Overview
Definition:
Heavy Menstrual Bleeding (HMB), also known as menorrhagia, is defined as excessive uterine bleeding that interferes with a woman's physical, emotional, social, and material quality of life
It is characterized by a loss of 80 ml or more of blood per menstrual cycle, although this exact volume is difficult to ascertain clinically
More commonly, it is described as menstrual periods that last longer than 7 days or are so heavy that they soak through one or more pads or tampons every hour for several consecutive hours
HMB is a common gynecological complaint among adolescents and can lead to significant morbidity, including iron deficiency anemia.
Epidemiology:
HMB affects approximately 10-20% of women of reproductive age
In adolescent populations, the prevalence is less precisely defined but is a frequent reason for gynecological consultation
Iron deficiency anemia secondary to HMB is particularly prevalent in menstruating females, with estimates ranging from 5-15% of women experiencing iron deficiency and 3-5% having overt iron deficiency anemia
It is a leading cause of hospital admissions and gynecological surgeries in some regions.
Clinical Significance:
HMB can significantly impact a child or adolescent's well-being, affecting school attendance, social activities, and emotional health
Chronic blood loss can lead to iron deficiency anemia, causing fatigue, impaired cognitive function, and reduced exercise tolerance
Prompt and accurate evaluation is crucial to identify underlying causes, manage symptoms effectively, and prevent long-term complications
For pediatric residents and those preparing for DNB/NEET SS, understanding the comprehensive evaluation and management of HMB is vital for comprehensive patient care in adolescent gynecology.
Clinical Presentation
Symptoms:
Excessive menstrual bleeding, defined by duration longer than 7 days
Passage of clots larger than a quarter
Soaking through pads or tampons hourly for several consecutive hours
Bleeding that interferes with daily activities (school, sports, social events)
Symptoms of anemia such as fatigue, pallor, shortness of breath, dizziness, headaches
Abdominal or pelvic pain may be associated with some causes of HMB.
Signs:
Pallor of mucous membranes and conjunctivae
Tachycardia in cases of significant anemia
Hypotension if acute blood loss is severe
Abdominal distension or a palpable pelvic mass in cases of fibroids or other structural abnormalities
Signs of underlying endocrine disorders (e.g., thyroid disease)
Pelvic examination findings may reveal cervical abnormalities or vaginal lesions, though often the pelvic exam is normal in functional HMB.
Diagnostic Criteria:
Diagnosis of HMB is primarily clinical, based on patient history of heavy and/or prolonged menstrual bleeding that negatively impacts quality of life
Objective quantification is difficult but can be aided by asking about the number of pads/tampons used, frequency of changes, presence of clots, and impact on daily activities
The PALM-COEIN classification system is used to categorize potential causes: PALM (structural): Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia
COEIN (non-structural): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified.
Diagnostic Approach
History Taking:
Detailed menstrual history including age of menarche, cycle length, duration, flow (pad/tampon use, clot passage), regularity of cycles
Associated symptoms like dysmenorrhea, dyspareunia, pelvic pain
Past medical history, including bleeding disorders, thyroid disease, liver disease, or use of medications (anticoagulants, hormonal contraceptives, IUDs)
Family history of bleeding disorders or gynecological conditions
Nutritional history, especially iron intake
Impact of bleeding on quality of life
Red flags: sudden onset of heavy bleeding, bleeding between periods, post-coital bleeding, suspicion of malignancy, significant anemia symptoms.
Physical Examination:
General examination: assess for pallor, vital signs, thyroid palpation, and any signs of systemic illness
Abdominal examination: palpate for masses, tenderness, or organomegaly
Pelvic examination (if appropriate and indicated, considering age and sexual activity): speculum examination to assess cervix and vagina for lesions, bleeding source, or discharge
Bimanual examination to assess uterine size, shape, mobility, and adnexal masses
In younger adolescents, a rectovaginal exam might be considered if pelvic exam is not feasible or informative.
Investigations:
Complete Blood Count (CBC): to assess for anemia (hemoglobin, hematocrit) and platelet count
Iron studies: Serum ferritin (most sensitive indicator of iron stores), serum iron, TIBC, transferrin saturation
Coagulation studies: PT, aPTT, INR, bleeding time, fibrinogen, Factor VIII and von Willebrand factor antigen and activity if coagulopathy is suspected
Thyroid function tests (TSH): to rule out hypothyroidism
Pregnancy test: to rule out pregnancy-related causes
Pelvic Ultrasound (transabdominal and/or transvaginal): to evaluate uterine size, endometrium, and ovaries, and to detect structural abnormalities like fibroids, polyps, adenomyosis
Endometrial biopsy: indicated in adolescents with persistent HMB and risk factors for endometrial hyperplasia or malignancy (obesity, PCOS, nulliparity with significant bleeding) or failure to respond to medical management
Hysteroscopy: may be used for direct visualization and biopsy of endometrial lesions.
Differential Diagnosis:
Functional HMB (most common in adolescents, often due to ovulatory dysfunction)
Pregnancy-related complications (ectopic pregnancy, miscarriage)
Uterine fibroids (leiomyomas)
Endometrial polyps
Adenomyosis
Endometrial hyperplasia or malignancy (rare in adolescents but important to consider)
Coagulopathies (e.g., von Willebrand disease, platelet dysfunction, rare factor deficiencies)
Thyroid dysfunction (hypothyroidism)
Polycystic Ovary Syndrome (PCOS)
Medications (e.g., anticoagulants, certain hormonal therapies)
Pelvic inflammatory disease (PID) or infections
Other rare causes like arteriovenous malformations.
Management
Initial Management:
For acute severe bleeding: hospitalization may be necessary
Intravenous fluids for hydration
High-dose estrogen therapy (e.g., conjugated estrogens 25 mg IV every 4-6 hours, or oral contraceptives) to stabilize the endometrium and reduce blood loss
Tranexamic acid (1 g every 6-8 hours orally or IV) can also be very effective
Blood transfusion if hemoglobin is severely low (<7 g/dL)
Address underlying cause if identified.
Medical Management:
Non-steroidal Anti-inflammatory Drugs (NSAIDs): Mefenamic acid or ibuprofen can reduce menstrual blood loss by 20-50% and also help with dysmenorrhea
Hormonal therapy: Combined oral contraceptives (COCs) are a mainstay
they regulate cycles and reduce bleeding
Progestins (oral or depot medroxyprogesterone acetate, or levonorgestrel-releasing intrauterine system - LNG-IUS) can effectively reduce menstrual blood loss
LNG-IUS is highly effective, reducing blood loss by >80%
Tranexamic acid: Oral tranexamic acid 1-1.5 g TID or QID during menstruation significantly reduces blood loss
Gonadotropin-releasing hormone (GnRH) agonists: used for severe bleeding unresponsive to other treatments or preoperatively, but usually for short-term use due to side effects.
Surgical Management:
Surgical options are typically reserved for cases unresponsive to medical management or when structural abnormalities require intervention
Dilatation and curettage (D&C): for acute bleeding and diagnosis/treatment of endometrial lesions
Endometrial ablation: destruction of the endometrium (e.g., rollerball, laser, microwave, radiofrequency)
Hysterectomy: definitive treatment, but rarely indicated in adolescents and young women
Myomectomy or polypectomy: surgical removal of fibroids or polyps if they are the cause of HMB.
Supportive Care:
Iron therapy is a cornerstone of management for all patients with HMB and evidence of iron deficiency or anemia
Patients with asymptomatic iron deficiency should receive oral iron supplements
Iron deficiency anemia requires prompt treatment
Nutritional counseling to improve dietary iron intake
Regular follow-up to monitor symptoms and response to treatment
Psychological support to address the impact of chronic bleeding and anemia on quality of life
Education about menstrual hygiene and management strategies.
Iron Therapy
Indications:
Iron therapy is indicated for all individuals with HMB and documented iron deficiency (serum ferritin <15 mcg/L) or iron deficiency anemia (hemoglobin <12 g/dL for women, <13 g/dL for men and non-pregnant adolescents) regardless of the underlying cause
Prophylactic iron therapy may be considered in adolescents with significant risk factors for iron deficiency and heavy bleeding even before deficiency is confirmed.
Oral Iron Formulations:
Ferrous sulfate (65 mg elemental iron) 325 mg orally 1-3 times daily
Ferrous fumarate (63 mg elemental iron) or ferrous gluconate (35 mg elemental iron) are alternatives
Common side effects include gastrointestinal upset (nausea, constipation, diarrhea)
Taking iron with food can reduce GI side effects, but may decrease absorption
Vitamin C supplements can enhance absorption.
Intravenous Iron Therapy:
IV iron is indicated for patients who do not tolerate oral iron, have severe malabsorption, severe anemia requiring rapid correction, or when oral iron is ineffective
Various formulations are available (e.g., iron sucrose, ferric carboxymaltose)
Dosing depends on the degree of anemia and iron deficit
Monitoring for infusion reactions is important
Typically, IV iron achieves faster and more complete replenishment of iron stores than oral therapy.
Monitoring And Duration:
Response to iron therapy should be monitored with serial CBC and ferritin levels
Treatment should continue until hemoglobin levels normalize and iron stores are replenished (ferritin >50 mcg/L)
This typically requires 3-6 months of therapy after normalization of hemoglobin
Patients with ongoing HMB may require long-term iron supplementation
Monitoring for side effects and adherence is crucial.
Complications
Early Complications:
Acute, severe blood loss leading to hypovolemic shock
Worsening anemia and fatigue
Impaired physical and cognitive function in children and adolescents
Increased risk of infection due to anemia.
Late Complications:
Chronic iron deficiency anemia leading to long-term sequelae such as impaired growth and development, cognitive deficits, reduced fertility potential (though less relevant in pediatric population)
Psychological distress, social isolation, and reduced quality of life
Increased risk of surgical complications if surgery is eventually required due to unmanaged bleeding.
Prevention Strategies:
Prompt diagnosis and initiation of appropriate medical management to control bleeding
Ensuring adequate iron intake through diet and supplementation
Regular screening for anemia in at-risk adolescent populations
Education on recognizing symptoms of heavy bleeding and seeking medical attention
Effective management of underlying causes of HMB.
Key Points
Exam Focus:
Distinguish functional HMB from organic causes using PALM-COEIN classification
Recognize von Willebrand disease as the most common inherited bleeding disorder in women and a frequent cause of HMB
Understand the role of NSAIDs, hormonal contraceptives, and LNG-IUS in medical management
Know the indications for iron therapy and the differences between oral and IV iron administration
Be aware of red flag symptoms requiring urgent investigation.
Clinical Pearls:
Always consider pregnancy in sexually active adolescents presenting with menstrual irregularities
Ask about pad/tampon use per hour and duration of menses to objectively assess HMB
Iron deficiency is very common
always check ferritin levels
Start iron therapy empirically if suspicion is high and awaiting results
LNG-IUS is highly effective and a good option for adolescents with HMB and no contraindications
Regular follow-up is key to ensure adherence and effectiveness of treatment.
Common Mistakes:
Attributing all HMB to ovulatory dysfunction without ruling out organic causes or coagulopathies
Delaying iron therapy until anemia is severe
Underestimating the impact of HMB on quality of life
Failing to consider pregnancy in sexually active adolescents
Prescribing oral iron without adequate counseling on side effects and adherence
Not considering IV iron for severe anemia or malabsorption.