Heavy Menstrual Bleeding (HMB)

This guideline applies to adults aged 18 years and over.

Introduction

Heavy menstrual bleeding (HMB) is defined as excessive menstrual blood loss with or without pain that affects the patient's physical, social, or emotional well-being. 

 

In scope                        

• Heavy menstrual bleeding

Not in scope               

• Post coital bleeding (PCB)
• Inter-menstrual bleeding (IMB)
• Dyspareunia
• Dysmenorrhoea

  

Red Flag Features

• Post menopausal bleeding (PMB)
• Pelvic mass with unexplained bleeding or weight loss
• Ascites
• Appearance of cervix consistent with cervical cancer

*This list is non exhaustive 

Investigations required prior to referral

• FBC for all women with HMB
• Coagulation screen if HMB since periods started and a personal or family history suggestive of coagulation disorder
• Transvaginal ultrasound 
• Consider other investigations depending on history and examination findings eg pregnancy test or swabs. 

 

Do not routinely carry out serum ferritin, female hormone or thyroid testing for women with HMB unless associated symptoms.

 

Management optimisation

Primary care management is suitable for:

• Patients with no identified pathology 
• fibroids <3cm, identified on ultrasound, that are not causing distortion of cavity
• suspected or diagnosed adenomyosis

 

Consider using Making a decision about managing heavy periods to make a shared decision:

Hormonal treatment options-consider individual risk factors and medical conditions using UKMEC:

•  Levonorgestrel (LNG)-IUS as first line treatment
• Combined oral contraception
• Progesterone-only pill (POP).
• Depo Provera (unlicensed use) - note effect on bone mineral density (BMD)- review risks/benefits every 2 years.  Use with caution in women under 18yo or with significant risk factors for osteoporosis and over age of 50.
• Norethisterone or Medroxyprogesterone (Provera)can be used long term cyclically providing investigations (ultrasound and histology) have been carried out particularly in women over 45 years old.

 

Non hormonal treatment options:

• Tranexamic acid
• NSAIDs
• Manage iron deficiency anaemia based on FBC result.

 

Advice and Guidance

Obtain advice and guidance by eRS

 

Referral instructions

Emergency

If the patient has severe anaemia causing them to be haemodynamically unstable, refer to on-call gynaecology Consultant.

Refer under Fast Track Suspected Gynaecology Cancer:

• PMB or USB on HRT if >65yo or BMI>40
• suspicious endometrium on transvaginal ultrasound
• features of gynaecological malignancy (pelvic mass associated with unexplained bleeding or weight loss)
• appearance of cervix consistent with cervical cancer

 

Routine referral criteria

Refer to Menstrual Bleeding Clinic:  

• Primary care treatment has been unsuccessful or declined
• Severe HMB
• History of Intermenstrual or Irregular Menstrual Bleeding
• Pathology on ultrasound not consistent with malignancy (eg fibroids >3cm, abnormally thickened endometrium (>7mm) or endometrial polyps)
• Infrequent heavy bleeding in women who are obese or have known PCOS

 

Referral to the Menstrual Bleeding Clinic is likely to involve outpatient hysteroscopy and if appropriate, discussion of LNG IUS insertion. Please advise women of this before referral. 

Referral instructions

Please include the following information where possible:

• Indication of parity
• Describe symptoms, duration & effect on quality of life
• Smear History (The patient will still be seen without this, but it speeds up appointment)
• Relevant past medical and surgical history
• Current regular medication (if not on proforma)
• Treatment tried so far and Contraception

• Transvaginal ultrasound within three months of the date of referral is required for all referrals to secondary care (with exception of suspected gynaecological cancer referrals).

 

Supporting Information

For professionals       NICE CKS Menorrhagia (HMB)

For patients                 Making a decision about managing heavy periods

             Period Blood Loss Chart

             RCHT 897 - Treatment for heavy periods (cornwall.nhs.uk)

Outpatient Hysteroscopy
Mirena leaflet

 

References                 

Menorrhagia (heavy menstrual bleeding) | Health topics A to Z | CKS | NICE

CEU-Unscheduledbleeding (rcog.org.uk)

Combined oral contraception

Progesterone-only pill (POP).

 

 

 

 

Page Review Information

 

Review date	15 November 2024
Next review date	15 November 2026
Clinical editor	Dr Melanie Schick
Contributors	Miss Lisa Verity, Consultant Gynaecologist, RCHT