To realise what is abnormal, an understanding of normal menstruation is required.

Causes of abnormal bleeding

Non-reproductive causes

• Systemic disease disorders of blood coagulation – e.g. von Willebrand's disease or prothrombin deficiency, leukaemia, idiopathic thrombocytopenic purpura and hypersplenism. Consider screening for adolescents who have had heavy menses since menarche, or if other signs present.
• Hypothyroidism – often associated with menorrhagia or intermenstrual bleeding (IMB). Measure thyroid-stimulating hormone and treat with levothyroxine.
• Cirrhosis – associated with reduced ability of liver to metabolise oestrogens, and hypoprothrombinaemia.

Diseases of the reproductive tract

• The most common causes during fertile age are those related to pregnancy, e.g. threatened, incomplete or missed abortion, ectopic pregnancy. Trophoblastic disease should be considered in women with recent pregnancy.
• Malignancies – endometrial and cervical carcinoma are the most common; also, ovarian carcinoma.
• Endometritis – usually presents as intermenstrual spotting.
• Fibroids, endometrial polyps and adenomyosis.
• Cervical lesions – erosions, polyps and cervicitis - presenting as post-coital spotting.
• Iatrogenic – hormones used for contraception or hormone replacement therapy (HRT) or management of other conditions. Some psychotropic drugs.

Dysfunctional uterine bleeding

Dysfunctional uterine bleeding (DUB) is defined as abnormal uterine bleeding in the absence of organic disease.¹

• It usually presents as heavy menstrual bleeding (menorrhagia). The diagnosis of DUB can only be made once all other causes of abnormal or heavy, uterine bleeding have been excluded. The pathophysiology is largely unknown.²
• The National Institute for Clinical Excellence defines heavy menstrual bleeding as 'excessive menstrual blood loss which interferes with the woman's physical, emotional, social and material quality of life, and which can occur alone or in a combination with other symptoms'.³

Investigations

Ask women to complete a menstrual calendar.

• Every woman presenting with heavy menstrual bleeding should have a full blood count taken.
• Serum ferritin, female hormone testing and thyroid testing are not routinely recommended. Only do this if there is a strong clinical suspicion of underlying pathology.³
• Coagulation studies, liver function tests or thyroid function tests only if there is a suspected problem.
• Luteal phase serum progesterone to determine if ovulating.

Management

This depends on the underlying cause.
If the patient is ovulating with menorrhagia, the presence of uterine lesion should be excluded. Consider referral for hysteroscopy, or transvaginal ultrasound.

Pharmacological

In dysfunctional uterine bleeding:³

• First-line: levonorgestrel-releasing intrauterine system - provided for long-term use (i.e. at least 12 months) is anticipated.
• Second-line: tranexamic acid or non-steroidal anti-inflammatory drugs (NSAIDs), if non-hormonal preferred, or combined oral contraceptive pills (COCPs).
• Third-line: norethisterone (15 mg) daily from days 5 to 26 of the menstrual cycle, or injected long-acting progestogens.⁴

Surgical

This should only be considered if:

• Pharmacological management has failed.
• There is severe impact on quality of life.
• There is no desire to conceive.
• The uterus is normal (or there are just small fibroids <3 cm).

Options include endometrial ablation and hysterectomy.

When to refer to secondary care

Referral to secondary care for further gynaecological assessment and examination should be made:

• In women aged over 45 yrs with heavy menstrual bleeding.
• If there is persistent IMB.
• If an abnormality is suspected on physical examination (other than fibroids < 3 cm in diameter).
• If there is suspicion from the history of increased risk of pathology, such as carcinoma (e.g. family history or endometrial or colonic cancer, nulliparity, obesity, tamoxifen or unopposed oestrogen therapy, abnormal smear, polycystic ovarian syndrome).
• If there is treatment failure.

Document references

1. Pitkin J; Dysfunctional uterine bleeding. BMJ. 2007 May 26;334(7603):1110-1.
2. Behara MA, Price TM. Dysfunctional Uterine Bleeding. e-Medicine. June 2009.
3. Heavy menstrual bleeding, NICE Clinical Guideline (January 2007)
4. Lethaby A, Irvine G, Cameron I; Cyclical progestogens for heavy menstrual bleeding. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD001016. [abstract]

Internet and further reading

• Menorrhagia, Clinical Knowledge Summaries (2007)
• Dysmenorrhoea, Clinical Knowledge Summaries (April 2009)
• Matytsina LA, Zoloto EV, Sinenko LV, et al; Dysfunctional uterine bleeding in adolescents: concepts of pathophysiology and management. Prim Care. 2006 Jun;33(2):503-15. [abstract]

Acknowledgements