[PDF] Heavy menstrual bleeding (HMB): - Pharmacological Management

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Heavy menstrual bleeding (HMB):

Pharmacological Management

Treatments for women with:

x no identified pathology, x fibroids less than 3 cm in diameter (which are not causing distortion of the uterine cavity) x suspected or diagnosed adenomyosis1

1. Consider a Levonorgestrel-releasing intrauterine

system (LNG-IUS) as the first treatment

2. If a woman with HMB declines an LNG-IUS or it is

not suitable, consider the following pharmacological treatments:

‡ QRQ-hormonal:

Tranexamic acid (may be purchased OTC)

NSAIDs (non-steroidal anti-inflammatory

drugs)

‡ hormonal:

Combined hormonal contraception (COC)

Cyclical oral progestogens.

Be aware that progestogen-only contraception may suppress menstruation, which could be beneficial to women with HMB.

3. If treatment is unsuccessful, the woman declines

pharmacological treatment, or symptoms are severe, consider referral to specialist care for: ‡ Investigations to diagnose the cause of HMB, if needed taking into account any investigations the woman has already had and

‡ Alternative treatment choices, including:

pharmacological options not already tried surgical options (refer to service restriction policy)

Treatments for women with:

x fibroids of 3 cm or more in diameter1

1. Consider referring women to specialist care to

undertake additional investigations and discuss treatment

2. If pharmacological treatment is needed while

investigations and definitive treatment are being organised, offer tranexamic acid and/or NSAIDs. Advise women to continue using NSAIDs and/or tranexamic acid for as long as they are found to be beneficial.

3. For women with fibroids of 3 cm or more in

diameter, take into account the size, location and number of fibroids, and the severity of the symptoms and consider the following treatments: x pharmacological: non-hormonal:

ƒ Tranexamic acid (may be purchased OTC)

ƒ NSAIDs

hormonal:

ƒ LNG-IUS

ƒ combined hormonal contraception

ƒ cyclical oral progestogens

x surgical (refer to service restriction policy) x Pre-treatment with a gonadotrophin-releasing hormone analogue before hysterectomy and myomectomy should be considered if uterine fibroids are causing an enlarged or distorted uterus Be aware that the effectiveness of pharmacological treatments for HMB may be limited in women with fibroids that are substantially greater than 3 cm in diameter.

If treatment is unsuccessful:

x consider further investigations to reassess the cause of HMB, taking into account the results of previous investigations and x offer alternative treatment with a choice of the options described above

Use of a gonadotrophin-releasing hormone analogue could be considered prior to surgery or when all other

treatment options for uterine fibroids, including surgery or uterine artery embolisation, are contraindicated. If this

treatment is to be used for more than 6 months or if adverse effects are experienced then hormone replacement

therapy (HRT) 'add-back' therapy is recommended3.

MOPB October 2018: Ulipristal (Esmya®) is not recommended for prescribing in Primary or Secondary care. For

existing patients please refer to MHRA August 2018: Esmya (ulipristal acetate) for symptoms of uterine fibroids: restrictions to use and requirement to check liver function before, during and after treatment.

For guidance on investigating the cause of HMB

including history taking, physical examination and laboratory tests please refer to NICE NG88 Heavy menstrual bleeding: assessment and management

Produced by West Essex CCG Medicines Optimisation Team; Approved MOPB October 2018; Review Date October 2020

Pharmacological treatment options3

Treatment Dosage, mechanism of

action and effect on bleeding

Is it a

contraceptive?

Adverse effects Other considerations

First-line

Levonorgestrel

-releasing intrauterine system a (LNG-IUS) releases progestogen and prevents proliferation of endometrium.

95% (full benefit may not be seen

for 6 months)

Yes Common: irregular

bleeding that may last for over 6 months, breast tenderness, acne, headaches

Less common:

amenorrhoea

Rare: uterine perforation

at time of insertion

Choose only if

long-term use is anticipated (at least 12 months)

Second-line

Tranexamic

Acid (oral)

Give 1g, 3 to 4 times daily from

day 1 of cycle for up to 4 days 58%

No Less common:

indigestion, diarrhoea, headache

If no improvement stop after

3 cycles.

Tranexamic acid should not

be used in combination with

COC or a LNG-IUS owing to

an increased risk of venous thromboembolism.4

Tranexamic acid tablets are

available over the counter as a pharmacy (P) medicine.

Patients do not need to have

been treated with a LNG-IUS (or any other treatment) before OTC tranexamic acid can be provided.

NSAIDsa

(oral) before, until heavy blood loss has stopped prostaglandin 49%

No Common: indigestion,

diarrhoea

Rare: worsening of

asthma in sensitive individuals, peptic ulcer, peritonitis

If no improvement stop after

3 cycles

endometrium

Yes Common: mood change,

headache, nausea, fluid retention, breast tenderness

Very rare: DVT, stroke,

heart attack

Third-line

Norethisterone

of cycle endometrium

83% in long term

Yesb Common: weight gain,

bloating, breast tenderness, headaches, acne

Rare: depression

Contraindications include

previous idiopathic or current venous thromboembolism.5 Other

Injectable

Gonadotrophin

-releasing hormone (Gn-RH)

Analoguea

and progestogen

89% of women

No Common: menopausal-

like symptoms

Less common:

osteoporosis, particularly trabecular bone with use > 6 months

Used prior to surgery

(hysterectomy or myomectomy) to reduce uterine size, fibroid size and perioperative blood loss.

If used for > 6 months give

add back HRT3 None of the above treatments have any impact on future fertility. Adverse effects: common: 1 in 100 chance; less common: 1 in 1,000 chance; rare: 1 in 10,000 chance; very rare: 1 in 100,000 chance.

a See Summary of Product Characteristics for current licensed indications. Unlicensed indication: The prescriber should follow

relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and

documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

while it is being taken.

Produced by West Essex CCG Medicines Optimisation Team; Approved MOPB October 2018; Review Date October 2020

References:

1. NICE guideline NG88 Heavy menstrual bleeding: assessment and management (March

2018) https://www.nice.org.uk/guidance/ng88

2. MHRA Central Alerting System - Esmya (ulipristal acetate) for symptoms of uterine fibroids:

restrictions to use and requirement to check liver function before, during and after treatment (August 2018)

3. NICE Bites October 2011 Heavy Menstrual Bleeding

4. National Institute for Health and Care Excellence. Menorrhagia. CKS

https://cks.nice.org.uk/menorrhagia#!scenario [Accessed 8.8.18]

5. Electronic Medicines Compendium https://www.medicines.org.uk/emc/product/1494

[Accessed 25.10.18]quotesdbs_dbs1.pdfusesText_1

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