REVIEW

Heavy menstrual bleeding

Prevalence
Between 4% and 51% of women experience HMB depending on
their country of origin and clinical settings where data had been
collected. Heavy menstrual bleeding affects one in three women
of reproductive age. In the UK, almost 1.5 million women per
year consult their GP with menstrual complaints and the annual
treatment cost exceeds 65 m.

Rashda Bano
Shreelata Datta
Tahir A Mahmood

Abstract

Causes of heavy menstrual bleeding

Heavy menstrual bleeding is defined as excessive menstrual blood loss

which interferes with the womans physical, emotional, social and material
quality of life, and which can occur alone or in combination with other
symptoms. All interventions should aim to improve quality of life rather
than focussing on menstrual blood loss alone. An accurate history may
indicate the cause of the bleeding. Indications for endometrial biopsy
include persistent intermenstrual bleeding as well as heavy menstrual
bleeding, in women aged 45 and over and those where there is evidence
of treatment failure. First line treatment includes tranexamic acid or nonsteroidal anti-inflammatory drugs or combined oral contraceptives.
Second line treatment options include, levonorgestrel-releasing intrauterine system (provided long-term use is anticipated), oral norethisterone or injectable long-acting progestogens.
In women with HMB alone who have failed to respond to the above
treatment options: with uterus no bigger than a 10-week pregnancy,
endometrial ablation should be considered in preference to hysterectomy.
Where hysterectomy is indicated, the route of hysterectomy should be
considered in the following order: first-line vaginal; second-line abdominal/laparoscopic.

Fibroids, polyps, coagulopathy, endometrial/cervical malignancy, thyroid disease, pelvic infection especially by Chlamydia,
and arteriovenous malformations are the possible causes of
HMB. Iatrogenic causes include use of anticoagulants etc.
Submucosal and intramural fibroids are particularly associated with HMB, although about 50% of fibroids cause no
symptoms. Coagulopathy should be considered in women who
fail to respond to medical management or women who present at
a young age. Coagulopathy may be inherited or acquired and
most common inherited disorder is von Willebrands disease.
Endometrial and cervical carcinomas are potential causes of
intermenstrual and post coital bleeding and rarely HMB. Untreated hypothyroidism may be associated with HMB. Chronic
endometrial infection may cause intermenstrual bleeding or
HMB. Chlamydia trachomatis has been proposed as a cause of
HMB.
Arteriovenous malformations (AVM) in the uterus may be
congenital or acquired and are a rare cause of HMB. Acquired
AVM may occur following uterine curettage after pregnancy.
Colour Doppler imaging is a useful diagnostic modality if AVM
malformation is suspected. Acute heavy bleeding from an AVM
may be required to be managed with uterine artery embolization.
Iatrogenic causes include the use of anticoagulants in women
with thromboembolic disease and copper IUD. Table 1 summarises the main causes of HMB.

Keywords abnormal uterine bleeding; endometrial ablation; heavy

menstrual bleeding; hormonal treatment; hysterectomy; long acting
injectable progestogens

Obesity and HMB

Introduction

Obesity is associated with abnormal uterine bleeding. There is

clear association between obesity, endometrial polyps, endometrial hyperplasia and ovulatory dysfunction. As PCOs are associated with obesity and obesity augments its development, many
of the effects of obesity on menstrual disorders are manifested
through PCOs. A survey of pre-menopausal women with endometrial polyps found that 82% reported abnormal uterine
bleeding. In obese women particularly in combination with hypertension, there is an increase risk for polyp development. In
addition, in infertility patients, Body Mass Index (BMI) was an
independent risk factor for the development of endometrial
polyps. Obese women would therefore appear to be at an
increased risk of developing endometrial polyps although the
basis for this is not known. Obesity also increases the risk of
malignancy developing within an endometrial polyp. In one
study it is reported that 86% of women with complex hyperplasia
were obese. Histological examination of pre-menopausal endometrial biopsies found that women with hyperplasia had a
significantly higher BMI than those without hyperplasia. In
another study the median BMI in the hyperplastic group was 38
kg/m2 compared with 30 kg/m2 in the non-hyperplastic group.

Heavy menstrual bleeding (HMB) is defined as excessive menstrual blood loss which interferes with a womans physical, social, emotional and/or material quality of life. It can occur alone
or in combination with other symptoms. The term heavy menstrual bleeding has replaced the term menorrhagia. The objective
definition of HMB is no longer used except for research purposes.

Rashda Bano MRCOG is a Specialist Registrar in Obstetrics and Gynaecology at Victoria Hospital, Kirkcaldy, Scotland. Conflicts of interest:
none declared.
Shreelata Datta MRCOG LLM is a Locum Consultant Obstetrician &
Gynaecologist at St Heliers Hospital, Carshalton, Surrey, UK. Conflicts
of interest: none declared.
Tahir A Mahmood MD FRCOG FRCPI MBA FACOG is a Consultant Obstetrician
and Gynaecologist at Victoria Hospital, Kirkcaldy, Scotland. Conflicts of
interest: none declared.

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REVIEW

suggested by history of excessive bleeding since menarche,

postpartum haemorrhage, surgery related bleeding, or a history
of two or more of following: bruising greater than 5 cm, epistaxis
once a month, frequent bleeding or a family history of bleeding
disorders.
According to NICE guideline, If the history suggests HMB with
structural or histological abnormality, with symptoms such as
intermenstrual or post coital bleeding, pelvic pain and /or pressure symptoms, a physical examination and/or other investigations (such as ultrasound) should be performed.
If the history suggests HMB without structural or histological
abnormality, pharmaceutical treatment can be started without
carrying out a physical examination or other investigations at
initial consultation at primary care unless treatment chosen is
LNG-IUS.
Measuring menstrual blood loss either directly (alkaline haematin) or indirectly (Pictorial blood loss assessment chart) is
not routinely recommended for HMB.

Summary of causes of HMB

Classification

Subtype

Local uterine pathology

Uterine fibroids
Uterine polyps
Chronic endometrial infection
Uterine cancer
Endometrial hyperplasia
Arteriovenous malformation
Polycystic ovaries (PCOs)
Hypothyroidism
Coagulopathy e.g. Von
Willebrands disease
Anticoagulation therapy
IUCD

Local pelvic pathology

Systemic disorders

Iatrogenic causes

Table 1

Examination
Women with complex endometrial hyperplasia are more
frequently obese. In addition, BMI is predictive of endometrial
thickness on an ultrasound scan and this is predictive of hyperplasia. Obese women are thus at increased risk of developing
endometrial hyperplasia.
A raised BMI is associated with earlier menarche and menstrual irregularities during adolescence. A raised BMI will
certainly impact on endometrial function in the context of an
increased risk of endometrial hyperplasia and endometrial carcinoma. Raised circulating oestrogen levels, as a consequence of
peripheral conversion of androgens by adipose tissue aromatase,
enzyme have been implicated in the increased proliferative activity of endometrial cells. Circulating adipokines have also been
associated with increased angiogenesis as well as cell proliferation. HMB is a common complaint among those women who are
premenopausal and who are subsequently diagnosed with
endometrial cancer. It would therefore not be unlikely if a raised
BMI was found to impact on the volume of menstrual blood loss.

A general physical examination should be performed to exclude

signs of anaemia, evidence of systemic coagulopathy and thyroid
disease.
An abdominal examination should be performed to exclude a
pelvic mass especially if there is a history of pressure symptoms
(fibroid or ovarian enlargement); a speculum examination
should be performed to assess vulva, vagina and cervix (this may
reveal sources of bleeding, such as a tumour, polyp or a
discharge suggesting infection). A bimanual examination should
be performed to elicit uterine enlargement.
A physical examination should be carried out before
 All LNG-IUS fittings.
 All investigations for structural abnormalities
 All investigations for histological abnormalities.
Women with fibroids that are palpable abdominally or who
have Intracavity fibroids and/or whose uterine length as
measured at ultrasound or hysteroscopy is greater than 12 cm
would require further assessment in a hospital setting.

Bleeding of endometrial origin

Investigations (Table 2)

In the majority of cases of HMB, the precise cause of heavy

bleeding lies at level of the endometrium. This was previously
termed as DUB or dysfunctional uterine bleeding and it is a
diagnosis of exclusion.

Laboratory tests
A full blood count test should be carried out on all women with
HMB. This should be done in parallel with any HMB treatment
offered. Testing for coagulation disorders (for example, von
Willebrands disease) should be considered in women who have
had HMB since menarche and have personal or family history
suggesting a coagulation disorder. A serum ferritin test, LH, FSH
should not routinely be carried out on women with HMB. Thyroid testing should be carried out only when other signs and
symptoms of thyroid disease are present.

History, examination and investigations for HMB

A history should be taken from the woman that should cover the
nature of bleeding and related symptoms that might suggest
structural or histological abnormality, impact on the quality of
life and other factors that may determine treatment options (such
as presence of co morbidity). The range and natural variability in
menstrual cycles and blood loss should be taken into account
when diagnosing HMB. A menstrual diary is often helpful to
determine the amount and timing of the bleeding. Flooding and
clots indicate significant loss. Inter menstrual and post coital
bleeding are suggestive of an anatomical cause, whereas pressure
symptoms, including bowel and urinary symptoms, can indicate
the presence of a large fibroid. A coagulation disorder may be

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 24:1

Endometrial biopsy
Dilatation and Curettage should not be used at all in the management of HMB.
If appropriate, a biopsy should be taken to exclude endometrial cancer or atypical hyperplasia. Indications for a biopsy
include, for example, persistent intermenstrual bleeding, and in
women aged 45 and over treatment failure or ineffective

2013 Elsevier Ltd. All rights reserved.

REVIEW

Summary of investigations for HMB and their benefits

Investigation type

Specific investigation

Indication

Blood test

FBC, TFTs
Coagulation screen

Histology
Imaging

Endometrial biopsy
Transvaginal and transabdominal ultrasound

To exclude anaemia and hypothyroidism,

where thyroid symptoms exist
To exclude a clotting disorder where a positive
family history or other symptoms exist
To exclude endometrial atypia or carcinoma
To identify uterine structural abnormalities
such as polyps and fibroids

Table 2

Summary of pharmaceutical treatments available for menorrhagia and their outcomes

Pharmaceutical treatment

Mechanism of action

Effect on menstrual bleeding

Is it a
contraceptive?

Side effects

Levonorgestrel-releasing
intrauterine system (LNGIUS)

Prevents endometrial
proliferation

Bleeding reduced by up to
95%; full benefit may take
upto 6 months

Yes

Tranexamic acid, two

tablets 3e4 times a day
orally for up to 4 days
during menses
Nonsteroidal antiinflammatory drugs
(NSAIDs), taken during
menses

It is an antifibrinolytic

Bleeding reduced by up
to 58%

No

Irregular bleeding; hormonal

problems such as breast
tenderness, acne or headaches,
uterine perforation at the time
of insertion (rare)
Indigestion; diarrhoea;
headaches

Reduces production of
prostaglandin

Bleeding reduced by up
to 49%

No

Combined oral
contraceptives (COCs),
taken daily for 21 days,
followed by a 7 day break

Prevents endometrial
proliferation

Bleeding reduced by 43%

Yes

Oral progestogen
(norethisterone), 15 mg
from day 5 to day 26 of
cycle
Injected or implanted
progestogen, injected
every 12 weeks or implant
for 3 years use

Prevents endometrial
proliferation

Bleeding reduced by up
to 83%

Yes

Prevents endometrial
proliferation

Bleeding is likely to stop

completely

Yes

Gonadotrophin-releasing
hormone analogue
(GnRH-a), given as a
monthly injection for 3e6
months

Stops oestrogen and

progesterone
production

Bleeding stopped completely

in 89% of women

No

Indigestion; diarrhoea,
worsening of asthma in
sensitive individuals; peptic
ulcers with possible bleeding
and peritonitis
Mood changes; headaches;
nausea; fluid retention; breast
tenderness, deep vein
thrombosis; stroke; heart
attacks
Weight gain; bloating; breast
tenderness; headaches; acne

Weight gain; irregular bleeding;

amenorrhoea; premenstrual-like
syndrome (including bloating,
fluid retention, breast
tenderness), loss of bone
mineral density,
Menopausal symptoms (such as
hot flushes, increased sweating,
vaginal dryness)

Adapted from Heavy Menstrual Bleeding NICE Clinical Guidelines, No. 44.National Collaborating Centre for Womens and Childrens Health (UK) London: RCOG Press;
2007.

Table 3

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A summary of various interventions for the treatment of HMB

Surgical treatment

Mechanism of action

Impact on
future fertility?

Side effects

Endometrial ablation

Destroys endometrial lining

Yes

Transcervical resection of fibroids

(hysteroscopic myomectomy)
Open myomectomy (fibroids >3 cm)

Surgical resection of
submucosal fibroids
Surgical resection of subserosal
or intramural fibroids
Surgical removal of
uterus  removal of ovaries

No

Vaginal discharge, period pain or

cramping, infection , perforation (rare)
Adhesions, perforation, haemorrhage,
recurrence, infection
Infection, haemorrhage, thrombosis,
recurrence, pain, adhesions
Infection, haemorrhage, urinary tract infection,
bowel damage, thrombosis, menopausal
symptoms with oophorectomy
Adhesions, perforation, recurrence, infection,
haemorrhage

Hysterectomy

Uterine artery embolization

Injection into blood vessels to

reduce blood flow to a
fibroid uterus

No
Yes

Potentially

Table 4

 Norethisterone (15 mg) daily from days 5 to 26 of the

menstrual cycle, or injected long-acting progestogens.
Other treatment options include GnRH analogue.
Danazol, Ethamsylate and Gestrinone are no longer recommended for use in treatment of HMB owing to their unacceptable
side effects.

treatment. Blind sampling methodologies (outpatient endometrial biopsy) are reasonable screening techniques but they are
ineffective at diagnosing focal lesions. Hysteroscopy and endometrial biopsy can be performed.
Role of imaging
Ultrasound is the first line diagnostic tool for identifying structural abnormalities.
Hysteroscopy and Magnetic resonance imaging (MRI) should
not be used as a first line diagnostic tool.
Saline infusion sonography should not be used as first line
diagnostic tool.

Non-hormonal treatments: these treatments can be used if

hormonal treatments are not acceptable to the woman or while
investigations and definitive treatment is being organized.
Antifibrinolytics e antifibrinolytics such as Tranexamic acid
reduce blood loss by upto 50% by inhibiting endometrial fibrinolysis. Side effects are rare but may include indigestion, diarrhoea or headache.
Cochrane reviews concluded that antifibrinolytic therapy
causes a greater reduction in objective measurements of heavy
menstrual bleeding when compared to placebo or other medical
therapies (NSAIDS, oral luteal phase progestagens and ethamsylate). This treatment is not associated with an increase in side
effects compared to placebo, NSAIDS, oral luteal phase progestagens or ethamsylate. Flooding, leakage and sex life is significantly improved after tranexamic acid therapy when compared
with oral luteal progestogens but no other measures of quality of
life were assessed.
Prostaglandin synthetase inhibitor e non-steroidal anti-inflammatory drugs are an example of prostaglandin synthetase
inhibitor and act by inhibiting endometrial prostaglandin production leading to reduction in menstrual blood loss. Mefenamic
acid is the most frequently used agent and reduces blood loss by
approximately 25%. This medicine has to be taken during
menstruation and is associated with gastrointestinal side effects
such as indigestion, diarrhoea, worsening of asthma and peptic
ulcer disease. When HMB coexists with dysmenorrhoea, NSAIDs
should be preferred to Tranexamic acid. There have been isolated
reports of NSAID-associated reversible female infertility and
probable mechanism is ovulatory failure due to non-rupture of
mature follicle.

Treatment for HMB

HMB has a major impact on a womans quality of life. Treatment
and care should take into account the womans needs and preferences. Women with HMB should have the opportunity to make
informed decisions about their care and treatment, in partnership
with their healthcare professionals. Women should be given information about mode of action, duration of action, side effects
and impact on fertility of different treatment options available.
Treatment can be either medical or surgical; medical management does not impact on future fertility in the long-term. Table 3
summarises the pharmacological treatments available, together
with their outcomes, whilst Table 4 considers surgical interventions for menorrhagia and their benefits.
Pharmaceutical treatments
Pharmaceutical treatment should be considered where no structural or histological abnormality is present, or for fibroids less
than 3 cm in diameter which do not distort the uterine cavity.
Hormonal and non-hormonal treatments are available and
should be considered in the following order.
 Levonorgestrel-releasing intrauterine system (LNG-IUS)
provided long-term (at least 12 months) use is anticipated.
 Tranexamic acid or non-steroidal anti-inflammatory drugs
(NSAIDs) or combined oral contraceptives (COCs).

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REVIEW

Cochrane reviews concluded that NSAIDs reduce HMB when

compared with placebo but are less effective than tranexamic
acid, danazol or LNG IUS. In the limited number of small studies
suitable for evaluation, no significant difference in efficacy was
demonstrated between NSAIDs and other medical treatments
such as oral luteal progestogen, ethamsylate, COC or another
type of intrauterine system, Progestasert.
Use of NSAIDs and/or Tranexamic acid should be stopped if it
does not improve symptoms within three menstrual cycles.

leading to amenorrhoea. Use of a Gonadotropin-releasing hormone analogue could be considered prior to surgery or when all
other treatment options for uterine fibroids, including surgery or
uterine artery embolization, are contraindicated. If this treatment
is to be used for more than 6 months or if adverse effects are
experienced then hormone replacement therapy (HRT) as addback therapy is recommended.
Danazol: Cochrane reviews concluded that Danazol appears
to be an effective treatment for heavy menstrual bleeding
compared to other medical treatments. The use of Danazol may
be limited by its side effect profile, its acceptability to women and
the need for continuing treatment. The small number of trials,
and the small sample sizes of the included trials limit the recommendations for clinical care. Further studies are unlikely in
the future and this review will not be updated unless further
studies are identified. There is no reliable evidence available
from randomized controlled trials regarding the benefits or
harms of the use of danazol for treating uterine fibroids.
Obesity and Treatment options: one clear effect of obesity is
that the management of HMB amongst women with a raised BMI
is a challenge. The treatments available for HMB may be limited
although data showing treatment outcome in relation to BMI are
lacking. Raised BMI is associated with poor efficacy of hormonal
contraception suggesting an effect or obesity on bioavailability or
action of steroids. Hysterectomy will have additional complications in the presence of a raised BMI. A recent publication reported that patients with a BMI of greater than 34 showed a trend
towards failure with this intervention. Some options seem to be
suited to obese women. The levonorgestrel-releasing intrauterine
system (LNG-IUS) is considered a first time treatment option
for management of HMB. It also protects against endometrial
hyperplasia in ovulatory dysfunction. A recent study amongst
adolescent women undergoing bariatric surgery showed a high
acceptance rate of this method for management of menstrual
complaints.

Hormonal treatments:
Combined oral contraceptive pills e the ombined oral contraceptive pill (OCP) is considered effective in the management
of HMB. Evidence from one randomized controlled trial of the
COCP (Ethinyl oestradiol 30 mcg and levonorgestrel 150 mcg for
21 days) found a reduction in blood loss of 43%. Side effects
include nausea, mood changes, breast tenderness and rarely
thromboembolic disease (risk increases in smokers, obese and
older women).
A Cochrane review found one small study which found no
significant difference between groups treated with OCP, mefenamic acid, low dose danazol or naproxen. Overall, the evidence
from the one study is not sufficient to adequately assess the
effectiveness of OCP.
Oral progestogens e norethisterone acetate (5 mg, three times
daily) taken from day 5 to day 26 of the menstrual cycle, is
effective in treating HMB. Side effects include weight gain,
bloating, breast tenderness, headache, acne and depression.
Cochrane reviews concluded that Progestogens administered
from day 15 or 19 to day 26 of the cycle offer no advantage over
other medical therapies such as danazol, tranexamic acid, nonsteroidal anti-inflammatory drugs (NSAIDs) and the IUS in the
treatment of menorrhagia in women with ovulatory cycles. Progestogen therapy for 21 days of the cycle results in a significant
reduction in menstrual blood loss, although women found the
treatment less acceptable than intrauterine levonorgestrel. This
regimen of progestogen may have a role in the short-term treatment of menorrhagia.
Injectable long acting progestogens e it is well recognized
that amenorrhoea occurs in many women when long acting
progestogens are used for contraception, and they can also be
used for the treatment of HMB. Side effects include irregular
bleeding, weight gain, amenorrhoea and less commonly bone
density loss.
Levonorgestrel releasing intrauterine system (LNG IUS) e
LNG IUS is an excellent alternative to surgery for women with
HMB who also seek reliable long-term contraception. It releases
the hormone at a rate of 20 mg per day and acts locally by causing
thinning and atrophy of endometrium. There is very little systemic absorption of the hormone so progestogen related side
effects are much less than with oral agents. Side effects include
breast tenderness, headache, acne or uterine perforation at time
of insertion. RCTs show that the LNG IUS reduces menstrual loss
by up to 96% after one year but that the full benefit may not be
seen for first 6 months. Women should be fully counselled that
they are likely to experience unscheduled spotting/bleeding in
first 5 to 6 months.
Gonadotropin releasing hormone analogues e GnRHa act by
down regulating the HPO axis and induce ovarian suppression,

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Surgical treatment for HMB

Typically, surgical management is only considered in women
who have completed their family, with the exception of polypectomy and myomectomy where fertility can be retained. In the
early 1990s, it was estimated that at least 60% of women presenting with HMB went on to have a hysterectomy. This was
often the only treatment offered. Since the 1990s the number of
hysterectomies has been decreasing rapidly. This reduction in
hysterectomy rates is considered to reflect not only the introduction of successful treatment options, such as the LNG-IUS,
but also having access to endometrial ablation techniques.
Dilatation and curettage should not be used as a treatment option
in any clinical situation. Table 4 summarizes surgical and
radiological treatments for HMB.
Polypectomy: endocervical polyps can be avulsed in the outpatient setting. Endometrial polyps can be removed blindly under
general anaesthetic, or by hysteroscopic resection either under
general anaesthetic, or in the outpatient setting.
Endometrial ablation: endometrial ablation is targeted destruction of endometrium. It should be considered where bleeding is
having a severe impact on a womans quality of life, and she does

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REVIEW

not wish to conceive in the future. Endometrial ablation should

be considered in women with HMB who have a uterus no bigger
than a 10-week pregnancy and also those with small uterine fibroids (less than 3 cm in diameter).
First generation techniques include hysteroscopic transcervical resection of endometrium, using an electrical diathermy
loop and roller ball ablation. These techniques offer treatment for
uterine cavities with sub mucous fibroids. Second generation
techniques have been developed for smoother and smaller cavities. These include fluid filled thermal balloon ablation, microwave ablation and impedance controlled endometrial ablation.
These procedures can be performed as a day case. Women who
undergo this procedure should be advised to use effective
contraception. Pre ablation endometrial histology should be obtained and hysteroscopy should be performed before and after
the procedure to exclude endometrial perforation. Post operatively, patients may complain of transient crampy abdominal
pain and a watery brown discharge for between 3 and 4 weeks.
Potential complications include device failure at time of procedure, endometritis, haematometra, fluid overload due to absorption of distension medium, uterine perforation and intra
abdominal injury including visceral burns. As a general rule, of
all the women undergoing endometrial ablation with a second
generation technique, 40e50% will become amenorrhoeic, 40
e60% will have markedly reduced menstrual loss and 20% will
have no difference in their bleeding. Long term trials show that
while most women are initially satisfied, many subsequently
choose or require repeat endometrial ablation or hysterectomy.
About 15% women would require hysterectomy during a 10-year
follow up following ablation independent of a technique used.
Cochrane reviews concluded Endometrial ablation techniques
offer a less invasive surgical alternative to hysterectomy. The
rapid development of new methods of endometrial destruction
has made systematic comparisons between methods and with the
gold standard first generation techniques difficult. Most of the
newer techniques are technically easier than hysteroscopy-based
methods to perform but technical difficulties with new equipment need to be ironed out. Overall, the existing evidence suggests that success rates and complication profiles of newer
techniques of ablation compare favourably with hysteroscopic
techniques.
Endometrial resection and ablation offers an alternative to
hysterectomy as a surgical treatment for heavy menstrual
bleeding. Both procedures are effective and satisfaction rates are
high. Although hysterectomy is associated with a longer operating time, a longer recovery period and higher rates of postoperative complications, it offers permanent relief from heavy
menstrual bleeding. The initial cost of endometrial destruction is
significantly lower than hysterectomy but, since re-treatment is
often necessary, the cost difference narrows over time.

intervention in an attempt to reduce the vascularity of the

fibroids.
Immediate complications include excessive blood loss and a
blood transfusion may be necessary. Difficulty achieving haemostasis may result in hysterectomy so patients should be
counselled pre operatively about this risk. Other risks include
infection.
Uterine Artery Embolization: uterine artery embolization is
carried out by interventional radiologist, usually under local
anaesthetic with or without sedation for fibroid related menorrhagia. The femoral artery is canalized on one or both sides and
fed into the iliac and then the uterine artery. Angiography is
carried out to confirm the correct position before introduction of
the embolic agent. Blockage of both uterine arteries results in
fibroids becoming avascular and shrinking in size. As the normal
myometrium subsequently derives its blood supply from the
vaginal and ovarian vasculature, UAE is thought to have no
permanent effect on the rest of the uterus. In the immediate postoperative period, patients may experience ischaemic pain and
small risk of sepsis is acknowledged. Occasionally, fibroids may
be expelled vaginally after UAE. Rarely, subserosal fibroids can
become adherent to the bowel and UAE can lead to bowel necrosis and peritonitis. There is a small risk of premature ovarian
failure but a recent study has shown that there is no evidence of a
deterioration of ovarian function after 1 year. This procedure is
currently not recommended for women who wish to maintain
their fertility.
Hysterectomy: hysterectomy should only be considered when a
woman has completed her family and when medical and less
invasive surgical options have failed or are inappropriate.
Vaginal hysterectomy e vaginal hysterectomy is appropriate
for women with HMB with a small uterus and adequate cervical
descent. Advantages of the vaginal route include the absence of
abdominal wound and minimal disturbance of the intestines.
This results in less post-operative pain, earlier mobilization and
earlier discharge from the hospital. Risks related to this approach
are bladder damage, bleeding, infection and bowel damage.
Abdominal hysterectomy e abdominal hysterectomy is indicated in women with a uterine size greater than 12 weeks of
pregnancy, endometriosis or a history of pelvic inflammatory
disease, previous c/section, or a long vagina and a narrow sub
pubic arch, making the vaginal approach technically difficult. A
subtotal abdominal hysterectomy may be performed according to
patient preference or if surgery is technically difficult owing to
adhesions or endometriosis. Patient must be warned of 15% risk
of residual bleeding from the cervix. In young patients with
HMB, the ovaries are usually conserved but a bilateral salpingo
oophorectomy may be carried out simultaneously after detailed
discussion with the patient, with particular attention to family
history. Women should be counselled as regards 1:72 lifelong
risk of developing ovarian cancer if the ovaries have been
retained at hysterectomy.
Laparoscopic hysterectomy e laparoscopic hysterectomy
could be laparoscopic assisted vaginal hysterectomy, laparoscopic total or subtotal hysterectomy. There is opportunity to
diagnose and treat other pelvic disease and to carry out other
adnexal surgery. There is less post-operative pain, less analgesia

Myomectomy: myomectomy is the surgical removal of intramural and subserosal fibroids from the uterine walls with conservation of the uterus. In women with multiple fibroids or a
significantly enlarged uterus, the abdominal approach is most
appropriate. Laparoscopic myomectomy may be performed in
selected cases. If a fibroid protrudes into the uterine cavity
(submucous), it may be removed hysteroscopically. GnRH
analogue therapy is often used for three months prior to surgical

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Care pathway for heavy menstrual bleeding

Woman presenting with HMB
Take history
Take full blood count

No structural or histological
abnormality suspected

Structural or histological
abnormality suspected
Physical exam

No abnormality/fibroids
less than 3 cm in diameter

Pharmaceutical treatment

Consider endometrial biopsy

for persistent intermenstrual bleeding,
and in women over 45 treatment failure
or ineffective treatment

Uterus is palpable
abdominally or pelvic mass

Consider
physical exam
Consider second pharmaceutical
treatment if first fails

Consider imaging,
first-line ultrasound
Provide information to woman
and discuss treatment options

Severe impact on quality

of life + no desire to
conceive + normal uterus
small fibroids
(<3cm diameter)

Endometrial
ablation

Other treatments have failed,

are contraindicated or declined
Desire for amenorrhoea
Fully informed woman requests it
No desire to retain uterus
and fertility

Hysterectomy
Dont remove
healthy ovaries

Myomectomy

Severe impact on quality of life

Fibroids (>3 cm diameter)

Uterine artery
embolisation

Care Pathway adapted from NICE Guideline and Models of Care in womens health (RCOG)

Figure 1

among women who are obese, who have significant pathology,

who have had previous surgery or who have pre-existing medical
conditions.

requirement, earlier mobilization and earlier discharge from

hospital. However this approach requires skills in advanced
laparoscopic surgery. Operating time tends to be longer during
the early stages of acquiring these skills, and complication rates
such as haemorrhage, bowel and bladder injury and a higher
chance of conversion of procedure to open technique tends to be
higher. These risks tend to be higher among women who are
obese, with associated co-morbidities such as endometriosis,
Pelvic Inflammatory Disease, previous caesarean sections, adhesions and previous abdominal and pelvic surgery (Figure 1).

Serious risks
 The overall risk of serious complications from abdominal
hysterectomy is approximately four women in every 100.
 Damage to the bladder and/or the ureter (seven women in
every 1000) and or long-term disturbance to the bladder
function.
 Damage to the bowel: four women in every 10 000.
 Haemorrhage requiring blood transfusion, 23 women in
every 1000.
 Return to theatre because of bleeding/wound dehiscence,
and so on: seven women in every 1000.

Risks related to various routes for hysterectomy

It is recommended that clinicians should counsel women as
regards risks associated with surgery which tend to be higher

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 24:1

2013 Elsevier Ltd. All rights reserved.

REVIEW

 Pelvic abscess/infection: two women in every 1000.

 Venous thrombosis or pulmonary embolism, four women
in every 1000.
 Risk of death within 6 weeks, 32 women in every 100 000.

Shankar M, Lee CA, Sabin CA, et al. von Willebrand disease in women with
menorrhagia: a systematic review. BJOG 2004; 111: 734e40.
Wedisinghe L, Lumsden MA. Heavy menstrual bleeding. In: Mahmood T,
Templeton A, Dhillon C, eds. Models of care in womens health.
London: RCOG Press, 2009; 67e80.

Frequent risk
Frequent risks include wound infection, pain, delayed wound
healing, keloid formation, numbness, tingling or burning sensation around the scar, frequency of micturition, urinary tract
infection and premature ovarian failure.

Practice points

Severe acute heavy menstrual bleeding

Severe acute HMB can occur as a result of a coagulopathy (most
commonly von Willebrands disease), prolapsed fibroids, AVMs,
or anti coagulation. Initial management is based on haemodynamic stability followed by treatment of the specific condition.A

FURTHER READING
Critchley HOD, Colin Duncan W, Brito-Mutunayagam S, Reynolds RM.
Obesity and menstrual disorders. In: Mahmood T, Arulkumaran S, eds.
Obesity e a ticking time bomb for reproductive health. London:
Elsevier Insights Series, 2013; 525e36.
Darlow KL, Horne AW, Critchley HO, et al. Management of vascular uterine
lesions associated with persistent low level HCG. J Fam Plann Reprod
Health Care 2008 Apr; 34: 118e20.
Lethaby AE, Cooke I, Rees M. Progesterone or progestogen releasing
intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev 2005; CD002126.
McGurgan P, ODonovan P. Second generation endometrial ablation: an
overview. Best Pract Res Clin Obstet Gynaecol 2007 Dec; 21: 931e45
[Epub 2007 May 23].
National Collaborative Centre for Womens and Childrens Health. Heavy
menstrual bleeding. London: RCOG Press, 2007. http://guidance.nice.
org.uk/CG44.
Rashid S, Khaund A, Murray LS, et al. The effects of UAE and surgical
treatment on ovarian function in women with uterine fibroids. BJOG
2010; 117: 985e9.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 24:1

The term menorrhagia should be replaced by heavy menstrual

bleeding.
HMB may have a major impact on a womans quality of life and
any intervention should aim to improve this rather than
focussing on menstrual blood loss.
The initial management should take place within a primary
care setting following an abdominal and pelvic examination
and measurement of full blood count.
If history or clinical findings are suggestive of structural abnormality, ultrasound should be the primary investigation
backed up by hysteroscopy.
Endometrial biopsy is indicated in cases of prolonged or
persistent inter menstrual bleeding and in cases of treatment
failure in women over 45 years.
Endometrial ablation is cheap safe and effective for relief of
HMB and may be offered as a first line treatment for women
who decline medical options.
Long term satisfaction is high with hysterectomy, but it is
associated with significant morbidity and mortality and should
be offered only if simpler alternatives have failed.
Healthy ovaries should not be removed at hysterectomy and
the route for hysterectomy should be determined by assessment of individual patients, as well as by the skill and experience of the individual clinician.

2013 Elsevier Ltd. All rights reserved.