Hypermenorrhoea (Heavy Menstrual Bleeding) - No Fibroids, OCP Declined

Clinical Clarification

CAUSES of Hypermenorrhoea (AUB Classification - PALM-COEIN)

Structural (PALM)

Non-structural (COEIN)

Key: Anovulatory bleeding (AUB-O) is the most common cause in reproductive-age women. Without progesterone to stabilize the endometrium, shedding is irregular, not limited in amount or duration, and not accompanied by spiral arteriolar vasoconstriction - Berek & Novak's Gynecology, p. 437.

• Hypothyroidism (TSH) - severe hypothyroidism causes HMB
• Hyperprolactinaemia
• Chronic PID
• Morbid obesity

NEXT STEP OF MANAGEMENT (OCP declined, wants future pregnancy)

Step 1 - Complete the workup (if not done)

• CBC (rule out anaemia, thrombocytopenia)
• TSH, prolactin
• Coagulation screen (PT, aPTT, bleeding time, von Willebrand studies) - especially if HMB since menarche
• Transvaginal ultrasound (adenomyosis, endometrial thickness, polyps)
• Endometrial biopsy if age >35 or risk factors for hyperplasia
• Day 21 progesterone (to confirm if ovulatory)

Step 2 - Medical Management Options (fertility-sparing, OCP declined)

• Up to 96% reduction in blood loss at 12 months
• ~50% of users become amenorrhoeic at 12 months
• Releases low-dose levonorgestrel locally into the uterine cavity - causes gland atrophy and decreases flow
• Does NOT impair future fertility (removed when pregnancy desired)
• Approved for contraception but highly effective for HMB
• First-line non-OCP option for menorrhagia - Swanson's Family Medicine Review, p. 411

• 1g TDS during menstruation (cycle days 1-5)
• Reduces blood loss by ~40-50%
• No hormonal effects, fertility preserved
• Good for women who want purely cycle-based treatment

• Taken during menstruation
• Reduce blood loss by 20-30%
• Also help if dysmenorrhoea is present

• Norethisterone 5mg TDS from day 5-26 of cycle
• Effective for anovulatory bleeding - addresses inadequate luteal phase
• Does not provide contraception (unlike OCP)
• Can be used if patient wants a hormonal option without combined pill

• Eventually induces amenorrhoea
• Provides contraception
• Note: Fertility return may be delayed after stopping

Step 3 - If Medical Management Fails (refractory cases)

Summary Algorithm for THIS Patient

Hypermenorrhoea + No fibroids on hysteroscopy + OCP declined + Wants future pregnancy
            ↓
Complete workup: CBC, TSH, coagulation screen, TVUS, Day 21 progesterone
            ↓
   ┌─────────────────────────────────────────┐
   │ FIRST-LINE: LNG-IUS (Mirena)            │
   │ - 96% reduce blood loss                 │
   │ - Reversible, fertility preserved       │
   └─────────────────────────────────────────┘
            OR (if IUS refused or not appropriate)
   ┌─────────────────────────────────────────┐
   │ Tranexamic acid + NSAID during periods  │
   │ ± Cyclic progestogen (day 5-26)         │
   └─────────────────────────────────────────┘
            If no response → Surgical evaluation

Sources: Swanson's Family Medicine Review, p. 410-411; Berek & Novak's Gynecology, p. 437; Rosen's Emergency Medicine.

Hypermenorrhoea - Full Detailed Explanation

1. Understanding the Clinical Scenario

• Heavy flow ("hypermenorrhoea")
• Cycles every 25 days (slightly frequent)
• Hysteroscopy (HSK) - no fibroids found (rules out submucosal leiomyoma)
• Doctor suggested OCPs but patient declined
• Wants future pregnancy (so fertility must be preserved)

2. CAUSES - Full Explanation Using PALM-COEIN

PALM = Structural Causes

• Endometrial polyps are fleshy overgrowths of the endometrial lining
• They cause heavy menstrual bleeding AND intermenstrual spotting
• Important: Hysteroscopy is actually the gold standard to diagnose polyps. If HSK was done and no polyps were reported, this is largely ruled out - BUT small polyps can be missed
• Associated with tamoxifen use and infertility
• Treatment: Hysteroscopic polypectomy (fertility-preserving)

• Endometrial glands and stroma embedded within the myometrium (uterine muscle)
• Causes the uterus to become bulky, boggy, and tender
• Classic presentation: Heavy, PAINFUL, regular cycles - "dysmenorrhoea + menorrhagia"
• NOT visible on hysteroscopy (hysteroscopy only sees the uterine cavity surface)
• Diagnosed on transvaginal ultrasound (heterogeneous myometrium, myometrial cysts) or MRI (most accurate)
• This is a commonly missed cause when hysteroscopy is done and called "normal"

• Endometrial hyperplasia from unopposed oestrogen can cause HMB
• Endometrial carcinoma - less likely in young women but must be considered if >35 years or risk factors (obesity, PCOS, nulliparity, diabetes)
• Diagnosed by endometrial biopsy

COEIN = Non-Structural Causes

• 5-20% of women with menorrhagia have an undiagnosed bleeding disorder
• Most common: Von Willebrand Disease (VWD) - a deficiency/dysfunction of VWF protein needed for platelet plug formation
• Suspect if:
  • Heavy bleeding since menarche (first period)
  • Easy bruising, epistaxis (nosebleeds)
  • Prolonged bleeding after dental work or surgery
  • Family history of bleeding disorders
  • Postpartum haemorrhage
• Also consider: Thrombocytopenia (low platelets), liver disease (reduced clotting factor production), anticoagulant drugs

In a normal ovulatory cycle, after ovulation the corpus luteum produces progesterone. Progesterone stabilises the endometrium by causing it to become secretory and structurally organised. When progesterone is withdrawn at the end of the cycle, the endometrium sheds in an orderly, synchronised way - with spiral arteriolar vasoconstriction that limits blood loss.

When there is no ovulation (anovulation), there is no progesterone. The endometrium is stimulated by oestrogen alone and keeps proliferating. When it eventually breaks down, it does so randomly, from different sites at different times, without vasoconstriction - so bleeding is heavy, irregular, and prolonged.

• Low oestrogen levels = irregular light/prolonged bleeding
• High sustained oestrogen = episodes of amenorrhoea followed by sudden heavy bleeding

• In ovulatory women, the endometrium itself can be the problem
• Imbalance between local vasoconstrictors (prostaglandin F2α, endothelin-1) and vasodilators (prostaglandin E2, prostacyclin I2)
• When vasodilators dominate, more blood loss occurs during menstruation
• This is why NSAIDs work - they block prostaglandin synthesis, shifting the balance toward vasoconstriction
• Chronic endometritis (e.g., from Chlamydia infection) can also cause menorrhagia

• Copper IUD causes heavier periods
• Anticoagulants (heparin, warfarin, NOACs)
• Steroids, tamoxifen
• Breakthrough bleeding with progestin-only pills / implants

• Arteriovenous malformations
• Myometrial hypertrophy
• Rare and poorly understood causes

3. Why the Doctor Suggested OCPs

1. Suppressing ovulation (no LH surge)
2. Providing cyclical progestogen that stabilises the endometrium
3. Thinning the endometrium (reduced blood loss)
4. Regularising cycles

4. NEXT STEP OF MANAGEMENT (OCP Declined, Fertility Desired)

Step 1 - Investigations That Should Be Done First

Step 2 - Medical Treatment Options (Fertility-Preserving, No OCP)

Option A: Levonorgestrel-IUS (LNG-IUS / Mirena) - BEST FIRST-LINE CHOICE

• A small T-shaped device placed inside the uterus
• Releases a tiny, steady dose of levonorgestrel (a progestogen) directly into the uterine cavity
• This causes: local endometrial gland atrophy → thins the endometrium → dramatically reduces menstrual flow
• Systemic absorption is minimal (avoids most hormonal side effects)

• Up to 96% reduction in blood loss at 12 months
• About 50% of women become completely amenorrhoeic (no periods) at 12 months
• As effective as surgical endometrial ablation

• No systemic hormonal effects
• Fertility fully restored when removed (woman can get pregnant shortly after removal)
• Lasts up to 5-7 years
• Does not interfere with the HPO axis in the same way OCPs do
• First-line non-pill option per ACOG and FIGO guidelines

• Irregular/unpredictable spotting in first 3-6 months (counsel the patient about this upfront)
• Cramping at insertion
• Small risk of expulsion or perforation

Option B: Tranexamic Acid (TXA)

• The endometrium normally breaks down fibrin clots through fibrinolysis (via plasminogen activators)
• In women with HMB, there is excess fibrinolytic activity in the endometrium
• Tranexamic acid is an antifibrinolytic - it blocks the conversion of plasminogen to plasmin, preventing clot breakdown
• This helps blood clots form and stay at the bleeding site, reducing blood loss

• No hormonal effects at all - does not affect fertility or ovulation
• Only taken during periods (not a daily medication)
• Can be combined with NSAIDs for additive effect

Option C: NSAIDs (e.g., Mefenamic Acid, Ibuprofen)

• Block COX enzymes → reduce prostaglandin synthesis
• Shift endometrial prostaglandin balance toward vasoconstrictors (PGF2α > PGE2)
• Reduce both blood loss AND dysmenorrhoea (pain)

Option D: Cyclic Oral Progestogens

• Artificially replaces the progesterone that is absent in anovulatory cycles
• Stabilises the endometrium so it sheds in an organised, controlled manner

• Norethisterone 5mg 3 times a day, days 5 to 26 of the cycle
• Medroxyprogesterone acetate (MPA) 10mg OD, days 12-26

• Works best for anovulatory AUB (AUB-O)
• Does NOT provide contraception (unlike OCPs)
• Fertility is preserved
• Side effects: Bloating, mood changes, breast tenderness

Option E: Depot Medroxyprogesterone Acetate (DMPA / Depo-Provera)

• IM injection every 3 months
• Eventually induces amenorrhoea in most women
• Downside: Fertility return may be delayed by 6-18 months after stopping - relevant for this patient who wants to conceive

Step 3 - If Medical Treatment Fails (Surgical Options)

5. The Big Picture - Putting It Together

Patient: Hypermenorrhoea, HSK = no fibroids, wants future pregnancy, OCP refused
         ↓
First: Investigate → TSH, CBC, Day 21 progesterone, TVUS, coag screen if indicated
         ↓
 Is there an identifiable cause?
 ├─ Hypothyroidism → Treat with levothyroxine
 ├─ PCOS → Metformin ± progestogens
 ├─ Adenomyosis on TVUS → LNG-IUS best option
 ├─ Polyp on TVUS → Hysteroscopic polypectomy
 ├─ VWD/Coagulopathy → TXA + DDAVP + haematology referral
 └─ No clear cause (AUB-E or AUB-O) → Proceed to treatment below
         ↓
Medical Treatment (OCP declined, fertility desired):
 FIRST CHOICE → LNG-IUS (Mirena) - 96% reduction, reversible
 ALTERNATIVE → Tranexamic acid + NSAID during periods
 IF ANOVULATORY → Add cyclic norethisterone day 5-26
         ↓
 No response after 3-6 months?
         ↓
Surgical review (ablation only if family complete; GnRH agonist as bridge)

Sources: Berek & Novak's Gynecology (PALM-COEIN, AUB-O mechanism, AUB-C); Swanson's Family Medicine Review (LNG-IUS 96% efficacy, management algorithm)

Updated Clinical Picture

What This Tells You Clinically

TRACK 1 - STOP THE BLEEDING (Immediate)

High-Dose Progestogen (Norethisterone) - Drug of Choice Here

• The endometrium has been continuously stimulated by oestrogen without progesterone (anovulatory)
• It has become thick, fragile, and unstable - shedding from random sites continuously
• High-dose progestogen rapidly stabilises and organises the endometrium, stopping the shedding
• Once stopped and dose reduced, a withdrawal bleed occurs (like a "reset"), after which normal cycles can resume

• Norethisterone 5 mg THREE times a day (every 8 hours) to stop active bleeding
• Once bleeding stops (usually within 24-48 hours), continue for another 7-10 days
• Then taper the dose and stop
• A withdrawal bleed will follow 2-3 days after stopping
• After this, start cyclic norethisterone (day 5-26) for ongoing cycle control

This is the standard approach in anovulatory prolonged bleeding without OCP - analogous to using progesterone to "lock down" a runaway endometrium.

If Extremely Heavy / Not Responding:

• IV conjugated oestrogen (Premarin 25mg IV) - rapidly promotes endometrial proliferation and re-epithelialisation to stop acute bleeding
• Then follow with progestogen to stabilise

Tranexamic Acid (Adjunct)

• 1g TDS during active bleeding
• Reduces ongoing blood loss by 40-50% by blocking fibrinolysis
• Can be used simultaneously with progestogen
• Safe, no fertility impact

NSAIDs (Adjunct)

• Mefenamic acid / Ibuprofen
• Reduces prostaglandin-driven vasodilation in endometrium
• Helps control flow + any pain

TRACK 2 - TREAT THE ANAEMIA

Iron Replacement (Mandatory)

• Ferrous sulphate 325 mg (contains ~65 mg elemental iron) - 2 to 3 tablets per day
• Total elemental iron needed: 200-300 mg/day
• Take on an empty stomach for best absorption (with vitamin C)
• Reticulocyte count rises in 4-7 days, peaks at 10 days
• Hb rises by ~1 g/dL per week with adequate iron
• Continue treatment for 3-6 months after Hb normalises to replenish iron stores (ferritin)

• If she has chest pain, breathlessness at rest, haemodynamic instability → transfuse 1-2 units packed RBCs
• If she is stable (just tired, pale) → IV iron (faster than oral, bypasses GI absorption issues) + oral iron ongoing
• IV iron options: Ferric carboxymaltose (single large dose), iron sucrose

TRACK 3 - LONG-TERM PREVENTION (Once Bleeding Controlled)

LNG-IUS (Mirena) - INSERT AFTER ANAEMIA IS CORRECTED

• Wait until Hb is >10 g/dL before insertion (reduces procedure risk)
• 96% reduction in blood loss at 12 months
• 50% achieve complete amenorrhoea
• Fully reversible - remove when she wants to conceive
• No systemic hormonal effects

• Cyclic norethisterone (day 5-26 each month)
• Tranexamic acid during each period

Complete Management Summary for This Patient

PROBLEM: Bleeding x 25 days + Hb 8 g/dL + No fibroids + OCP declined

STEP 1 → STOP BLEEDING (Immediately)
   Norethisterone 5mg TDS until bleeding stops, then taper
   + Tranexamic acid 1g TDS
   + NSAIDs (mefenamic acid 500mg TDS)

STEP 2 → TREAT ANAEMIA (Simultaneously)
   Hb 8, stable → IV Ferric Carboxymaltose OR Oral Ferrous Sulphate 325mg TDS
   Hb 8, symptomatic → 1-2 units packed RBCs + IV iron

STEP 3 → INVESTIGATE THE CAUSE
   TSH, Prolactin, Day 21 progesterone
   TVUS (adenomyosis? polyp?)
   Coagulation screen if HMB since menarche

STEP 4 → LONG-TERM CONTROL (Once stable, Hb > 10)
   Insert LNG-IUS (Mirena) ← FIRST CHOICE
   OR Cyclic norethisterone day 5-26

STEP 5 → CONTINUE IRON for 3-6 months to replenish stores