Menstrual disturbances account for a large number of presentations to the primary care physician as well as the specialist; this article will focus on heavy menstrual bleeding and dysmenorrhoea.
Heavy menstrual bleeding (HMB) is defined as excessive menstrual blood loss (MBL) that interferes with a woman’s social, physical, emotional and/or material quality of life. HMB accounts for around one-fifth of gynaecologist visits. A quantitative definition of 80ml of menstrual blood loss or more per period is sometimes used, usually in a research setting.1 HMB has replaced the term ‘menorrhagia’ after the FIGO classification system (see Table 1) was published in 2012. This system also provides a simple framework by which to recall the causes of abnormal uterine bleeding in the form of the acronym ‘PALM-COEIN’.2 It must be remembered that these pathological processes can cause abnormal bleeding patterns other than HMB, such as intermenstrual or postmenopausal bleeding. Nonetheless, the acronym provides the clinician with a sound structure upon which to base the history, examination and investigations.
It should be borne in mind that 80 per cent of women with HMB do not have an anatomical pathology. In these women, higher concentrations of endometrial prostaglandins such as PgF2α and PgE2 have been found.3
Dysmenorrhoea can be regarded as primary and secondary. Primary dysmenorrhoea refers to pain that is not related to organic disease and is characteristically cramping lower abdominal pain radiating to the back and thighs. It can be associated with gastrointestinal or neurological symptoms. A recent Canadian study found that 60 per cent of women experience dysmenorrhoea. One fifth of these women need time off work/study to cope.4 Despite how common it is, most women do not seek medical attention. The pathogenesis of dysmenorrhoea has been well studied and is believed to be mediated by the cyclical production of prostaglandins leading to uterine hypercontractility, ischaemic-related pain caused by reduced pelvic blood flow and increased peripheral nerve hypersensitivity.
Secondary dysmenorrhoea is menstrual pain caused by an identifiable pelvic pathology. It is often associated with dyspareunia and can precede the onset of bleeding by a few days. There is an overlap between causes of secondary dysmenorrhoea and chronic pelvic pain (see Table 2).5
A full medical, gynaecological and family history should be taken. The gynaecological history should include menstrual frequency, volume as quantified by number of pads/tampons changed per day, presence of flooding or clots and symptoms of anaemia. Menstrual pain should be assessed in terms of disturbance to activities of daily living, need for analgesics and associate symptoms, which may include dyschezia, dyspareunia and mood disturbances. A general medical and surgical history may also illuminate other causative factors such as coagulopathy and risk factors for malignancy. Medication history, such as use of anticoagulants and iron supplementation, is important.
Table 1. The FIGO classification system.
|Structural abnormalities||Non-structural abnormalities|
|P – polyps||C – coagulopathy|
|A – adenomyosis||O – ovulatory dysfunction|
|L – leiomyoma||E – endometrial|
|M – malignancy and hyperplasia||I – iatrogenic|
|N – not yet classified|
Examination can give important clues about causative factors. A large fibroid uterus is often palpable abdominally. Speculum examination allows assessment of ongoing blood loss and may reveal cervical causes of bleeding. Asking women to document the number of pads used and the degree of staining is helpful. A bimanual examination in a woman with endometriosis may elicit hyperalgesia and may reveal the presence of uterosacral nodules or fixation of the uterus. Although up to 47 per cent of women with endometriosis on laparoscopy have normal pelvic examinations, the finding of nodular disease can help with planning surgical management.6
The investigation of women with heavy and/or painful menstrual periods should include: bHCG; Pap smear; pelvic ultrasound scan (USS) and HyCoSy can be considered if USS shows evidence of an endometrial polyp; full blood count; iron studies; and clotting studies if indicated on history.
Antifibrinolytic agents and non-steroidal anti-inflammatory drugs (NSAIDs) are first-line agents. Both should be used only during menstruation. In a systematic review, tranexamic acid was found to be significantly more effective at reducing MBL than any NSAID. Differences between NSAIDs were studied in the same review, which found there was no significant difference between mefenamic acid and naproxen. Despite concerns, there is no evidence that long-term use of antifibrinolytics increase the risk of venous thrombosis.7
The combined oral contraceptive pill (COCP) is a good choice for women who are also seeking contraception. One non-randomised study reported a 53 per cent decrease in MBL. The COCP is also an option for older women who are non-smokers without risk factors for thromboembolic disease.8
Table 2. Causes of pelvic pain in women undergoing diagnostic laparoscopy for pelvic pain
|Chronic pelvic inflammatory disease||5|
Cyclical progestogens are often used during episodes of HMB as they oppose the proliferative effects of oestrogen on the endometrium. Norethisterone 5mg or medroxyprogesterone acetate 10mg, both used three times daily during 21 days of a 28 day cycle, have been shown to be effective at reducing MBL.9
The levonorgestrel-releasing intrauterine system (LNG-IUS) exposes the endometrium to continuous progestogen, hence causing atrophy and a reduction in menstrual bleeding of up to 80 per cent at six months and over 90 per cent by 12 months. Gupta et al found that the LNG-IUS was significantly more effective than the usual treatment, which included a combination of NSAIDs and hormonal treatment. When compared to other medical therapies, women using the LNG-IUS were more likely to cancel their planned hysterectomies.8
Endometrial ablation is suitable for women who have completed their family as pregnancy, while rare after endometrial ablation, carries serious health risks. Ablation can be performed either hysteroscopically or with various proprietary systems using thermal, radio-frequency (RF) or microwave energy. It is a good option for women with HMB, benign endometrium and a cavity that is not distorted by fibroids. The RF endometrial ablation system produces a significant reduction in MBL or amenorrhoea in 90 per cent of users. In a systematic review, women who underwent endometrial ablation were more likely to be dissatisfied than those who had had a hysterectomy, though the latter group took longer to get back to their daily routine. When compared with the LNG-IUS, the pictorial blood loss assessment chart score was significantly lower in the endometrial ablation group and fewer women had side effects a year after treatment than the LNG-IUS group.
The LNG-IUS and hysterectomy have been compared in a systematic review that found health-related quality of life at 12 months was higher in both groups, with no significant difference observed between groups. Pain, however, was significantly higher in the LNG-IUS group. With longer follow-up periods, more and more women initially treated with LNG-IUS seek further therapy. In a large hospital-based Finnish study comparing LNG-IUS to hysterectomy after five years of follow up, 42 per cent of women in the LNG-IUS group had undergone hysterectomy. This figure was much lower in a recent UK study comparing LNG-IUS to medical management that found at two years of follow up only six per cent of women in each group had undergone hysterectomy. The differences may reflect the different follow-up periods or the different study settings.10
In women whose HMB is caused by fibroids, surgical management is more likely to be required. Surgical options include myomectomy or hysterectomy, depending on the woman’s preferences and desire for future fertility. In women who have completed their family and desire to avoid hysterectomy, uterine artery embolisation (UAE) can be considered. Among a register of 1387 patients who underwent the procedure, 83 per cent stated an improvement in their symptoms at two years. However, in a randomised trial, 28 per cent of women undergoing UAE required hysterectomy at five years of follow up.11
Although the management of primary dysmenorrhoea is the focus of the discussion below, most of these treatments are also appropriate in the first-line management of secondary dysmenorrhoea. NSAIDs have been shown in a systematic review to be effective in the treatment of primary dysmenorrhoea. In this review, ibuprofen had the most favourable profile in terms of side effects and efficacy. NSAIDs can be used alone or with other analgesics, such as paracetamol and codeine.
The COCP is a useful option for women who have pain refractory to simple analgesics. They operate by inhibition of ovulation. A systematic review has concluded that COCPs are significantly more effective than placebo for pain relief. There is some evidence that monophasic preparations are more effective for the treatment of dysmenorrhoea than multiphasic preparations.5
It is unusual for primary dysmenorrhoea to require treatment more intensive than the above. Secondary dysmenorrhoea caused by endometriosis can be amenable to other hormonal therapies such as high-dose progestogens, androgens and GNRH analogues. The levonorgesterel-releasing intrauterine system (LNG-IUS) can also be used for treatment of adenomyosis and endometriosis pain.
Medical treatments are successful in the treatment of 70–75 per cent of women with dysmenorrhoea. In those with refractory pain, surgical treatments focused on interrupting sensory nerve pathways have been developed. Presacral neurectomy (PSN) involves removal of nerves from the hypogastric plexus. This has traditionally been done by laparotomy, although laparoscopic techniques are evolving. Uterine nerve ablation (UNA) involves division of the uterosacral ligaments and can be done laparoscopically (LUNA).12
The utility of alternative therapies in the treatment of dysmenorrhoea has been the subject of several systematic reviews. Spinal manipulation has been shown to be ineffective. Magnesium and Vitamin B1 show some benefit in the relief of dysmenorrhoea.5
- National Institute for Health and Care Excellence. NICE Guideline CG 44. Heavy Menstrual Bleeding. 2007. Available from www.nice.org.uk/ guidance/CG44.
- Munro MG, Critchley H, Broder MS, Fraser IS. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. International Journal of Gynecology and Obstetrics 2011 (113) 3–13
- Hallberg L, Hogdahl AM, Nilson L, Rybo G. Menstrual blood loss – a population study. Acta Obstetricia et Gynecologica Scandinavica 1966;45:320–51.
- Dawood MY. Primary dysmenorrhea: advances in pathogenesis and management. Obstet Gynecol. 2006 Aug;108(2):428-41.
- Luesley DM. Baker PM. Obstetrics and Gynaecology: an Evidence-based Text for MRCOG. 2nd Ed. CRC Press 2010. Pg 567-587.
- Nezhat C, Santolaya J, Nezhat FR. Comparison of transvaginal sonography and bimanual pelvic examination in patients with laparoscopically confirmed endometriosis. J Am Assoc Gynecol Laparosc. 1994;1(2):127–130.
- Lethaby A1, Augood C, Duckitt K, Farquhar C. Non-steroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD000400.
- Gupta J, Kai J, Middleton L, Pattison H, Gray R, Daniels J; ECLIPSE Trial Collaborative Group. Levonorgestrel intrauterine system versus medical therapy for menorrhagia. N Engl J Med. 2013 Jan 10;368(2):128-37
- Lethaby AE1, Cooke I, Rees M. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD002126.
- Hurskainen R, Teperi J, Rissanen P, Aalto AM, Grenman S, Kivelä A et al. Clinical outcomes and costs with the levonorgestrel-releasing intrauterine system or hysterectomy for treatment of menorrhagia: randomized trial 5-year follow-up. JAMA. 2004 Mar 24;291(12):1456-63.
- 11 National Institute for Health and Care Excellence. Uterine artery embolisation for fibroids. NICE interventional procedures guidance [IPG367] 2010. Available at www.nice.org.uk/Guidance/ipg367.
- 12 Wilson ML, Farquhar CM, Sinclair OJ, Johnson NP. Surgical interruption of pelvic nerve pathways for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev. 2000;(2):CD001896.