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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

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.

No cause identified in ~50% of women.

Common causes:

  • Uterine and ovarian pathologies
    • Uterine fibroids 
    • Endometrial polyps
    • Adenomyosis
 
  • Systemic conditions
    • Coagulation disorders
    • Hypothyroidism

Guidelines

Perform FBCFull blood count in ALL patients

Consider the following:
  • Clotting pannel 
  • TFT 

If history and/or examination suggests 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 ulrasound
 
  • Suspected large fibroids (palpable uterus / pelvic mass / obese women)
    • 1st line: pelvic ultrasound
 
  • Suspected adenomyosis
    • 1st line: transvaginal ultrasound
    • 2nd line: transabdominal ultrasound / MRI

NICE recommends considering endometrial biopsy at the time of hysteroscopy if any of the following:
  • Obese 
  • PCOS
  • Women who takes tamoxifen 
  • Unsuccessful to treatment
 

The above-listed factors are risk factors for endometrial hyperplasia / cancer.

Offer ultrasound prior:
  • Uterine artery embolisation
  • Myomectomy 

NICE recommends considering starting pharmacological treatment without investigating the cause if the history and/or examination suggests 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

Author: Adams Lau
Reviewer:
Last Edited: 16/03/25