Postpartum hemorrhage

Disease Description (Causes and Symptoms)

• Definition: A condition in which menstrual bleeding is excessively heavy, generally referring to bleeding of approximately 80 mL or more per cycle or menstruation lasting 7 days or longer; it may cause anemia.
• Main causes: Uterine fibroids, adenomyosis, endometrial hyperplasia, endometrial polyps, endometrial cancer, structural abnormalities of the uterus, bleeding disorders (e.g., von Willebrand disease, immune thrombocytopenia, etc.), hormonal imbalance, and many cases with no identifiable cause.
• Pathophysiology summary: Structural lesions (fibroids, polyps, etc.) increase vascular and mechanical bleeding from the endometrium, while hormonal imbalance causes excessive endometrial growth or unstable blood vessels. When a coagulation disorder is present, bleeding may continue excessively.
• Main symptoms: Increased menstrual bleeding (excessive use of pads/tampons, passage of blood clots), prolonged menstruation, fatigue, dizziness, symptoms of anemia, and disruption of daily or work activities.

Treatment Methods

• Basic principles: Identify the cause (structural lesions, hormonal abnormalities, coagulation disorders, etc.) and provide cause-specific treatment. The goals are to correct anemia and reduce the amount of bleeding.
• Medication treatment
  • Iron supplementation: Oral iron supplements if anemia is present (transfusion may be considered in severe cases).
  • Antifibrinolytic: Tranexamic acid — short-term reduction in the amount of bleeding.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs): May reduce menstrual cramps and partially reduce the amount of bleeding.
  • Hormone therapy: Oral contraceptives (combined oral contraceptives), progestins (oral or injectable), levonorgestrel-releasing intrauterine system (LNG-IUS, hormonal IUD) — effective for long-term control of bleeding.
  • Hormone suppressants (such as GnRH agonists): Limited use, including to reduce bleeding and uterine size before surgery.
• Procedural/surgical treatment
  • Hysteroscopic surgery (polyp removal, removal of endometrial tissue, etc.) — a priority consideration when the cause is within the uterus.
  • Fibroid treatment: Depending on the size and location of the fibroid, myomectomy (uterus-preserving), uterine artery embolization (UAE), etc.
  • Endometrial curettage or ablation (may be irreversible in some cases).
  • Hysterectomy (removal of the uterus): Selected when conservative treatment is not possible, treatment has failed, or malignancy is suspected.
• Lifestyle management and precautions
  • Record the amount and duration of bleeding (number of pads/tampons, presence of blood clots, symptoms by date).
  • Seek emergency medical care immediately if symptoms of anemia (dizziness, chest pain, fainting) occur.
  • Pregnancy should be assessed (excessive menstrual bleeding may be caused by a pregnancy-related problem).
• Risk of complications: Iron-deficiency anemia, reduced quality of life if treatment is delayed, surgery-related complications (infection, bleeding, and postoperative complications), and the possibility of cancer depending on the underlying cause.

Checklist Before an Outpatient Visit (Including Items to Bring and Example Questions)

• Items/history
  • A list of medications currently being taken (contraceptives, anticoagulants, iron supplements, etc.).
  • Bring copies of recently performed test results, if available (pelvic ultrasound, CBC (hemoglobin), coagulation tests, etc.).
  • Menstrual diary: Duration of the most recent 2–3 cycles, amount of pad/tampon use (maximum number used per day), presence of blood clots, and severity of pain.
  • Possibility of confirming pregnancy (timing of the last sexual intercourse, pregnancy test results).
  • Past surgical history (uterine surgery and other gynecological surgery).
  • Family history of bleeding disorders (such as von Willebrand disease) or personal tendency to bleed (nosebleeds, bleeding gums, etc.).
• Items the doctor may ask about during the outpatient visit (examples)
  • When did your menstruation begin, and how many days does it last on average? How many pads/tampons do you use per day?
  • Do you see blood clots? What are their color and appearance?
  • Do you have symptoms of anemia such as fatigue, dizziness, or shortness of breath?
  • Are you currently taking any medications, especially anticoagulants, anti-inflammatory drugs, or hormones?
  • Is there a possibility of pregnancy, or are you planning a pregnancy?

Examples of General Questions to Ask the Doctor

• What is the cause of this bleeding? What additional tests are needed?
• What are the effects and side effects of the medication or procedure being prescribed now?
• My anemia is severe; are iron supplements alone sufficient? In what situations is a transfusion necessary?
• I am planning a pregnancy in the future; what treatment is appropriate?
• If surgery is necessary, what are the alternatives, recovery period, and risk of complications?

Examples of Disease-Specific Questions

• How should I record the amount of menstrual bleeding numerically? (For example, the number of pads/tampons used per day and the time it takes for one to become saturated.)
• If I want to preserve my uterus (including plans for pregnancy), what treatment options are recommended?