Heavy Menstrual Bleeding (HMB)
NICE Guideline [NG88] Heavy menstrual bleeding: assessment and management. Last updated: May 2021.
NICE CKS Menorrhagia (heavy menstrual bleeding)
Improvements and re-structuring has been made to this article to improve clarity and flow.
Date: 13/02/26
This article only covers HMB as a presentation; a separate article on fibroids Uterine Fibroids (Leiomyoma) is available to improve clarity.
Note that NICE made a single guideline that covers HMB with no identified pathology, fibroid and adenomyosis.
Background Information
Definition
NICE defines HMB as excessive menstrual blood loss (that is subjective to the women), which interferes with physical, social, emotional and/or material quality of life.
Traditionally, menorrhagia has been defined as blood loss >80 mL and/or duration of >7 days. But this definition is no longer considered useful.
Aetiology
No cause identified in ~50% of women.
Important causes:
| Uterine and ovarian causes |
|
| Systemic conditions |
|
Clinical Features
As mentioned above, HBM is a subjective definition of excessive menstrual blood loss (by the patient), which interferes with physical, social, emotional and/or material quality of life.
Supportive features include:
- Soaking or having to change many pads / tampons per day (e.g. more than every 1-2 hours)
- Passage of large blood clots
- ‘Flooding episodes‘ where there is bleeding through clothes / sheets
- Features of iron deficiency anaemia (e.g. fatigue, pallor, dizziness, weakness)
Cause-specific clinical features:
| Cause of HBM | Supportive clinical features (non-exhaustive) |
|---|---|
| Fibroids | Common in women of reproductive age
|
| Adenomyosis | Common in 40-50 y/o (perimenopausal) women
|
| Endometrial polyps | Common in perimenopausal and postmenopausal women
|
Although endometriosis can cause HMB, it is NOT a main feature or main cause of HMB.
The predominant clinical manifestations of endometriosis are pelvic pain, dysmenorrhea, and deep dyspareunia.
Diagnosis
Laboratory Tests
Perform FBC (to check for iron deficiency anaemia) in ALL patients
Consider the following (based on clinical context):
- Pregnancy test
- Clotting panel
- TFT
- Vaginal / cervical swabs
Investigations for Underlying Cause
If history and/or examination suggest a high risk of an underlying cause → arrange further investigations to determine the underlying cause.
If the examination is difficult / inconclusive (e.g. in obese women) → offer a pelvic ultrasound
Choice of investigations depends on the suspected underlying cause:
| Suspected pathology | Investigation |
|---|---|
| Submucosal fibroids |
|
| Polyps | |
| Endometrial pathology | |
| Large fibroids |
|
| Adenomyosis |
|
NICE specifically recommended the following:
- Do not use saline infusion sonography as a first-line diagnostic tool for HMB
- Do not use MRI as a first-line diagnostic tool for HMB
- Do not use dilatation and curettage alone as a diagnostic tool for HMB
Management
Referral Criteria
Referral to secondary care is indicated if:
- Suspected cancer
- >55 y/o with post-menopausal bleeding (due to possible endometrial cancer)
- Ascites and/or pelvic or abdominal mass, which is not obviously due to uterine fibroids (due to possible ovarian cancer)
- Fibroids ≥3 cm (consider referral as they may benefit from secondary care management) (see the Uterine Fibroids (Leiomyoma) article for more information)
- HMB failed to improve with primary care management
- Iron deficiency anaemia failed to respond to treatment, and other causes have been excluded
NICE recommends considering starting pharmacological treatment without investigating the cause if the history and/or examination suggest a low risk of fibroid / uterine cavity abnormality / adenomyosis.
Primary Care Management
The following management applies for HMB secondary to:
- No identified pathology, or
- Fibroids <3 cm, or
- Adenomyosis
Choice of management is largely determined by whether the patient is planning to conceive (at the moment or in the near future).
Patient NOT Planning to Conceive
1st line: levonorgestrel intrauterine system (LNG-IUS)
2nd line (either):
- Non-hormonal options: NSAIDs / tranexamic acid
- Hormonal options: COCP / cyclical oral progestogen (norethisterone)
Key contraindications to LNG-IUS:
- History / current cancer (breast / cervical / endometrial)
- Unexplained, uninvestigated vaginal bleeding (due to possible endometrial cancer)
- Distorted uterine cavity (e.g. due to submucosal fibroids, intrauterine adhesions, large endometrial polyps, congenital uterine anomalies – typically seen on ultrasound / other imaging)
- Current PID
It is important to not mix up the copper IUD and LNG-IUS
- Copper IUD can worsen or cause HMB
- LNG-IUS often causes oligomenorrhoea / amenorrhoea, thus used to treat HMB
Patient IS Planning to Conceive
Only non-hormonal treatment is appropriate:
- Tranexamic acid, or
- Other NSAIDs
References