Heavy menstrual bleeding

National Institute for Health and Care Excellence

Key priorities for implementation

Impact on women

For clinical purposes, heavy menstrual bleeding (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

History taking, examination, and investigations

• 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
• Ultrasound is the first-line diagnostic tool for identifying structural abnormalities

Education and information provision

A woman with HMB referred to specialist care should be given information before her outpatient appointment. The Institute's information for patients ('Understanding NICE guidance') is available from www.nice.org.uk/CG044publicinfo

Pharmaceutical treatment

• 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 provided long-term (at least 12-months) use is anticipated
  • tranexamic acid or non-steroidal anti-inflammatory drugs (NSAIDs) or combined oral contraceptives
  • norethisterone (15 mg) daily from days 5 to 26 of the menstrual cycle, or injected long-acting progestogens
• If hormonal treatments are not acceptable to the woman, then either tranexamic acid or NSAIDs can be used

Non-hysterectomy surgery

In women with HMB alone, with uterus no bigger than a 10-week pregnancy, endometrial ablation should be considered preferable to hysterectomy

Hysterectomy

• Taking into account the need for individual assessment, the route of hysterectomy should be considered in the following order: first-line vaginal; second-line abdominal

Competencies

• Maintenance of surgical, imaging, or radiological skills requires a robust clinical governance framework including audit of numbers, decision making, case-mix issues and outcomes of all treatments at both individual operator and organisational levels. These data should be used to demonstrate good clinical practice