Article
Background:
Heavy menstrual bleeding (HMB), a prevalent and distressing condition, is primarily defined by the patient's perception and observable signs like frequent pad or tampon changes, large clots, and disruption of daily activities.
Women with HMB often experience reduced health-related quality of life, attributed to irritation, inconvenience, associated pain, self-consciousness, and social embarrassment.
Despite its impact, less than half of those with heavy bleeding seek medical assistance, leading to suboptimal care.
Recommendations on diagnostic evaluation of HMB:
- Perform a complete blood cell count for women reporting HMB, excluding ferritin, thyroid, or hormone testing.
- Evaluate for coagulation disorders, like von Willebrand disease, in women experiencing HMB since the onset of their periods.
- Consider pelvic ultrasonography if the uterus is palpable abdominally or if pelvic examination results are inconclusive; transvaginal ultrasonography is preferred for women with significant dysmenorrhea or a bulky, tender uterus.
- Early outpatient hysteroscopy is recommended during HMB investigations if the patient's history suggests submucosal fibroids, polyps, or endometrial pathology.
- Focus on interventions that enhance the quality of life rather than fixating on blood loss.
Recommendations on treatment of HMB:
- If there is low suspicion of an anatomic abnormality after history and physical examination, contemplate empirical pharmacologic management.
- For women with fibroids smaller than 3 cm without cavity distortion, other pathology, or suspected adenomyosis, consider the Levonorgestrel-releasing intrauterine system (LNG-IUS) as first-line treatment.
- In case of LNG-IUS refusal, discuss non-hormonal options such as Tranexamic acid, nonsteroidal anti-inflammatory drugs (NSAIDs), combined hormonal contraception, or cyclical progestin-only medication.
Conclusion:
In conclusion, regular inquiries about menstrual health in primary care can enhance outcomes and patient contentment. These recommendations offer a structure for the assessment and treatment choices for women experiencing HMB and is applicable in outpatient settings.
Reference:
Douglass LA, Davis AM. Assessment and Management of Heavy Menstrual Bleeding. JAMA. 2020;323(3):270-1.
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