Heavy menstrual bleeding (HMB) is a form of abnormal uterine bleeding (AUB) characterized by excessive menstrual blood loss, defined clinically as >80 mL blood loss per cycle.
- More commonly subjectively defined as excessive bleeding that physically, emotionally, socially, and financially affects quality of life.
- The term menorrhagia is being abandoned due to confusion.

EPIDEMIOLOGY

  • AUB is common (20-30% prevalence) and a leading cause of outpatient gynecological visits.
  • ~1 in 5 US women experience HMB; higher prevalence in adolescence and 5th decade of life.
  • Study showed 37.9% prevalence in reproductive-aged women in an outpatient setting.
  • HMB linked to decreased quality of life and increased healthcare costs.
  • Can present acutely or chronically.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Caused by interference with hemostatic, endocrine, paracrine functions of the endometrium or myometrial contractility.
  • FIGO PALM-COEIN classification used:
  • PALM (structural causes):
    • Polyp (AUB-P)
    • Adenomyosis (AUB-A)
    • Leiomyoma (AUB-L)
    • Malignancy/hyperplasia (AUB-M)

  • COEIN (nonstructural causes):

    • Coagulopathy (AUB-C)
    • Ovulatory dysfunction (AUB-O)
    • Endometrial dysfunction (AUB-E)
    • Iatrogenic (AUB-I)
    • Not yet classified (AUB-N)

  • Structural causes:

  • Polyps → abnormal outgrowth of hypertrophied endometrium causing irregular HMB.
  • Adenomyosis → affects myometrial contraction, exact cause unclear.
  • Leiomyomas → benign myometrial tumors, estrogen/progesterone sensitive.

  • Excess estrogen → endometrial hyperplasia.

  • Ovulatory dysfunction → thickened endometrium, noncyclical irregular bleeding.

  • Genetics: Adolescents at risk due to immature HPO axis; screen for bleeding disorders (e.g., von Willebrand disease).

RISK FACTORS

  • Obesity

GENERAL PREVENTION

  • Combined oral contraceptives (COCs) with dominant progesterone prevent HMB; lower estrogen doses reduce bleeding.
  • Progesterone-only contraceptives reduce blood loss but cause irregular bleeding.

DIAGNOSIS

HISTORY
- Detailed menstrual history: cycle length, duration, variability, blood loss.
- Change of pads every 2-3 hours ≈ >80 mL blood loss.
- Clots, flooding sensation are indicators.
- Screen for coagulopathy using family history of bleeding, frequent epistaxis, gum bleeding, bruising, bleeding after surgery/dental work/postpartum.
- Anovulatory bleeding = irregular, unpredictable, lacking ovulatory symptoms.

PHYSICAL EXAM
- Assess hemodynamic stability if acute blood loss.
- Look for obesity, thyroid enlargement, skin signs (petechiae, ecchymosis), hyperandrogenism (hirsutism, acne).
- Speculum exam: inspect vulva, urethra, vagina, anus, perineum for trauma/bleeding source.
- Bimanual exam: uterine or cervical abnormalities, masses.

DIFFERENTIAL DIAGNOSIS

  • Normal menses
  • Pregnancy complications
  • Bleeding from cervical, vaginal, GI sources

DIAGNOSTIC TESTS & INTERPRETATION

Initial tests
- Pregnancy test, CBC
- Type and crossmatch if severe bleeding
- PT/INR, PTT, TSH with reflex T4, CMP, iron studies, STI panel
- Coagulopathy workup if suspected: vWF antigen, ristocetin cofactor activity, factor VIII
- Ovulatory dysfunction: thyroid, hCG, prolactin, FSH
- Transvaginal ultrasound; further imaging as needed

Follow-up tests
- Saline infusion sonohysterography, diagnostic hysteroscopy, hysterosalpingography for polyps and submucosal leiomyomas
- MRI for adenomyosis and leiomyoma characterization, rule out leiomyosarcoma

Diagnostic procedures
- Endometrial biopsy +/- hysteroscopy for women >40 or high-risk <40 years

TREATMENT

MEDICATION

  • First Line:
  • Acute bleeding:
    • Conjugated equine estrogen 25 mg IV q4-6h for 24 hours + IV antiemetics
    • Monophasic 35-mg estrogen-containing OCP TID for 7 days, then daily
    • Medroxyprogesterone or norethindrone 20 mg TID for 7 days
    • Tranexamic acid 10 mg/kg IV (max 600 mg/dose) or 1.5 g PO q8h for 5 days

  • Chronic bleeding:

    • NSAIDs: ibuprofen 600 mg q6h or 800 mg q8h; naproxen 500 mg + 250-500 mg BID; mefenamic acid 500 mg TID
    • Monophasic 30-35 mg estrogen-containing OCP daily
    • Medroxyprogesterone or norethindrone 5-10 mg daily
    • Depot medroxyprogesterone 150 mg SC q3mo
    • Levonorgestrel-releasing IUD (19.5-52 mg)
    • Etonogestrel subdermal implant

  • Second Line:

  • Danazol, GnRH agonists, aromatase inhibitors, SERMs, SPRMs (not currently available in US) for leiomyoma and adenomyosis

ISSUES FOR REFERRAL

  • Gynecology referral for:
  • IUD placement or endometrial sampling if PCP uncomfortable
  • Persistent bleeding despite treatment
  • Suspected malignancy

ADDITIONAL THERAPIES

  • Iron supplementation (oral preferred, IV if intolerant) for anemia
  • MRI-guided focused ultrasound (MgFUS) approved for uterine fibroids; reduces bleeding in adenomyosis

SURGERY/OTHER PROCEDURES

  • Dilation and curettage for acute severe bleeding
  • Surgery directed by pathology:
  • Polypectomy for polyps
  • Hysterectomy for adenomyosis
  • Leiomyoma: myomectomy preferred if fertility desired; otherwise, laparoscopic radiofrequency ablation, uterine artery embolization, or hysterectomy

  • Malignancy: hysterectomy ± chemo/radiotherapy

  • Conservative surgery (myomectomy, endometrial ablation, uterine artery embolization) better for 1-2 year symptom control but similar long-term to meds/IUD

  • Hysterectomy is curative but reserved for treatment failure or malignancy

REFERENCES

  1. Marnach ML, Laughlin-Tommaso SK. Evaluation and management of abnormal uterine bleeding. Mayo Clin Proc. 2019;94(2):326-335.
  2. Cheong Y, Cameron IT, Critchley HO. Abnormal uterine bleeding. Br Med Bull. 2019;131(1):119.
  3. Sangkomkamhang US, Lumbiganon P, Pattanittum P. Progestogens or progestogen-releasing intrauterine systems for uterine fibroids (other than preoperative medical therapy). Cochrane Database Syst Rev. 2020;11(11):CD008994.

ICD10 Codes

  • N92.0 Excessive and frequent menstruation with regular cycle
  • N92.3 Ovulation bleeding
  • N92.2 Excessive menstruation at puberty

Clinical Pearls

  • HMB often associated with structural uterine disorders.
  • Thorough history and physical exam essential to identify AUB cause.
  • Treatment tailored to cause, severity, and patient fertility desires.
  • Initial goals: stop bleeding, treat anemia, restore quality of life.