BEST PRACTICE GUIDELINES - Heavy Menstrual Bleeding (HMB)


Heavy menstrual bleeding (HMB) has an adverse effect on the quality of life of many women. It is not a problem associated with significant mortality. The effectiveness of the various treatments as well as their risks and benefits are discussed in relation to their use in the treatment of HMB. The implications of each treatment in relation to fertility are also discussed.


 This guideline aims to avoid this by including evidence-based and comprehensible discussions so that women can understand why doctors advise for or against a particular treatment.


  •  For clinical purposes, HMB should be defined as excessive menstrual blood loss which interferes with the woman’s physical, emotional, social and material quality of life, and which can occur alone or in combination with other symptoms. Any interventions should aim to improve quality of life measures. [D]

  •  Initially, a history should be taken from the woman. This should cover the nature of the bleeding, related symptoms that might suggest structural or histological abnormality, impact on quality of life and other factors that may determine treatment options (such as presence of co-morbidity). [D(GPP)]

  •  If the history suggests HMB without structural or histological abnormality, pharmaceutical treatment can be started without carrying out a physical examination or other investigations at initial consultation in primary care, unless the treatment chosen is levonorgestrel-releasing intrauterine system (LNG-IUS). [D(GPP)]

  •  If the history suggests HMB with structural or histological abnormality, with symptoms such as intermenstrual or post-coital bleeding, pelvic pain and/or pressure symptoms, a physical examination and/or other investigations (such as ultrasound) should be performed. [D(GPP)]

  •  Measuring menstrual blood loss either directly (alkaline haematin) or indirectly (‘pictorial blood loss assessment chart’) is not routinely recommended for HMB. Whether menstrual blood loss is a problem should be determined not by measuring blood loss but by the woman herself. [D (GPP)]


  • A full blood count test should be carried out on all women with HMB. This should be done in parallel with any HMB treatment offered. [C]

  • Testing for coagulation disorders (for example, von Willebrand disease) should be considered in women who have had HMB since menarche and have personal or family history suggesting a coagulation disorder. [C]

  • Female hormone testing should not be carried out on women with HMB. [C]. Thyroid testing should only be carried out when other signs and symptoms of thyroid disease are present. [C]

  • If appropriate, a biopsy should be taken to exclude endometrial cancer or atypical hyperplasia. Indications for a biopsy include, for example, persistent intermenstrual bleeding, and in women aged 45 and over treatment failure or ineffective treatment. [D(GPP)]

  • Imaging should be undertaken in the following circumstances:

• The uterus is palpable abdominally
• Vaginal examination reveals a pelvic mass of uncertain origin
• Pharmaceutical treatment fails. [d(gpp)]

  •  Ultrasound is the first-line diagnostic tool for identifying structural abnormalities. [A]

  •  Hysteroscopy should be used as a diagnostic tool only when ultrasound results are inconclusive, for example, to determine the exact location of a fibroid or the exact nature of the abnormality. [A]

  •  If imaging shows the presence of uterine fibroids then appropriate treatment should be planned based on size, number and location of the fibroids. [D(GPP)]

  •  Saline infusion sonography should not be used as a first-line diagnostic tool. [A]

  •  Magnetic resonance imaging (MRI) should not be used as a first-line diagnostic tool. [B]

  •  Dilatation and curettage alone should not be used as a diagnostic tool. [B]

  •  Where dilatation is required for non-hysteroscopic ablative procedures, hysteroscopy should be used immediately prior to the procedure to ensure correct placement of the device. [D(GPP)]

 Pharmaceutical treatments for HMB

  •  Pharmaceutical treatment should be considered where no structural or histological abnormality is present, or for fibroids less than 3 cm in diameter which are causing no distortion of the uterine cavity. [D(GPP)] If history and investigations indicate that pharmaceutical treatment is appropriate and either hormonal or non-hormonal treatments are acceptable, treatments should be considered in the following order:

 levonorgestrel-releasing intrauterine system (LNG-IUS) provided long-term (at least 12 months) use is anticipated [A].

  •  Women offered an LNG-IUS should be advised of anticipated changes in the bleeding pattern, particularly in the first few cycles and maybe lasting longer than 6 months.

 2. Tranexamic acid [A] or nonsteroidal anti-inflammatory drugs (NSAIDs) [A] or combined oral contraceptives (COCs) [B].

  •  When HMB coexists with dysmenorrhea, NSAIDs should be preferred to tranexamic acid. [D(GPP)]. Use of NSAIDs and/or tranexamic acid should be stopped if it does not improve symptoms within three menstrual cycles. [D(GPP)]

 3. Norethisterone (15 mg) daily from days 5 to 26 of the menstrual cycle, or injected long-acting progestogens. [A]

  •  When a first pharmaceutical treatment has proved ineffective, a second pharmaceutical treatment can be considered rather than immediate referral to surgery. [D] Use of a gonadotrophin-releasing hormone analogue could be considered prior to surgery or when all other treatment options for uterine fibroids, including surgery or uterine artery embolisation (UAE), are contraindicated. If this treatment is to be used for more than 6 months or if adverse effects are experienced then hormone replacement therapy (HRT) ‘add-back’ therapy is recommended.**[B] Danazol should not be routinely used for the treatment of HMB. [A]


 Oral progestogens given during the luteal phase only should not be used for the treatment of HMB. [A]

Etamsylate should not be used for the treatment of HMB. [A]
Non-hysterectomy surgery for HMB

Endometrial ablation

  •  Endometrial ablation should be considered where bleeding is having a severe impact on a woman’s quality of life, and she does not want to conceive in the future. [C]

  •  Endometrial ablation may be offered as an initial treatment for HMB after full discussion with the woman of the risks and benefits and of other treatment options. [A]

  •  Women must be advised to avoid subsequent pregnancy and on the need to use effective contraception, if required, after endometrial ablation. [D(GPP)]

  •  Endometrial ablation should be considered in women who have a normal uterus and also those with small uterine fibroids (less than 3 cm in diameter). [A]

  •  In women with HMB alone, with uterus no bigger than a 10 week pregnancy, endometrial ablation should be considered preferable to hysterectomy. [A]

  •  All women considering endometrial ablation should have access to a second-generation ablation technique. [D(GPP)]

  •  Second-generation ablation techniques should be used where no structural or histological abnormality is present. [A]

  •  Impedance-controlled bipolar radiofrequency ablation fluid-filled thermal balloon endometrial ablation (TBEA) microwave endometrial ablation (MEA) free fluid thermal endometrial ablation

  •  First-generation ablation techniques (for example, rollerball endometrial ablation (REA) and transcervical resection of the endometrium (TCRE)) are appropriate if hysteroscopic myomectomy is to be included in the procedure. [D(GPP)]

Dilatation and curettage should not be used as a therapeutic treatment. [C]

Further interventions for uterine fibroids associated with HMB

  •  Uterine Artery Embolozation (UAE), myomectomy or hysterectomy should be considered in cases of HMB where large fibroids (greater than 3 cm in diameter) are present and bleeding is having a severe impact on a woman’s quality of life. [C].

  •  Prior to scheduling of UAE or myomectomy, the uterus and fibroid(s) should be assessed by ultrasound. If further information about fibroid position, size, number and vascularity is required, MRI should be considered. [D(GPP)]

  •  Pre-treatment before hysterectomy and myomectomy with a gonadotrophin-releasing hormone analogue for 3 to 4 months should be considered where uterine fibroids are causing an enlarged or distorted uterus. [A].

  •  Hysterectomy should not be used as a first-line treatment solely for HMB. Hysterectomy should be considered only when:
    • Other treatment options have failed, are contraindicated or are declined by the woman
    • There is a wish for amenorrhea
    • The woman (who has been fully informed) requests it
    • The woman no longer wishes to retain her uterus and fertility. [C]

  •  Women offered hysterectomy should be informed about the increased risk of serious complications (such as intraoperative hemorrhage or damage to other abdominal organs) associated with hysterectomy when uterine fibroids are present. [C]

  •  Women should be informed about the risk of possible loss of ovarian function and its consequences, even if their ovaries are retained during hysterectomy. [D(GPP)]

Removal of ovaries at the time of hysterectomy

  •  Removal of healthy ovaries at the time of hysterectomy should not be undertaken. [D(GPP)]

  •  Removal of ovaries should only be undertaken with the express wish and consent of the woman. [D(GPP)]

  •  If removal of ovaries is being considered, the impact of this on the woman’s wellbeing and, for example, the possible need for hormone replacement therapy (HRT) should be discussed. [D(GPP)]

  •  Women considering bilateral oopherectomy should be informed about the impact of this treatment on the risk of ovarian and breast cancer. [D(GPP)]

Potential unwanted outcomes of interventions for HMB










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