Clinical Strategies for Managing Heavy Menstrual Bleeding
Heavy menstrual bleeding (HMB) is the most common bleeding symptom that young women / women with bleeding disorders experience, and sometimes, it is the only sign of a bleeding disorder. Ninety percent (90%) of women with an underlying bleeding disorder experience HMB. In adolescents, HMB is associated not only with iron deficiency (in up to 60% of patients) and fatigue but also with missed school days, social events, outdoor activities, and physical education. Despite the negative impact of bleeding disorders on health-related quality of life, there is still a long delay between the onset of symptoms and the diagnosis of a bleeding disorder, particularly in the female population. Recognizing that many people still do not recognize the signs and symptoms of HMB, increasing awareness is essential.
This learning module seeks to increase awareness, knowledge, and understanding of bleeding disorders, proper screening tools, and management strategies among healthcare professionals who are the first to see the signs and symptoms of bleeding disorders in women and girls.
Designed to enhance provider understanding of HMB and its connection to bleeding disorders, this brief animation highlights key aspects of care, including signs and symptoms, diagnostic questions, an introduction to screening tools and diagnostic tests, and recommended next steps.
This webinar will increase awareness, knowledge, and understanding of bleeding disorders, proper screening tools, and management strategies among healthcare professionals who are the first to see the signs and symptoms of bleeding disorders in women and girls.
Learning Objectives
– Describe the clinical features that correlate with true heavy menstrual bleeding (HMB)
– Identify the first-line therapies for HMB
– Identify screening tools for possible underlying bleeding disorders
Faculty
Oluyemisi Adeyemi-Fowode, MD, FACOG, FAAP
Pediatric and Adolescent Gynecologist
Texas Pediatric & Adolescent Gynecology
Bethany Samuelson Bannow, MD, MCR
Associate Professor, Division of Hematology & Medical Oncology
Oregon Health & Science University
Erica Godsey, APRN, MSN, CNP
Director of Nursing
Cascade Hemophilia Consortium
This webinar will provide one hour of continuing education credits as outlined in the accreditation overview (below). To access the course, please click the registration button below.
The objective of this reading curriculum is to provide the essential resources needed to acquire fundamental clinical knowledge on heavy menstrual bleeding (HMB) due to inherited blood disorders.
ETIOLOGY OF HMB
ACOG Committee Opinion No. 651: Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign. Obstet Gynecol. 2015; 126(6):e143-e146. doi:10.1097/AOG.0000000000001215
Munro MG, Critchley HO, Broder MS, Fraser IS. FIGO Working Group on Menstrual Disorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. 2011; 113(1):3-13. doi:10.1016/j.ijgo.2010.11.011
SCREENING TOOLS
Borzutzky C, Jaffray J. Diagnosis and Management of Heavy Menstrual Bleeding and Bleeding Disorders in Adolescents. JAMA Pediatr. 2020; 174(2):186-194. doi:10.1001/jamapediatrics.2019.5040
Jain S, Zhang S, Acosta M, Malone K, Kouides P, Zia A. Prospective evaluation of ISTH-BAT as a predictor of bleeding disorder in adolescents presenting with heavy menstrual bleeding in a multidisciplinary hematology clinic. J Thromb Haemost. 2020; 18(10):2542-2550. doi:10.1111/jth.14997
Matteson KA, Scott DM, Raker CA, Clark MA. The menstrual bleeding questionnaire: development and validation of a comprehensive patient-reported outcome instrument for heavy menstrual bleeding. BJOG. 2015; 122(5):681-689. doi:10.1111/1471-0528.13273
McDonald L, Grabell J, Leung J, Hopman W, James P. Evaluating the impact of the self-BAT screening tool on patient outcomes: Results of the let’s talk period project. Haemophilia. 2024; 30(6):1400-1405. doi:10.1111/hae.15113
Screening and Management of Bleeding Disorders in Adolescents With Heavy Menstrual Bleeding: ACOG COMMITTEE OPINION, Number 785. Obstet Gynecol. 2019; 134(3):e71-e83. doi:10.1097/AOG.0000000000003411
DIAGNOSTIC EVALUATION
James AH. Heavy menstrual bleeding: work-up and management. Hematology Am Soc Hematol Educ Program. 2016; 2016(1):236-242. doi:10.1182/asheducation-2016.1.236
Kouides PA, Conard J, Peyvandi F, Lukes A, Kadir R. Hemostasis and menstruation: appropriate investigation for underlying disorders of hemostasis in women with excessive menstrual bleeding. Fertil Steril. 2005; 84(5):1345-1351. doi:10.1016/j.fertnstert.2005.05.035
Practice Bulletin No. 128: Diagnosis of Abnormal Uterine Bleeding in Reproductive-Aged Women. Obstetrics & Gynecology 120(1):p 197-206, July 2012. | DOI: 10.1097/AOG.0b013e318262e320
LABORATORY TESTING
James AH, Kouides PA, Abdul-Kadir R, et al. Evaluation and management of acute menorrhagia in women with and without underlying bleeding disorders: consensus from an international expert panel. Eur J Obstet Gynecol Reprod Biol. 2011; 158(2):124-134. doi:10.1016/j.ejogrb.2011.04.025
Dickerson KE, Menon NM, Zia A. Abnormal Uterine Bleeding in Young Women with Blood Disorders. Pediatr Clin North Am. 2018; 65(3):543-560. doi:10.1016/j.pcl.2018.02.008
Thomas W, Downes K, Desborough MJR. Bleeding of unknown cause and unclassified bleeding disorders; diagnosis, pathophysiology and management. Haemophilia. 2020; 26(6):946-957. doi:10.1111/hae.14174
TREATMENT FOR THE ADOLESCENT
ACOG Committee Opinion No. 735: Adolescents and Long-Acting Reversible Contraception: Implants and Intrauterine Devices. Obstet Gynecol. 2018; 131(5):e130-e139. doi:10.1097/AOG.0000000000002632
Adeyemi-Fowode OA, Bercaw-Pratt JL. Intrauterine Devices: Effective Contraception with Noncontraceptive Benefits for Adolescents. J Pediatr Adolesc Gynecol. 2019; 32(5S):S2-S6. doi:10.1016/j.jpag.2019.07.001
Adeyemi-Fowode OA, Santos XM, Dietrich JE, Srivaths L. Levonorgestrel-Releasing Intrauterine Device Use in Female Adolescents with Heavy Menstrual Bleeding and Bleeding Disorders: Single Institution Review. J Pediatr Adolesc Gynecol. 2017; 30(4):479-483. doi:10.1016/j.jpag.2016.04.001
Alaqzam TS, Stanley AC, Simpson PM, Flood VH, Menon S. Treatment Modalities in Adolescents Who Present with Heavy Menstrual Bleeding. J Pediatr Adolesc Gynecol. 2018; 31(5):451-458. doi:10.1016/j.jpag.2018.02.130
Khalighi M, Wheeler AP, Adeyemi-Fowode OA, et al. Does a Bleeding Disorder Lessen the Efficacy of the 52-mg Levonorgestrel-Releasing Intrauterine System for Heavy Menstrual Bleeding in Adolescents? A Retrospective Multicenter Study. J Adolesc Health. 2022; 71(2):204-209. doi:10.1016/j.jadohealth.2022.02.018
Pradhan S, Gomez-Lobo V. Hormonal Contraceptives, Intrauterine Devices, Gonadotropin-releasing Hormone Analogues and Testosterone: Menstrual Suppression in Special Adolescent Populations. J Pediatr Adolesc Gynecol. 2019; 32(5S):S23-S29. doi:10.1016/j.jpag.2019.04.007
Stanley J, Adeyemi-Fowode O. Intrauterine Foley Balloon Catheter to Manage Acute Heavy Menstrual Bleeding in a Perimenarchal 10-Year-Old Girl. Obstet Gynecol. 2019; 134(1):77-80. doi:10.1097/AOG.0000000000003330
TREATMENT FOR THE ADULT
American College of Obstetricians and Gynecologists’ Committee on Clinical Consensus–Gynecology. General Approaches to Medical Management of Menstrual Suppression: ACOG Clinical Consensus No. 3. Obstet Gynecol. 2022; 140(3):528-541. doi:10.1097/AOG.0000000000004899
Bofill Rodriguez M, Lethaby A, Jordan V. Progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev. 2020; 6(6):CD002126. Published 2020 Jun 12. doi:10.1002/14651858.CD002126.pub4
Chi C, Huq FY, Kadir RA. Levonorgestrel-releasing intrauterine system for the management of heavy menstrual bleeding in women with inherited bleeding disorders: long-term follow-up. Contraception. 2011;83(3):242-247. doi:10.1016/j.contraception.2010.07.010
Hillard PA. Menstrual suppression: current perspectives. Int J Womens Health. 2014; 6:631-637. Published 2014 Jun 23. doi:10.2147/IJWH.S46680
Kingman CEC, Kadir RA, Lee, CA, Economides DL. The use of levonorgestrel-releasing intrauterine system for treatment of menorrhagia in women with inherited bleeding disorders. BJOG. 2004; 111:1425-1428. doi:10.1111/j.1471-0528.2004.00305
National Hemophilia Foundation. (2021). MASAC Document #265:MASAC Guidelines for Pregnancy and Perinatal Management of Women with Inherited Bleeding Disorders and Carriers of Hemophilia A or B. Retrieved from MASAC Guidelines for Pregnancy | NBDF
Nguyen AT, Curtis KM, Tepper NK, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep 2024; 73(No. RR-4):1–126. DOI: http://dx.doi.org/10.15585/mmwr.rr7304a1.
Schaedel ZE, Dolan G, Powell MC. The use of the levonorgestrel-releasing intrauterine system in the management of menorrhagia in women with hemostatic disorders. Am J Obstet Gynecol. 2005; 193(4):1361-1363. doi:10.1016/j.ajog.2005.05.002
Stewart A, Cummins C, Gold L, Jordan R, Phillips W. The effectiveness of the levonorgestrel-releasing intrauterine system in menorrhagia: a systematic review. BJOG. 2001; 108(1):74-86. doi:10.1111/j.1471-0528.2001.00020.x
QUALITY OF LIFE
Matteson KA, Scott DM, Raker CA, Clark MA. The menstrual bleeding questionnaire: development and validation of a comprehensive patient-reported outcome instrument for heavy menstrual bleeding. BJOG. 2015; 122(5):681-689. doi:10.1111/1471-0528.13273
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Our thanks to Hemophilia of Georgia for their support of this project.