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Menstrual bleeding is described to be heavy when you bleed more than 80ml of blood during menstrual flow in which case you change heavily soaked sanitary pad more frequent than expected in average population. It can also be defined in terms of duration when you bleed longer  than 7 days in a monthly cycle.

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Heavy menstrual flow is a symptom and a pointer to a diseased condition. Causes of heavy menstrual flow include but not limited to

  • uterine fibroid,
  • endometrial hyperplasia,
  • cancer of the uterus,
  • endometrial polyps,
  • anovulatory cycle,
  • pelvic inflammatory disease and
  • endometriosis

Other causes include hypothyroidism (it reduces von Willebrand factor resulting in acquired vWB disease resulting in excessive menstrual blood loss; it also causes reduction in basal metabolic rate of the body, which increase the time needed for endometrial regeneration, causing increased and prolonged menstrual flow), foreign body (IUCD) and  anticoagulant.


Your doctor will ask questions related to the following clinical history from you in order to identify the cause or severity of the heavy menstrual flow:

  1. Passage of large clots during the regular menstrual cycle.
  2. Aneamia due to excessive blood loss.
  3. Features of hypothyroidism
  4. History of bleeding disorder.
  5. History of dyspareunia (pain during sex)
  6. Endometrial hyperplasia must be considered in a woman who are obese, aged 70 0r older, nulliparous or have diabetes.
  7. Postpartum endometritis commonly caused by chlamydia often cause bleeding par vaginum in the weeks following a delivery.
  8. Abdominal pain
  9. Bulky uterus if multiple masses or huge mass present
  10. Pressure symptoms: frequency, constipation
  11. Infertility

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When your doctor examines you, clinical examination may reveal: pallor (sign of reduced red blood), bradycardia (low heart rate), goiter, bruises on general examination, palpably enlarged abdominal mass, tender uterus or adnexae which indicates endometriosis.


  1. Abdominal or Transvaginal ultrasonography: Either of these could in case of uterine fibroid reveal- Hypoechoic mass within the uterus, posterior shadowing from the mass, degenerating fibroids may have calcifications or cystic components, multiple fibroids appear as an enlarged, irregularly shaped, diffusely heterogeneous uterus. However, if cancerous, rapidly growing mass may be observed in the uterus.
  2. Endometrial biopsy: The procedure often reserved for women in whom endometrial polyps, hyperplasia and carcinoma is suspected.
  3. Thyroid function test
  4. Coagulation profile
  5. Hysteroscopy: This method enables your doctor to have a pre-operative intracavitatory view of the uterus or endometrium.



Available treatment options include both Medical and Surgical.



This is usually the first line of management. The National Institute for Health and Care Excellence (NICE) guidelines suggest the following order:

  • Levonorgestrel intrauterine system (LNG-IUS): The long term use of at least 12 months is expected. With this method, reduction in mean blood loss of about 95% is achieved by one year after the insertion of (LNG-IUS). It provides a highly effective alternative to surgical treatment, with few side-effects which include amenorrhea or irregularity in menstrual flow.
  • Use of antifibrinolytics: Tranexamic acid reduces blood loss by 50% and is taken during menstruation
  • Mefenamic acid, which inhibits prostaglandin synthesis and reduces blood loss by 30%, or COCP, which will induce slightly lighter periods.
  • Gonadotrophin-releasing hormone (GnRH) agonists: these drugs act on the pituitary to stop the production of oestrogen by desensitizing response to endogenous GnRH which results in amenorrhea by reducing secretion of LH and FSH. Your doctor will prescribe this for you in short term because it predisposes you to osteoporosis. Examples of GnRH agonist gooserelin, nafarelin etc.


Surgical treatment is normally restricted to women for whom medical treatments have failed or where there are associated symptoms such as pressure symptoms from fibroids or prolapse. Women contemplating surgical treatment for HMB must be certain that their family is complete. Available surgical treatment options include:

  • Myomectomy: This is used for women in whom cause of heavy menstrual bleeding is huge or multiple fibroid.
  • Endometrial ablation.
  • Hysterectomy: This is definitive treatment for heavy menstrual bleeding. Your doctor will use this method for you if you have completed your family size.



Gynaecology textbook- Ten teachers

Explain Medicine

Examination review for Ultrasound by Steven M. Penny

VIDEO CREDIT: Dr. Amy Wrennick


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