Heavy menstrual bleeding (HMB) is a common gynecological condition that affects women of reproductive age. It can have a significant impact on a woman's quality of life, leading to physical discomfort, emotional distress, and interference with daily activities. This article aims to provide a comprehensive guide to understanding HMB, its causes, diagnosis, and management options at different levels of healthcare.
I. History and Examination:
When a woman presents with heavy menstrual bleeding, a thorough history and examination are essential. The healthcare provider needs to evaluate the patient's age, reproductive status, and any associated symptoms. Additionally, a speculum examination and pelvic examination should be performed to assess any abnormalities and determine the appropriate course of action.
II. Supportive Treatment:
Supportive treatment plays a crucial role in managing HMB. Depending on the presence or absence of abnormalities, contraception preferences, and age, different treatment options may be considered. These include:
For adolescents experiencing heavy menstrual bleeding, it is important to rule out pregnancy. If no abnormality is found, supportive treatment options such as nonsteroidal anti-inflammatory drugs (NSAIDs), tranexamic acid, oral contraceptive (OC) pills, or progestogens can be considered.
b) Women of Reproductive Age:
In women of reproductive age without abnormalities, supportive treatment options include NSAIDs, tranexamic acid, progestogens, or LNG (levonorgestrel) intrauterine system. If these measures fail to provide relief, referral to a higher center is recommended.
c) Women above 40 Years:
For women above 40 years of age, it is crucial to rule out malignancy. If no abnormalities are detected, supportive treatment options such as NSAIDs, tranexamic acid, OC pills, or progestogens can be considered. Referral to a higher center should be considered if the bleeding persists.
III. Management at Secondary Level (CHC):
When managing HMB at the secondary level of healthcare, several approaches can be taken based on the diagnostic findings:
a) Secretory/Non-secretory Endometrium without Hyperplasia:
For cases without hyperplasia, treatment options may include NSAIDs, tranexamic acid, combined OC pills, progestogens, or the use of a levonorgestrel-releasing intrauterine system (LNG IUS).
b) Hyperplasia without Atypia:
Hyperplasia without atypia can be managed with progestogens or the LNG IUS. Hormonal therapy should be continued for 6 months. If there is no relief or recurrence, referral to a higher center is recommended.
c) Hyperplasia with Atypia/Malignancy:
In cases of hyperplasia with atypia or malignancy, immediate referral to a higher center is necessary for further evaluation and appropriate management.
IV. Management at Tertiary Level:
At the tertiary level of healthcare, the management of HMB involves a comprehensive approach, including history, examination, and ultrasonography. Treatment options depend on the presence or absence of structural abnormalities:
a) Thickened Endometrium, Fibroids & Polyps:
For patients with a thickened endometrium or the presence of fibroids and polyps, referral to a specialist in fibroid and polyp management is recommended. Tranexamic acid and blood transfusion, if indicated, can be used for acute bleeding episodes.
b) Absence of Obvious Cause:
In cases where no obvious cause is identified, treatment options such as NSAIDs, tranexamic acid, OC pills, progestogens, LNG IUS, or ablative techniques can be considered. If these measures fail to provide relief, hysterectomy may be considered as a last resort. However, it is important to seek a second opinion before proceeding with invasive procedures.
V. Hormone Therapy:
Hormone therapy is an important component of managing HMB. Two commonly used hormone therapies include:
a) Norethisterone: Administered orally at a maximum daily dose of 40 mg, norethisterone is typically prescribed in divided doses from the fifth day of the cycle for three weeks. This treatment is repeated in a cyclical manner for a total of 4-6 cycles.
b) Medroxyprogesterone Acetate: Similar to norethisterone, medroxyprogesterone acetate is administered orally at a maximum daily dose of 40 mg. It is taken in divided doses from the fifth day of the cycle for three weeks and repeated in a cyclical manner for a total of 4-6 cycles.
It is important to note that hormone therapy should be tailored to the individual patient's condition and administered under medical supervision.
VI. Counseling and Management Approach:
Counseling plays a vital role in managing HMB. Healthcare providers should offer supportive counseling to patients, addressing their concerns, providing information about the condition, and discussing treatment options. It is important to emphasize the importance of a high threshold for invasive procedures and consider the patient's preferences and specific condition while deciding on the management approach.
Heavy menstrual bleeding (HMB) can significantly impact a woman's well-being and quality of life. Through a comprehensive approach, including history, examination, and appropriate investigations, HMB can be effectively managed at different levels of healthcare. Supportive treatments, hormone therapy, and, in some cases, invasive procedures may be considered based on the individual patient's condition. By understanding the causes and available management options, healthcare providers can provide optimal care and improve the quality of life for women with HMB.
This blog article is based on guidelines developed by national experts in India and is intended to provide general information about the management of heavy menstrual bleeding (HMB). The article is not a substitute for professional medical advice, diagnosis, or treatment. Individual patient management may vary based on specific circumstances, and it is recommended to consult with a qualified healthcare provider for personalized guidance. The author and publisher assume no responsibility for any direct or indirect consequences resulting from the use or misuse of the information presented in this article.
Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. Guidelines for Management of Heavy Menstrual Bleeding.