Heavy Menstrual Bleeding (HMB) - Treatment and Management

Definition and Classification

• PALM (structural - diagnosable by imaging/histology): Polyps, Adenomyosis, Leiomyoma, Malignancy/hyperplasia
• COEIN (non-structural): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not otherwise classified

Initial Evaluation

1. History - amount/duration of blood loss, bleeding since menarche, family history of coagulopathy, medications
2. Pregnancy test - always exclude ectopic/intrauterine pregnancy
3. Labs - CBC, thyroid function, prolactin, fasting glucose, coagulation screen (especially von Willebrand disease if bleeding since menarche), STI screening
4. Pelvic ultrasound (TVUS) - high sensitivity/specificity for polyps, fibroids, adenomyosis; MRI if TVUS is declined or inconclusive
5. Endometrial biopsy - indicated in women ≥45 years, or younger with risk factors: obesity, unopposed estrogen exposure, PCOS, persistent AUB refractory to medical therapy, elevated familial cancer risk

Medical Management (First-Line)

Non-Hormonal Options

Tranexamic acid is more effective than NSAIDs in decreasing HMB and is preferred as a first-line non-hormonal option. - Berek & Novak's Gynecology

Hormonal Options

• Reduces menstrual blood loss by 71-95%, with ~50% of women becoming amenorrhoeic after 1 year
• FDA-approved for HMB in women requiring contraception; recommended as first-line medical therapy for this group
• Reductions of up to 90% reported in some series
• Superior to combined oral contraceptive pills (35-69% reduction)

• Reduce HMB by ~50% with similar reduction in pain
• Preferred in young, healthy women with anovulatory bleeding and no concern for endometrial pathology
• Acute (emergency) regimen: 1 pill every 6 hours for 5-7 days - bleeding should cease within 24 hours
• Continued cyclically for prevention of recurrence
• Also appropriate for adolescents, especially if contraception is needed

• Preferred in older, obese, or perimenopausal women where endometrial pathology is a concern, or when estrogen is contraindicated
• Works by reducing estrogen receptor availability and stabilizing the endometrium
• Regimens:
  • Medroxyprogesterone acetate (MPA) 20 mg TID for 7 days (ACOG recommendation)
  • MPA 10 mg orally daily for 10 days
  • MPA 5-10 mg orally for 10 days (with IV conjugated estrogens 25 mg q4h for acute profuse bleeding)
• Long-term options: continuous oral norethindrone, norethindrone acetate, or MPA

• Induce amenorrhea by creating a hypo-oestrogenic state; also shrink fibroids
• Limited by: menopausal side effects, bone mineral density loss (>6 months use), rebound fibroid regrowth on cessation, high cost
• Used short-term (e.g., pre-operatively to shrink fibroids)

• Elagolix 300 mg twice daily or relugolix 40 mg daily - oral alternatives for fibroid-related HMB
• A 2025 meta-analysis (PMID 39821450) confirms efficacy of GnRH antagonists in uterine fibroid management

• Licensed only where surgery/UAE is inappropriate or has failed
• Use with caution - associated with severe liver injury; requires liver function monitoring

Special Populations

Acute/Profuse Bleeding (Emergency)

1. Combined OCP 1 pill every 6 hours until bleeding stops, then taper
2. IV conjugated estrogens 25 mg every 4 hours (up to 3 doses) + simultaneous progestin
3. Tranexamic acid for antifibrinolytic support
4. If intrauterine clots detected: suction curettage, misoprostol (uterotonicson), or intrauterine Foley balloon tamponade (26F, 30 mL)
5. Blood transfusion if profound anaemia

Adolescents

• Mild bleeding (adequate Hb, minimal disruption): menstrual charting, reassurance, supplemental iron
• Moderate-severe: COCPs first-line (also addresses contraception)
• LNG-IUS highly effective (up to 90% reduction) and FDA-approved; local anaesthesia aids insertion
• Endometrial ablation and D&C are generally avoided in adolescents (fertility concerns)
• Coagulopathies: COCPs, tranexamic acid, or intranasal desmopressin (DDAVP)

Coagulopathy (e.g., Von Willebrand Disease)

• COCPs, tranexamic acid, or desmopressin
• Avoid combined contraceptives and tranexamic acid if active thrombotic disease

Perimenopausal Women

• Progestin-only therapy preferred (endometrial pathology concern)
• Must exclude endometrial hyperplasia/malignancy before long-term management

Radiological / Minimally Invasive Interventions

Surgical Management

Uterus-Preserving Surgery

• Hysteroscopic polypectomy - for endometrial polyps; risk: uterine perforation
• Transcervical resection of fibroids (TCRM) - complications: hyponatraemia (fluid overload), thermal injury
• Myomectomy (open or laparoscopic) - for symptomatic fibroids; 25-30% recurrence; conversion to hysterectomy <1%

Non-Uterus-Preserving Surgery

• Endometrial ablation/resection
  • Ablates endometrium to basal layer using electrical, thermal, or laser energy
  • Requires: failure of medical therapy, no desire for fertility, no pathologic diagnosis

  • 90% report reduced blood loss at 2 years; 25-35% achieve amenorrhoea

  • Note: ~29% require hysterectomy by 60 months post-ablation
  • Contraindicated in women wishing to retain fertility
• Hysterectomy (last resort)
  • Total preferred over subtotal (cervical stump bleeding risk)
  • Reserved for: refractory disease, malignancy on endometrial sampling, patient preference after all alternatives explored
  • Complications: damage to surrounding organs, fistula

Management Summary by Cause

Recent Evidence (2024-2026)

• A 2025 Cochrane systematic review (PMID 40183418) assessed preoperative medical therapy before fibroid surgery, supporting use of GnRH analogues to reduce fibroid size and blood loss pre-operatively.
• A 2025 meta-analysis (PMID 39617186) reviewed etiology of HMB across age groups, confirming coagulopathies (especially von Willebrand disease) are a significantly underdiagnosed cause - screening is important.
• A 2024 systematic review (PMID 38654586) highlighted unmet needs in adolescents with HMB, noting self-management strategies are often inadequate and specialist referral is underutilized.