heavy%20menstrual%20bleeding
HEAVY MENSTRUAL BLEEDING
Treatment Guideline Chart
Heavy menstrual bleeding is prolonged (>7 days) or excessive (>10 mL) uterine bleeding occurring at regular intervals over several menstrual cycles.
It is menstrual blood loss that is excessive and interferes with patient's physical, emotional, social and quality of life.
It is also referred to as menorrhagia or hypermenorrhea.
It is a common problem in women of reproductive age that usually causes anemia.
Uterine fibroids and polyps are the most common pathology identified.

Surgical Intervention

Considered in cases where patient does not desire future pregnancy, or in the presence of pelvic disease (ie uterine fibroid tumors)

Endometrial Ablation (EA)

  • Aims to destroy or remove the endometrium and the superficial myometrium which reduces or completely stops menstrual blood loss
  • Should be considered in women who have a normal or ≤10-week pregnancy-sized uterus, those with <3-cm uterine fibroids, those wherein medical treatment has failed, who completed child-bearing or who are not candidates for major surgery
  • After endometrial ablation, women are advised to avoid subsequent pregnancy and the need to use effective contraception, if required
  • Results in faster return to normal activities compared with hysterectomy but is associated with a 22% reintervention rate
  • Divided into 1st- and 2nd-generation methods, depending on whether direct visualization is needed or not

Hysteroscopic-Guided Endometrial Ablation

  • First-generation methods, eg transcervical resection of the endometrium (TCRE), rollerball EA (REA)
  • Performed through a hysteroscope
  • Recommended in patients who will also undergo hysteroscopic myomectomy
  • Involves distending the uterine cavity with fluid and then resecting the tissue with an electrosurgical loop (TCRE method) or burning the tissue with a heated rollerball (REA method)
  • Takes more time to perform, requires regional or general anesthesia and is technically more difficult than 2nd-generation methods
  • Not suitable for patients with cardiac or renal disease due to 4% risk of fluid overload

Non-Hysteroscopic Methods

  • Second-generation technologies, eg thermal balloon endometrial ablation (TBEA), microwave EA (MEA), hydrothermablation, bipolar radiofrequency EA, endometrial cryotherapy
  • Used when there is no structural or histological abnormality identified
  • Not done under direct visualization of the uterine cavity
  • Easier to learn and safer to use
    • Risks of complications are fewer and anesthetic requirement is lesser than hysteroscopic ablation

Hysterectomy

  • Appropriate for women who have completed their family, have failed or are contraindicated for other treatment options, do not want to retain their uterus, fertility or menstrual bleeding, and are willing to assume the risks of surgery
  • 3 main routes: Abdominal hysterectomy (AH), vaginal hysterectomy (VH) and laparoscopic hysterectomy (LH)
    • Choice of route depends on the size or mobility of the uterus, size and location of uterine fibroids, size and shape of the vagina, presence of other gynecological conditions and history of previous surgery
    • VH is the preferred route; contraindicated in patients with large uterus, presence of pathology and low uterine mobility
  • Possible unwanted outcomes include infection and less commonly, intraoperative hemorrhage, damage to other abdominal organs and urinary dysfunction
  • Bilateral oophorectomy is not recommended if patient has healthy ovaries

Myomectomy

  • Recommended for women with >3-cm uterine fibroids who want to retain their uterus and fertility
  • May be performed via an abdominal approach, laparoscopically, or hysteroscopically
  • Possible unwanted outcomes include adhesions (which may result in pain and/or impaired fertility), infection, perforation and recurrence of fibroids

Uterine Artery Embolization (UAE)

  • Advised in patients with >3-cm uterine fibroid who want to retain their uterus and fertility and avoid surgery
  • Done by an interventional radiologist through injecting particles in the uterine arteries causing blockage and then shrinkage of the fibroids
  • Studies showed that effect on HMB that is associated with uterine fibroid is similar to hysterectomy and myomectomy

Magnetic Resonance-Guided Focused Ultrasound Surgery (MRgFUS)

  • Uses focused high-intensity ultrasound waves to destroy fibroid tissue  
  • A noninvasive approach with shorter recovery time  
  • Effective and safe to use for uterine fibroids in the short term



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