History

• Heavy Menstrual Bleeding (menorrhagia) is defined as:
  • Excessive menstrual blood loss which interferes with the woman's physical, emotional, social and material quality of life, alone or in combination with other symptoms.

Examination

• Pelvic and speculum examination if the history is suggestive of structural or histological abnormality, or a Levonorgestrel - IUS is the chosen treatment.

• Abdominally palpable pelvic mass
• Suspicious lesions of the lower genital tract detected
• Post-coital bleeding
• Intermenstrual bleeding
• Post menopausal bleeding
• Systemic disorders causing excessive bleeding
• Risk Factors for endometrial pathology e.g. diabetes, obesity, tamoxifen treatment, family history, polycystic ovary syndrome (PCOS)

• Pelvic (transvaginal if available) ultrasound scan if structural abnormality is suspected, the uterus is palpable abdominally, or failure of pharmacological treatment
• Full blood count (FBC) recommended for all women with heavy menstrual bleeding
• Ferritin, and gonadotrophin levels should not be routinely carried out
• Thyroid function test (TFT) only if other signs or symptoms suggest thyroid disease
• Coagulation studies (e.g. von Willebrand's) only if heavy menstrual bleeding since menarche, personal or family history suggestive of coagulation disorder

Treatment aims are to improve quality of life and alleviate associated symptoms, not necessarily to cure heavy bleeding.

All patients should be strongly encouraged to keep BMI in health range; obesity contributes to high circulating oestrogens and heavy menstrual bleeding. Surgical management is likely to be declined if BMI is over 35.

Weight Management

Adult weight management pathway

Pharmaceutical Treatment

Appropriate when no suspicion of structural or histological abnormality, fibroids less than 3cm diameter and causing no distortion of the uterine cavity.

Determine whether hormonal contraception is acceptable before recommending treatment, preference for hormonal vs non-hormonal, and benefits vs risk of long term treatment should be considered.

Outcomes of ongoing medical therapy should be carefully monitored, and medications should be maintained for at least three cycles before considering alternative treatments.

First Line
Levonorgestrel-IUS should be offered.

• Women should persevere for at least 6 cycles to see benefit
• Can be used in conjunction with non-hormonal treatment
• Please note that sexual health services are only able to offer IUS for contraception. They are not commissioned to provide IUS fitting for heavy menstrual bleeding alone.

Formulary chapter 7.3.2: Progestogen-only contraceptives

Second Line

• 2.11 Antifibrinolytic drugs and haemostatics Tranexamic acid
• NSAIDs may be 1st choice where dysmenorrhoea co-exists, see 10.1.1 Non-steroidal anti-inflammatory drugs (NSAIDs)
• Combined Oral contraceptive, for a minimum trial 3 months, unless UKMEC contraindicated

Formulary chapter 7.3.1: Combined hormonal contraceptives

Third Line

• Progesterones

Formulary Chapter 7.3.2: Progestogen-only contraceptives

Dilatation and curettage (D&C)

Dilatation and curettage (D&C) commissioning policy

This is not routinely commissioned in Devon for diagnosis or treatment of heavy menstrual bleeding.

Ultrasound scans and camera tests, with sampling of the lining of the uterus (hysteroscopy and biopsy), can be used to investigate heavy periods.

There is very little evidence to suggest that D&C works to treat heavy periods and the one study identified by NICE showed the effects were only temporary.

Medication and intrauterine systems (IUS) are more effective treatments for heavy periods.

Surgery

Referral for the surgical management of heavy menstrual bleeding commissioning policy

Surgery may be a more definitive and successful long term treatment than medication, but this must be weighed against surgical complications and fertility issues. Endometrial ablation, surgical management of fibroids, and hysterectomy are all options, though women should be counselled that hysterectomy is a last resort and the other options should have been tried first.

Referral Criteria

Referral for specialist advice and surgery, if appropriate, is only commissioned in women without significant fibroids or structural or histological abnormalities, if they have failed treatment with appropriate pharmacotherapy including IUS.

Required in referral letter

• Details of treatments tried or reasons why not appropriate should be recorded in the referral letter
• Please specify if there is a clinical reason why an IUS is not appropriate for the patient
• Findings of pelvic and speculum examination
• Pelvic (transvaginal if available) ultrasound scan
• Up to date smear, as per local guideline (however it is not necessary to perform additional smears as this is not an investigation for bleeding of any kind)
• Full Blood Count (FBC)
• Ferritin, Thyroid Function Test (TFT), clotting studies only if clinically indicated

Referrals submitted without this information may be returned.

A referral proforma is available to download but its use is optional.

Referral Instructions

For Referral to Gynaecology

e-Referral Service selection:

• Specialty: Gynaecology
• Clinic Type: Menstrual Disorders
• Service: DRSS-Eastern-Gynaecology-Devon CCG- 15N

Referral Forms

HMB referral template

Patient Information

MyHealth patient information - HMB

Evidence

NICE guidance - ng88

Pathway Group

This guideline has been signed off by the Eastern locality on behalf of NHS Devon.

Publication date: November 2018

Updated: September 2022