PROLONGED AND HEAVY MENSTRUAL BLEEDING: CLINICAL PRESENTATION

HISTORY

Other than your age, the number of children you have had (most women with HMB are in their 40s and are usually nulliparous or women with a very low parity), your doctor will ask you specific questions to ascertain your complaints of HMB because many patients have different ideas as to what constitutes a ‘heavy period’.

QUESTIONS TO CONFIRM HMB

  • How often does your sanitary wear needs to be changed in a day and how many sanitary wears do you wear now for the whole menstrual period compared to the time your periods were normal years back?
  • Are there presence of clots?
  • How large are the clots and how often do you see the clots?
  • Is the bleeding so heavy (flooding) that it spills over your towel/tampon and on to your pants, clothes or beddings?
  • How long does the menses last and has there been an increase in the number of days your period flow compared to the past?
  • Have you had to take any time off work due to this bleeding?
  • Do you ever feel terrified due to the bleeding?
  • How long have you been having HMB and why did you decide to present now and not earlier?
  • Remember a single episode of heavy bleeding does not necessarily equate to HMB. From the definition, the bleeding has to be recurrent, cyclical and must occur in consecutive cycles for it to be HMB. Isolated epeisode of heavy bleeding can be due to complications of pregnancy and abormal bleeding common with anovulatory cycles.

QUESTIONS TO ASSESS COMPLICATIONS OF EXCESSIVE BLOOD LOSS (ANAEMIA)

  • Do you feel dizzy, weak or have you ever experienced fainting attacks at the height of bleeding or just after the menstrual period finished? Anaemia which is a complication of excessive blood loss, can present with fainting attacks and dizziness when acute especially at the height of bleeding or just after it.
  • Do you have trouble catching your breath, pant at every small chores or get easily tired while doing chores you normally do without flinching? Anaemia when left untreated in its chronic state can result in heart failure which may then present as above.
  • Do you notice any leg swelling recently? Leg swelling is a rather late feature of untreated heart failure due to chronic anaemia. Some causes of HMB such as huge uterine fibroids may also rarely present with leg swelling due to the effect of the fibroid mass compressing on the inferior vena cava, a large vein carrying blood from the legs and abdomen to the heart.

QUESTIONS TO ASSESS FOR THE POSSIBLE CAUSES OF HMB

  • What is your cycle length and is it regular? Despite most causes of HMB occuring in regular cycles, anovulatory cycles precisely PCOS can present with heavy bleeding alternating with periods of prolonged irregular scanty or erratic bleeding. This is often referred to as anovuatory DUB.
  • Do you notice any abdominal swelling or feel any hard mass in your tummy? Uterine fibroids, adenomyosis and endometrial cancer commonly present as a growth in the uterus, the first two being commoner in younger women while endometrial cancer is commoner in older women.
  • If yes, for how long have you noticed it and how rapidly has it been getting bigger? Although uterine fibroids have a variable rate of growth, endometrial cancer is more likely to grow at a faster rate.
  •  Do you notice any weight loss? Now that will help to differentiate the more common uterine fibroid from the more rapidly growing endometrial cancer which is usually associated with weight loss.
  • Do you notice excessive or frequent urination or leg swelling? Questions pertaining to the pressure effect of the mass will also be asked e.g. huge uterine fibroids is often a cause of fruequent urination due to the pressure effect on the bladder and a rare cause of leg swelling due to the presssure effect of a posterior fibroid on the inferior vena cava dampening the return of blood from the legs to the heart.
  • Do you notice worsening menstrual pain or new onset of severe lower abdominal pain occuring during or after the menstrual flow? Uterine fibroid and adenomyosis are more likely to present with an abdominal swelling associated with secondary dysmenorrhea. Lower abdominal pain felt on the abdominal mass itself is often a feature of a degenerating uterine fibroid while PID on the other hand may present with HMB associated with severe secondary dysmenorrhea and or lower abdominal pain without any abdominal mass.
  • Do you have painful intercourse on deep penetration? PID and uterine fibroids may present with deep dyspareunia.
  • Do you have any other abnormal bleeding? Intermenstrual bleeding is common with endmetrial polyps, endometrial hyperplasia and endometrial cancer. Submucous fibroids may also cause prolonged menstrual bleeding associated with intermenstrual spotting and bleeding. Patients with anovulatory cycles, may also present with irregular but HMB alternating with periods of spotting or scanty bleeding. Post coital bleeding may be seen in women with cervical cancer, cervical polyps, fibroid polyps, endometrial polyps and PID.
  • Is there any history of abnormal vaginal discharge? PID is often associated with the passage of malodourous yellowih vaginal discharge associated with lower abdominal pain, abnormal vaginal bleeding, secondary dysmenorrhea and HMB. Submucous fibroids may be associated with the passage of watery clear or brownish vaginal discharge that is non offensive. A similar but more brownish or blood stained intermenstrual discharge may be seen in endometrial polyps. Cervical cancer on the other hand is often asociated with profuse very foul smelling watery vaginal discharge associated with post coital bleeding.
  • Are you on any form of contraception? Although the use of IUCD is often associated with an increase in the menstrual flow and a slight increase in menstrual pain within the first two to three months of insertion in many women, these symptoms usually resolve within few months in most women who select IUCD using the WHO MEC guidelines on the use of contraception. However, women with ab initio heavy menstrual flow (e.g. those with submucous uterine fibroids and DUB) and those with moderate to severe primary dysmenorrhea, who go on to use IUCD as a form of contraception, may develop severe HMB and severe secondary dysmenorrhea. Similarly, progesterone only contraceptives such as progesterone only pills and depo provera are commonly associated with irrregular scanty and in some women a total absence of menses for many months and years. However, a few women, may come down with heavy erratic mentrual flow. Therefore any woman with the complaint of HMB must be aked if she is on any form of contraception and the specific type ascertained.

QUESTIONS TO EXCLUDE SYSTEMIC CAUSES OF HMB

QUESTIONS TO EXCLUDE BLEEDING DISORDERS

  • Is there a history of bleeding disorder in your family?
  • Did you experience excessive bleeding from a previous tooth extraction?
  • Has your menses been heavy from the very first moment you started menstruating?
  • Have you always noticed excessive bleeding from previous small cuts sustained in the past?

QUESTIONS TO EXCLUDE HYPOTHYROIDISM

  • Is there a history of neck swelling?
  • Is there a history of recent excessive weight gain?
  • Is there a a history of cold intolerance?
  • Do you always feel weak and lazy?

PHYSICAL EXAMINATION

You will be examined for any signs of anaemia and thyroid disease by a quick general examination of your body. An abdominal and pelvic examination will also be done to palpate for any pelvic masses and visualize the cervix for any mass or discharge. Swabs will be taken if pelvic infection is suspected and a cervical smear must be done if one is due or if none has ever been done for screening of premalignant lesions of the cervix.

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