How will physicians manage heavy menstrual bleeding?

08/31/2023

Within the state of Indiana, the Girls and Women Only (GO) Clinic is the only specialty clinic of its kind and IHTC is the only federally designated Hemophilia Treatment Center (HTC), as well as a center of excellence in the treatment of bleeding and clotting disorders. Learn how to best manage heavy menstrual bleeding from IHTC’s Sweta Gupta, MD.

Heavy menstrual bleeding (HMB) is defined as menstruation at regular intervals but with excessive flow and duration. Clinically, it’s defined as blood loss of more than 80 ml per cycle.¹ Crucially, it’s more common than expected—affecting about 1 of every 5 women in the US.²

Accurate diagnosis and effective management can help mitigate negative effects of HMB. These effects can include:

•  Complications such as iron deficiency anemia, menstrual pain, hospitalizations, the need for blood transfusions, and gynecological issues that may be linked to HMB, including endometriosis, fibroids, uterine polyps, and possibility of miscarriage³
• Reduced quality of life resulting from interruptions to daily activities, limitations on activities, missed time at work or school, embarrassment, and social implications³

Additionally, identifying the cause of HMB can help bring to light an underlying condition or pathology that may have gone untreated.¹ According to the CDC, “Heavy menstrual bleeding (heavy periods) may be the most noticeable symptom of a bleeding disorder. If left untreated, heavy menstrual bleeding can place women and girls at an increased risk for health problems.”²

Moreover, similar to how identifying issues like abnormal blood pressure or heart rate can help diagnose potentially serious health conditions, identifying abnormal menstruation patterns during adolescence may help enable early diagnosis of certain medical conditions in adulthood.³ 

Managing heavy menstrual bleeding—a roadmap

Managing heavy menstrual bleeding takes more than meets the eye; the following steps provide a high-level roadmap for helping patients reduce symptoms, risk for complications, and negative impact on quality of life. 

1. Diagnose via a detailed symptom assessment and historical evaluation

The healthcare provider should meet with the patient (and family member for adolescent patients) to obtain a thorough understanding of current symptoms and a personal and family history of bleeding and clotting.

The latter is necessary for two reasons. To begin, collecting this history helps determine whether an underlying bleeding disorder is the cause of HMB.

Per the American College of Obstetricians and Gynecologists (ACOG), the frequency of bleeding disorders in the general population is approximately 1%–2%, but bleeding disorders are found in approximately 20% of adolescent girls who present for evaluation of heavy menstrual bleeding and in 33% of adolescent girls hospitalized for heavy menstrual bleeding.^4-6 In other words, underlying bleeding disorder is a cause worth exploring.

Another reason for obtaining a complete history of bleeding and clotting is to assess inherited clotting risk prior to considering hormonal therapy for HMB.

Symptoms of HMB include:

• Periods lasting longer than 7 days (7)
• Soaking through a pad or tampon in 1 to 2 hours (2)
• Passing clots larger than the size of a quarter (1)

Note: The above three symptoms can be easily remembered as “721”

• Iron deficiency, anemia, or need for blood transfusion
• Missing days of school or work due to bleeding

Symptoms that could indicate an underlying bleeding disorder include:

• Excessive bleeding after surgery, dental work, or childbirth
• Frequent and prolonged nosebleeds
• Prolonged bleeding from cuts or wounds
• Easy bruising
• Family history of a bleeding disorder

In addition to symptom assessment and historical evaluation, providers may also use tests such as a blood test, pap test, endometrial biopsy, or ultrasound to diagnose and determine the underlying cause.⁷ HMB can be caused by abnormal blood clotting, disruption of normal hormonal regulation, or uterine pathology such as fibroids or polyps. Diagnosing the underlying cause is important in selecting the most appropriate treatment option.¹

2. Educate on treatment options and clarify misinformation and stigmas

Once diagnosed, providers should educate patients on both hormonal and nonhormonal therapies as well as clarifying misinformation and stigmas about either category.

Nonhormonal therapy—this category includes antifibrinolytics such as tranexamic acid and aminocaproic acid and are an option for patients who don’t want to use hormonal agents or who don’t fully respond to them.

Antifibrinolytics can be effective in reducing menstrual blood loss and improving quality of life. Also, unlike hormonal options, studies have shown no increased risk of thrombosis with the use of antifibrinolytic therapies.⁸

On the negative side, nonhormonal agents are not an option for patients with menstrual irregularity, as they don’t help regulate an irregular menstrual cycle and they do not help treat menstrual cramping. Finally, like most therapies, not all patients will respond to nonhormonal treatments.

Hormonal therapy—commonly referred to as birth control pills or contraceptive methods—a misnomer when used for treatment of HMB—this category consists of various options for delivering hormones (estrogen and/or progesterone). These options include pills, vaginal implant or ring, intrauterine device (IUD), implants, and injection (eg, Depo-Provera shot). When used as a form of hormonal therapy, these products can help reduce menstrual blood flow, regulate the menstrual cycle, lessen menstrual cramps, and prevent hemorrhagic ovarian cysts.

The major and well-publicized drawback of estrogen-containing hormonal therapy is its contraindication in women at increased risk for thrombosis—unless they are on anticoagulation medication. This risk should be discussed during the historical evaluation, so proper education can be provided at this stage.

It’s important that patients and their families are given accurate information about all types of treatments for HMB, so they can make fully informed decisions. Currently, this includes addressing misinformation and harmful stigmas surrounding the use of hormonal therapy for HMB.

Providers can help by discussing the following with patients and their families:

• Fears about the long-term effect on growth and fertility in adolescents—the concept of ovulation suppression often feeds parental fears of long-term effects on growth and fertility. However, the use of hormonal therapy in women and girls—particularly young girls—does not adversely affect either.

According to the American College of Obstetricians and Gynecologists, “Most girls have completed 95% of their growth by menarche, so concern about the use of estrogen and closure of the epiphyseal plates should not preclude hormone use for the treatment of heavy menstrual bleeding.”

• Hesitation due to birth control stigmas—because the same products are also used for contraception, hormonal therapies come with a complex set of stigmas that make it difficult for some parents to accept them as a form of bleeding therapy. Additionally, some parents are uncomfortable with their young daughters taking what they know as “birth control,” as they fear it will lead to a false sense of security, promoting earlier sexual activity.

Even after their children with severe HMB have suffered trauma due to hospitalization and blood transfusions, some reluctant parents continue to hesitate to use hormonal therapy to circumvent these negative experiences.

That said, Sweta Gupta, MD, a pediatric hematologist-oncologist with the Indiana Hemophilia & Thrombosis Center (IHTC), notes that once these destigmatizing hurdles are cleared, these families often soon realize the many benefits of hormonal therapy.

“It can take several discussions with caregivers to understand that hormonal therapy is a safe option with no long-term adverse effects, the intention being to use this treatment as an effective modality to control HMB and not necessarily birth control in all young girls and women,” Dr. Gupta explains.

In addition to hormonal and nonhormonal therapies, more invasive procedures and surgical interventions may be used to treat HMB in life-threatening situations or when medical management fails. But once stabilized, patients are transitioned to maintenance therapy.

3. Select treatment using shared decision making

When it comes to making treatment decisions, providers should work with patients and their families to choose HMB therapy based on:

• Severity of menstrual bleeding and other coexisting symptoms
• Risk of thrombosis
• Patient goals
• Patient preferences and cultural values

4. Screen for and treat anemia

For patients with HMB, treatment doesn’t always stop at addressing the heavy bleeding or irregular cycles. Dr. Gupta says using the menstrual cycle as a vital sign can help identify a number of potential health concerns, including iron deficiency anemia.

“A consequence of heavy menstrual bleeding is iron deficiency anemia, and when young girls and women are referred to our clinic, we don’t always see this being adequately addressed,” warns Dr. Gupta.

Particularly if a patient with HMB also reports symptoms including headaches, fatigue, decreased attention span, poor school or work performance, and/or excessive craving for ice (pagophagia), they should be evaluated for iron deficiency anemia. If anemia is left untreated, patients can experience poor quality of life, need for hospitalizations for blood transfusions, problems during pregnancy, including preterm labor, and consequences for the newborn.

Optimal management of heavy menstrual bleeding—expertise in a multidisciplinary specialty setting

Most effectively managing HMB requires the combined expertise of a hematologist and adolescent medicine/gynecologist, under one roof to conduct detailed symptom assessment and historical evaluation, provide objective education on treatment options and clarification of misinformation, and finally, to deliver specialized, lifespan care through a shared process of decision making—collaborating closely with patients, their families, and multidisciplinary providers.

For primary care physicians, pediatricians, and gynecologists, the #1 way to help patients presenting with heavy menstrual bleeding is to partner with a specialty clinic like the Girls and Women Only (GO) Clinic at IHTC.

Within the state of Indiana, the GO Clinic is the only specialty clinic of its kind and IHTC is the only federally designated Hemophilia Treatment Center (HTC), as well as a center of excellence in the treatment of bleeding and clotting disorders.

For each patient, the GO Clinic brings together the expertise of a hematologist and an adolescent medicine physician and/or gynecologist to provide care from start to finish. This includes in-depth evaluation and discussion, full lab workup, diagnosis, education, treatment selection, prescriptions, close follow-up, and even placement of devices such as IUDs. Providing comprehensive, coordinated care in a single appointment maximizes patient convenience and accelerates diagnosis and treatment.

Give patients the best chance for effective, long-term control of HMB—learn more about managing HMB and refer a patient to the GO Clinic at IHTC. Learn more at: www.ihtc.org

^References:

^{1.  Herman MC, Mol BW, Bongers MY. Diagnosis of heavy menstrual bleeding. Womens Health (Lond). 2016;12(1):15-20. doi:10.2217/whe.15.90} 

^{2.  Bleeding Disorders in Women: Free Materials about Signs and Symptoms. Centers for Disease Control and Prevention. Last reviewed August 17, 2022. Accessed November 22, 2022. https://www.cdc.gov/ncbddd/blooddisorders/women/materials/better-you-know-freematerials.html}

^{3.  What Are Bleeding Disorders in Women? Centers for Disease Control and Prevention. Last reviewed December 20, 2017. Accessed November 22, 2022. https://www.cdc.gov/ncbddd/blooddisorders/women/facts.html}

^{4. Venkateswaran L, Dietrich JE. Gynecologic concerns in pubertal females with blood disorders. J Pediatr Adolesc Gynecol. 2013;26(2):80-85. doi:10.1016/j.jpag.2012.07.001}

^{5.  Haamid F, Sass AE, Dietrich JE. Heavy Menstrual Bleeding in Adolescents [published correction appears in J Pediatr Adolesc Gynecol. 2017 Dec;30(6):665]. J Pediatr Adolesc Gynecol. 2017;30(3):335-340. doi:10.1016/j.jpag.2017.01.002}

^{6.  Smith YR, Quint EH, Hertzberg RB. Menorrhagia in adolescents requiring hospitalization. J Pediatr Adolesc Gynecol. 1998;11(1):13-15. doi:10.1016/s1083-3188(98)70101-9}

^{7.   Heavy Menstrual Bleeding. Centers for Disease Control and Prevention. Last reviewed August 17, 2022. Accessed November 22, 2022. https://www.cdc.gov/ncbddd/blooddisorders/women/menorrhagia.html} 

^{8.  Thorne JG, James PD, Reid RL. Heavy menstrual bleeding: is tranexamic acid a safe adjunct to combined hormonal contraception?. Contraception. 2018;98(1):1-3. doi:10.1016/j.contraception.2018.02.008}