Heavy Menstrual Bleeding (HMB)
This article only covers HMB as a presentation; a separate article on fibroids is available to improve clarity. Note that NICE made a single guideline that covers HMB with no identified pathology, fibroid and adenomyosis.
NICE Guideline [NG88] Heavy menstrual bleeding: assessment and management. Last updated: May 2021.
NICE CKS Menorrhagia (heavy menstrual bleeding)
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.
Causes
No cause identified in ~50% of women.
Common causes:
- Uterine and ovarian pathologies
- Uterine fibroids
- Endometrial polyps
- Adenomyosis
- Systemic conditions
- Coagulation disorders
- Hypothyroidism
Guidelines
Investigation and Diagnosis
Laboratory Tests
Perform FBC in ALL patients
Consider the following:
- Clotting pannel
- TFT
Investigations for Underlying Cause
If history and/or examination suggest a high risk of fibroids / uterine cavity abnormality / adenomyosis → arrange further investigations to determine the underlying cause.
Choice of investigations depends on the suspected underlying cause:
NICE: Take into account the woman’s history and examination when deciding whether to offer hysteroscopy or ultrasound as the first-line investigation.
- Suspected submucosal fibroids / polyps / endometrial pathology
- 1st line: hysteroscopy +/- endometrial biopsy
- 2nd line: pelvic (transabdominal) ultrasound
- Suspected large fibroids (palpable uterus / pelvic mass / obese women)
- 1st line: pelvic (transabdominal) ultrasound
- Suspected adenomyosis
- 1st line: transvaginal ultrasound
- 2nd line: pelvic (transabdominal) ultrasound / MRI
Endometrial Biopsy During Hysteroscopy
NICE recommends considering endometrial biopsy at the time of hysteroscopy if any of the following:
- Obese
- PCOS
- Women who take tamoxifen
- Unsuccessful treatment of heavy menstrual bleeding
The above-listed factors are risk factors for endometrial hyperplasia / cancer.
Pre-procedure Imaging
Offer ultrasound prior to:
- Uterine artery embolisation
- Myomectomy
Management
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.
The following management is for:
- HMB with no identified pathology
- Fibroids <3 cm
- Adenomyosis
1st line: levonorgestrel intrauterine system (LNG-IUS) – progestogen-containing hormonal IUS
2nd line:
- Non-hormonal options: NSAIDs / tranexamic acid
- Hormonal options: COCP / cylical oral progestogens (e.g. norethisterone)
If the patient is planning to conceive, offer non-hormonal options.
References
Original Guideline