Diagnosis of Heavy Menstrual Bleeding

Abstract

Heavy menstrual bleeding (HMB) is an important health problem. This paper gives an overview of the diagnosis of HMB. For each woman, a thorough history should be taken as one should ascertain whether there are underlying factors that could cause complaints of HMB. Objectively knowing whether or not the blood loss is excessive could also be very beneficial. The pictorial blood assessment chart score can help with diagnosis. Physical examination starts with standard gynecological examination. Imaging tests are widely used in the work-up for women with HMB. The first step in imaging tests should be the transvaginal ultrasound. Other diagnostic tests should only be performed when indicated.

Heavy menstrual bleeding (HMB) is an important health problem that affects many premenopausal women. It is defined as menstruation at regular intervals but with excessive flow and duration. Clinically, it is defined as blood loss of more than 80 ml per cycle [1]. It can be embarrassing, annoying and inconvenient and the bleeding can interfere with daily activities.

HMB can be caused by abnormal blood clotting, disruption of normal hormonal regulation or uterine pathology (e.g., fibroids, polyps, adenomyosis). It is important to diagnose the underlying cause in order to determine the best treatment option.

History

Many women who seek treatment for HMB complain about their physical, social and emotional well-being. For each woman, a thorough history should be taken to establish the true nature of her symptoms. Asking about duration, intensity and regularity of the menstrual blood loss (MBL) will identify the bleeding problem and suggest whether or not it is a structural or histological abnormality. Blood clots and menstruation of more than 7 days are independent predictors for HMB [2]. Nevertheless, the clinician must take into account the fact that there is a wide variation in menstrual cycles between women. This variation should be discussed with the patient and can sometimes be reassuring for women. Patient-focused discussions on HMB have revealed that women feel that it is important that the clinician takes the time to assess the impact of HMB on daily living [3].

One should also ascertain whether there are underlying factors that could cause women to present with complaints of HMB. The amount of suffering that women experience from abnormal menstrual bleeding is not only dependent on the severity of the bleeding abnormality itself, but also on the way they cope with it. Women in a vulnerable position are more likely to have coping difficulties than women in a stable position. For example, a history of sexual assault is twice as common among women with symptoms of dysmenorrhea, HMB and sexual dysfunction as compared with women without such complaints, in other words, 30% among women with gynecologic complaints versus 15% in an unselected population. As this is likely to be the result of differences in coping, it is to be expected that women with a history of sexual assault will be less satisfied with a particular treatment effect, as their complaints were at least partially explained by their capacity to cope with the problem. When there is a history of sexual assault, it should be included in the evaluation and management of HMB, as these women may benefit from psychological help in addition to gynecological assessment and therapy [4,5].

Although a large amount of blood loss is the main reason to consult a general practitioner or gynecologist, women's perception of the severity of bleeding does not often correlate with the objective amount of blood loss. Only 40–50% of women with complaints of HMB exceed 80 ml blood loss [6,7]. Knowing whether or not the woman is suffering from HMB can be very beneficial for both patient and clinician; evaluating the actual amount of blood loss means that many women could be reassured that their blood loss is not excessive. Nevertheless, any complaints about blood loss should be fully examined. Women who experience blood loss of less than 80 ml can then be counseled differently from women who do have HMB. Therefore, evaluating the blood loss is the first step toward diagnosing HMB.

A few methods have been developed for measuring MBL. The gold standard for the measurement of MBL is alkaline hematin extraction [1,6]. This is a very time-consuming and stressful method, as women need to collect all of their menstruation blood including all used towels or tampons. This method is not practical for daily use and is only used in research. Another simplified method is counting numbers of used towels or tampons, but Fraser et al. did not find a correlation between the numbers and the volume of blood loss. Therefore, this method is not used anymore [6]. Higham et al. developed a subjective method to determine whether or not women meet the diagnosis of HMB: the pictorial blood assessment chart (PBAC). The self assessed PBAC consists of diagrams representing different soiled towels and tampons. Women are instructed to count their number of used towels or tampons each day and then divide them by level of soiling. The chart is scored using the scoring system devised by Higham et al. This measurement method has a specificity and sensitivity of 80–90% [8,9]. Other studies have confirmed the accuracy of the PBAC compared with the alkaline hematin extraction method for the diagnosis of HMB. A PBAC score of 150 points most accurately correlates with MBL of 80 ml. [2,9].

Although the PBAC score is not a quantitative measurement, it can reliably predict HMB. A menstruation scorecard for one menstrual period is sufficient for diagnosis, probably because of the constancy of individual MBL [1,9]. In conclusion, the PBAC is a useful measure for accurately diagnosing HMB.

In addition to assessing the menstruation cycle and amount of blood loss, a personal or family history of bleeding disorders must also be assessed. For example, disorders of hemostasis should be suspected in a woman with a history of bleeding associated with surgery, dental extraction, childbirth, bruising or HMB since menarche (see also laboratory testing).

Physical examination

Gynecological examination

Standard gynecological examination includes speculum examination and vaginal examination (bimanual examination). The speculum examination is particularly important for women with dysfunctional blood loss, such as irregular bleeding or intermenstrual bleeding because during the speculum examination the cervix can be clearly examined. An ectropion, cervical polyp, myoma nascens (intrauterine fibroid visualized extruding through the cervical canal) or malignancy can be diagnosed and, if necessary, the patient can receive additional treatment or additional diagnostic testing. During a gynecological examination, a cervical smear and triple swabs can be obtained. Although a standard speculum examination for HMB is not supported by the literature, a speculum examination should always be a fixed item in the gynecological examination.

The vaginal examination gives information about the vagina, cervix and uterus. It determines the size, shape and mobility of these structures and may suggest the presence of fibroids, adenomyosis or possible malignancy (e.g., tumor growth in the parametria). The vaginal examination is also the most appropriate examination for choosing the type of surgical approach for a hysterectomy if required; vaginal, abdominal or laparoscopic.

Laboratory testing

Laboratory testing is selective and depends upon information obtained from the patient's history and physical examination.

Hemoglobin & ferritin

Women with menorrhagia can lose a great deal of blood each month and may become anemic. Determination of hemoglobin concentration (Hb) is an important factor in the assessment of iron supplementation, yet a hemoglobin threshold should not be used for diagnosis of HMB, as the absence of anemia does not exclude the diagnosis of HMB. Janssen et al. describes that 20% of women with HMB had a normal hemoglobin. However, anemia makes the clinical impression of excessive blood loss plausible. Three quarters of women suffering from anemia had MBL exceeding 80 ml/day [9]. Although the gold standard measure for iron stores in the body is serum ferritin, this may only be important if anemia also exists (Hb <7.5 mmol/l) [10,11].

Coagulation factors

Testing for coagulation abnormalities may only be considered if HMB is objectified and other causes, such as intracavitary pathology, are excluded. Hemostasis disorders should be suspected in women with a history of bleeding associated with surgery, dental extraction, childbirth, bruising or HMB since menarche. The prevalence of von Willebrand disease as an underlying coagulation disorder in patients with HMB varies from 10 to 20% [12,13]. A 61% of women with HMB since menarche have von Willebrand disease or factor XI deficiency versus 7% of women who develop HMB at a later age [14,15]. The frequency of other potential bleeding disorders is less certain and requires further investigation. Testing for coagulation disorders should be considered in women who have a personal history that suggests a coagulation disorder. Nevertheless, standard screening for coagulation is not necessary, as it is expensive and often has no implications for the choice of treatment [16].

Endocrine examination

Endocrine examination is not indicated in HMB [16]. Endometrium from women with HMB is indistinguishable in terms of sex steroid immunoreactivity compared with women without HMB, and there are no differences in plasma gonadotropin or sex steroid levels between women with or without HMB [17]. Thyroid function has never shown a clear relationship with HMB and should therefore not be checked [18]. In cases with obvious symptoms of hypothyroidism, it is of course useful to check thyroid function.

Imaging tests

In daily practice, imaging tests are widely used in the work-up for women with HMB. The diagnosis of HMB is mostly a combination of one of the following imaging tests: transvaginal ultrasonography (TVS); saline infusion sonography (SIS); hysteroscopy; and MRI.

Anatomical abnormalities of uterine muscle and cavity, such as polyps, fibroids or adenomyosis, can be visualized by using these techniques. The aim is to make a distinction between these abnormalities so an appropriate treatment can be offered.

Transvaginal ultrasonography

A transvaginal ultrasound should be the first diagnostic test for identifying structural abnormalities [16]. Subserosal and intramural fibroids can be visualized with ultrasound, and endometrial thickness can be assessed. However, ultrasound cannot reliably distinguish between polyps, submucous fibroids and adenomyosis. So if structural abnormalities are suspected, further diagnostic tests such as SIS or hysteroscopy, are required [19,20].

Saline infusion sonography & gel infusion sonography

SIS or gel infusion sonography (GIS) are used to visualize intracavitary abnormalities and should only be used if TVS is inconclusive or if structural abnormalities are suspected. SIS and GIS are techniques in which a catheter is placed into the endometrial cavity and sterile saline or gel is instilled while a transvaginal ultrasound examination is performed. The saline or gel distends the uterine cavity to aid detection of intracavitary abnormalities. This procedure is only used as a diagnostic tool, it is not a therapeutic procedure. No differences in sensitivity and specificity are found between SIS or GIS, although the image quality of SIS is slightly better [21,22]. De Kroon et al. show in a meta-analyses that the overall sensitivity and specificity of SIS for intracavitary lesions is 0.95 (95% CI: 0.93–0.97) and 0.88, respectively, (95% CI: 0.85–0.92). The likelihood ratios were respectively 8.23 (95% CI: 6.2–11) and 0.06 (95% CI: 0.04–0.09). So a normal SIS or GIS excludes intracavitary pathology [23]. In conclusion, an SIS/GIS should be used when TVS is inconclusive. It is a reliable diagnostic procedure for excluding intracavitary abnormalities in women with HMB.

Hysteroscopy

Hysteroscopy provides direct visualization of the uterine cavity by endoscopy with access through the cervix. Intracavitary abnormalities, such as polyps or fibroids, can be directly visualized. If required, a target biopsy or removal of the pathology can be performed during the same procedure. Hysteroscopy is a highly sensitive and specific test, both around 93–98% (Grimbizi, Soguktas).

Three studies compare TVS, SIS and hysteroscopy for detecting intracavitary pathology. The sensitivity of TVS varies from 0.69 to 0.89, and for SIS and hysteroscopy 0.94 and 0.84–0.98, respectively. The specificity was 0.56–0.71 for transvaginal ultrasound, 0.60–0.91 for SIS and 0.88–0.93 for hysteroscopy [24–26].

Van Dongen et al. compared pain scores for SIS and office hysteroscopy. Both methods were well tolerated by women, but SIS induced significantly less discomfort than outpatient hysteroscopy [27].

In conclusion, the sensitivities of TVSU, SIS and hysteroscopy are all high, but TVSU and SIS are better tolerated by patients. Based upon these data, hysteroscopy should only be performed if structural abnormalities are suspected after TVS and SIS.

Outpatient versus day case hysteroscopy

Trials which compare outpatient hysteroscopy with day case hysteroscopy in terms of patient satisfaction and acceptability show no difference in satisfaction (84 vs 77%) and acceptability (89%). Patients recover significantly more quickly from outpatient hysteroscopy than from day case hysteroscopy and pain scores after the procedure are equivocal [28,29]. Therefore, diagnostic hysteroscopy should be performed in an outpatient setting.

MRI

MRI is used to visualize internal structures of the body in detail. For the diagnosis of HMB there are only a few indications for using MRI, such as adenomyosis or for assessment of the suitability of fibroids for uterine artery embolization.

If the clinician suspects that a woman has adenomyosis, MRI can be used in the workup for HMB as detecting and diagnosing adenomyosis is often difficult and can be missed in daily practice. TVSU and MRI can both be used as diagnostic tools for detecting adenomyosis, and both have a similar diagnostic accuracy [30]. However, the accuracy of MRI seems to be higher than the TVU. Only an experienced sonographer has the expertise to get the accuracy of 70% required to detect adenomyosis. On the other hand, MRI is less dependent on expertise, as a relatively inexperienced radiologist can get an accuracy of around 80%. The combination of both tests results in the best accuracy, approximately 90% [31,32].

MRI is also used for the visualization of fibroids, but this is not supported by literature and the workup for fibroids should start with TVS. Regardless of the indication, we have to keep in mind that imaging with MRI only has value if the result will affect the choice of treatment.

Pathology

Endometrial sampling

There is lack of consensus for endometrial sampling of premenopausal women presenting with HMB. The NICE guideline recommends endometrial sampling in women of 45 years and over or if treatment is ineffective [16]. One retrospective trial investigated the cut-off age for endometrial sampling of premenopausal women presenting with abnormal uterine bleeding (AUB) and found a higher prevalence of atypical hyperplasia and carcinoma in women over 45 years of age. They did not, however, find a significant difference in simple and complex hyperplasia. Nevertheless, this study was not specified for HMB and was independent of the findings from examination [33].

Consider performing endometrial sampling in women greater than 45 years. Obviously, sampling is indicated if TVS or hysteroscopy show abnormalities of the endometrium which make histologic pathology likely.

Investigation of HMB

A flowchart outlining a suggested algorithm for investigating women with HMB is shown in Figure 1. Considering the variety of underlying causes for HMB and the increased uptake of concomitant ‘see & treat’ services, further research is needed to better define what the optimal testing strategies in HMB are.

Figure 1.

Flowchart for the investigation of heavy menstrual bleeding.

GIS: Gel infusion sonography; HMB: Heavy menstrual bleeding; PBAC: Pictorial blood assessment chart; SIS: Saline infusion sonography.

Conclusion & future perspective

This chapter gives an overview of the diagnosis of HMB. Many women who seek treatment for HMB complain about both their physical, social and emotional well-being. Objectively knowing whether or not the blood loss is excessive could be very beneficial for both patient and clinician. This determination will clarify the patient's complaint, and it will also influence the choice and expectations of treatment. The PBAC score can help with diagnosis as it predicts HMB reliably. The clinician must also take into account the fact that there is a wide variation in menstrual cycles and amount of blood loss between women. This variation should be discussed with the patient as this information can sometimes be reassuring for her. For each woman a thorough history should be taken to establish the true nature of her symptoms. One should ascertain whether there are underlying factors that could cause these women to present with complaints of HMB.

Physical examination starts with standard gynecological examination. In daily practice, imaging tests are widely used in the work-up for women with HMB. The diagnosis of HMB is mostly a combination of one of the following imaging tests: TVS; SIS; hysteroscopy; and magnetic resonance imaging (MRI). The first step in imaging tests should be the transvaginal ultrasound. If this is inconclusive or if intracavitary abnormalities are suspected then the physician can perform an SIS or gel infusion sonography (GIS) to visualize the uterine cavity. Laboratory tests, endometrial sampling, hysteroscopy and MRI should only be performed when indicated.

Executive summary

• Many women who seek treatment for heavy menstrual bleeding (HMB) complain about both their physical, social and emotional well-being.

• There is a wide variation in menstrual cycles between women, so diagnosing whether the patient really suffers from HMB can be beneficial for both physician and patient. The pictorial blood assessment chart can help with diagnosis as it reliably predicts HMB.

• Bleeding disorders could be an underlying cause of HMB, therefore the physician has to pay attention to this while assessing the patient's history. However, there is no need to screen all women with HMB for coagulation disorders.

• The first step in imaging tests is the transvaginal ultrasound. If this is inconclusive or if intracavitary abnormalities are suspected then the physician can perform an saline infusion sonography.

• Saline infusion sonography/gel infusion sonography are reliable diagnostic procedures for excluding intracavitary abnormalities in women with HMB.

• Laboratory tests, endometrial sampling and MRI should only be performed when indicated.