Q: Surgical or Interventional

Fertility-Preserving: • Myomectomy (removal of intramural fibroids) can improve blood loss by enhancing uterine contractility with menses. This is an option for patients who want to conceive. • Hysteroscopic resection of intrauterine lesions can reduce blood flow in the setting of uterine polyps or submucosal fibroids. This is an option for patients who want to conceive and can be very effective at decreasing menstrual blood loss. Non-Fertility-Preserving: • Endometrial ablation (destruction of the uterine lining) is effective in controlling menstrual blood loss but has limited efficacy over time (approximately 5 years). This is not an option for patients who would like to conceive in the future. • Uterine artery embolization has not been studied as a method to reduce menstrual blood flow in the absence of uterine fibroids (but in patients with fibroids, it has been shown to reduce menstrual blood loss). This is not an option for patients who would like to conceive in the future. • Hysterectomy is a definitive treatment option to stop menstrual bleeding. This is not an option for patients who would like to conceive in the future. Managing Acute Heavy Menstrual Bleeding: • If the patient is unstable, surgical or interventional options are required. • TXA: IV: 10 mg/kg every 8 hours • High dose combined hormonal contraceptives with a taper • Reverse anticoagulants if present • Provide targeted hemostatic therapy if a patient has a bleeding disorder

Q: Treating Iron Deficiency

This is an important component of the management of a patient with heavy menstrual bleeding. See our comprehensive module on iron deficiency! https://www.hemequity.com/iron-education-home(https://www.hemequity.com/iron-education-home)

Question 1

Non-Hormonal Medical

Accepted Answer

This is often the first line option for patients while they are being investigated as to the cause of HMB. These treatments are also good options for those patients for whom hormonal therapy was ineffective/not tolerated, those who decline/not candidates for interventional options, or for those who wish to conceive and therefore cannot use hormonal therapy.

• Tranexamic Acid (TXA; an anti-fibrinolytic) 25 mg/kg po TID i.e. typically 1000-1500 mg PO TID on days of bleeding 
    • Contraindications:
       • Active thrombosis (i.e within the last 3 months)
          • NOTE: There is no increased risk of venous or arterial thrombosis with use of TXA for HMB. Read more here (https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(21)00162-0/fulltext#:~:text=We%20report%20a%20four%2Dfold,no%20association%20with%20arterial%20thrombosis)and here.(https://www.rpthjournal.org/article/S2475-0379(22)01409-1/fulltext) 
    • Subarachnoid hemorrhage

• NSAIDs (ibuprofen/naproxen) started 24-48 hours pre-menses and continued for the first few days of heavy bleeding 
    • Contraindications:
       • Asthma sensitive to NSAIDs
       • Active GI bleed or peptic ulcer
       • Uncontrolled hypertension

• Diagnosed bleeding disorders: Refer to hematology for specific hemostatic therapy

Question 2

Hormonal

Accepted Answer

1) Combined hormonal contraceptive (estradiol + progestin) to reduce menstrual blood flow by 35-69%, suppress ovulation (preventing hemorrhagic ovarian cysts), and regulate the menstrual cycle. All monophasic options can be used continuously to prevent periods altogether or with a shortened hormone-free interval. For dosage details, please click here.(http://www.dpic.org/article/professional/hormonal-and-iud-contraceptive-agents-available-canada)

• Oral: there are many formulations, but when prescribing for patients with HMB, monophasic pills rather than multiphasic pills are better for continuous usage to for minimize breakthrough bleeding (e.g Ethinylestradiol/levonorgestrel (Alesse)). These pills can be used continuously (for two to three months at a time) or with a shortened pill-free interval (i.e. a 4-day break instead of the traditional 7-day break). Multiphasic pills (e.g. Ethinylestradiol/norgestimate (Tri-Cyclen)) will decrease blood loss but patients will experience increased breakthrough bleeding when used continuously.
 • Transdermal (patches): ethinyl estradiol/norelgestromin (Evra) (changed weekly)
 • Vaginal (ring): etonogestrel/ethinyl estradiol (NuvaRing) (changed every 3 weeks)

Contraindications:
 • Smoker  ≥35 years ( ≥15 cigarettes per day).
 • Vascular disease - Multiple risk factors for arterial cardiovascular disease (such as older age, high cholesterol, diabetes, obesity, and hypertension)
 • Untreated hypertension (SBP>160mmHg, DBP>100mmHg)
 • Acute DVT/PE
 • History of venous thromboembolism (VTE) not on anticoagulation → referral to hematology warranted
 • Major surgery with prolonged immobilization
 • Known thrombophilia
 • Current and/or history ischemic heart disease
 • History of stroke
 • Complicated valvular heart disease (pulmonary hypertension, risk for atrial fibrillation, history of subacute bacterial endocarditis)
 • Systemic lupus erythematosus (positive or unknown) antiphospholipid antibodies)
 • Migraine with aura
 • Peripartum cardiomyopathy with normal/mildly impaired cardiac function <6 months
 • Breast cancer or other hormone-sensitive cancer (i.e. endometrial cancer)
 • Unexplained vaginal bleeding
 • Severe decompensated cirrhosis, hepatocellular adenoma, malignant hepatoma
 • Complicated solid organ transplantation (graft failure, cardiac allograft vasculopathy)

https://static.wixstatic.com/media/fc69a4_1c7acffbbaa34028a70e1e6f280727bb~mv2.png

In patients with a history of thrombosis who are on anticoagulation: Hormonal therapy does not increase the risk of recurrent venous thromboembolism (VTE) if the patient is on anticoagulation.

2) Progestin-only methods to reduce menstrual blood flow by 70-95%. These do not suppress the formation of hemorrhagic ovarian cysts. 
 • Oral:
    • Daily pills Drospirenone ((Slynd); also a contraceptive), Norethisterone ((Micronor); also a contraceptive), Dienogest ((Visanne); not a contraceptive)
 • Injectable:
    • Depot medroxyprogesterone acetate ((Depo-Provera); every 3 months)
 • Implants:
    • 52 mg levonorgestrel intrauterine device (IUD; Mirena), changed every8 years for contraception or 5 years for menstrual suppression Kyleena (19.5 mg) works well for contraception but has lower rates of amenorrhea so it is not as good a choice for treating heavy menstrual bleeding
    • 68 mg etonogestrel (Nexplanon) subdermal implant works well for contraception but there is significant breakthrough bleeding and no menstrual suppression so it is not a good choice for treating heavy menstrual bleeding

Contraindications to Progesterone:
 • Current progestin receptor-positive breast cancer
 • Abnormal vaginal bleeding that has not been evaluated
 • Pregnancy

Contraindications to IUD
 • Pregnancy
 • Current pelvic inflammatory disease (PID) or active cervicitis
 • Puerperal sepsis
 • Immediately post septic abortion
 • Known distorted uterine cavity
 • cervical or endometrial cancer awaiting treatment
 • Malignant trophoblastic disease with persistently elevated Bhcg and active intrauterine disease
 • Pelvic tuberculosis

3) GNRH agonists or antagonists to stop/suppress menstruation. These medications do not contain hormones, rather they act on the hormonal system.
 • Agonist: Leuprolide (e.g. Lupron)
 • Antagonist: Elagolix or relugolix (e.g. Orlissa or Myfembree) 
 • Contraindications
    • Pregnancy or actively trying to conceive

https://static.wixstatic.com/media/fc69a4_1c7acffbbaa34028a70e1e6f280727bb~mv2.png

Copper IUDs increase menstrual bleeding!

Question 3

Surgical or Interventional

Accepted Answer

Fertility-Preserving:
 • Myomectomy (removal of intramural fibroids) can improve blood loss by enhancing uterine contractility with menses. This is an option for patients who want to conceive.
 • Hysteroscopic resection of intrauterine lesions can reduce blood flow in the setting of uterine polyps or submucosal fibroids. This is an option for patients who want to conceive and can be very effective at decreasing menstrual blood loss.

Non-Fertility-Preserving:
 • Endometrial ablation (destruction of the uterine lining) is effective in controlling menstrual blood loss but has limited efficacy over time (approximately 5 years). This is not an option for patients who would like to conceive in the future.
 • Uterine artery embolization has not been studied as a method to reduce menstrual blood flow in the absence of uterine fibroids (but in patients with fibroids, it has been shown to reduce menstrual blood loss). This is not an option for patients who would like to conceive in the future.
 • Hysterectomy is a definitive treatment option to stop  menstrual bleeding. This is not an option for patients who would like to conceive in the future.

Managing Acute Heavy Menstrual Bleeding: 
 • If the patient is unstable, surgical or interventional options are required. 
 • TXA: IV: 10 mg/kg every 8 hours 
 • High dose combined hormonal contraceptives with a taper
 • Reverse anticoagulants if present
 • Provide targeted hemostatic therapy if a patient has a bleeding disorder

Question 4

Treating Iron Deficiency

Accepted Answer

This is an important component of the management of a patient with heavy menstrual bleeding. See our comprehensive module on iron deficiency! 
https://www.hemequity.com/iron-education-home(https://www.hemequity.com/iron-education-home)

How to Treat Heavy Menstrual Bleeding