Synopsis
Assess heavy menstrual bleeding by its effect on quality of life, identify pregnancy, anaemia, structural disease, bleeding disorders and endometrial risk, and select treatment, ultrasound or hysteroscopy in the correct order.
- NICE defines heavy menstrual bleeding by adverse physical, social, emotional or material quality-of-life effects; an exact measured blood volume is not required.
- Clarify cycle interval and regularity, bleeding duration, flooding, clots, night changes, products used, pain, intermenstrual or postcoital bleeding, change from baseline and impact on activity.
- Ask about pregnancy possibility, contraception, fertility goals, anticoagulants, tamoxifen, PCOS or infrequent cycles, obesity, pelvic pressure, discharge and relevant personal or family bleeding history.
- NICE recommends a full blood count for every patient with HMB, performed in parallel with treatment; ferritin is not a routine universal test but is appropriate when iron deficiency is clinically suspected.
- Consider coagulation testing when heavy bleeding has been present since periods began and the personal or family history suggests a bleeding disorder.
- Do not routinely order female hormone tests, and request thyroid function only when other symptoms or signs suggest thyroid disease.
- If history suggests low risk of fibroid, cavity abnormality, adenomyosis or endometrial disease, NICE allows pharmacological treatment without investigation; examine before an LNG-IUS is fitted.
- Choose outpatient hysteroscopy first when submucosal fibroid, polyp or endometrial pathology is suspected, particularly with persistent intermenstrual bleeding or relevant risk factors.
- Choose pelvic ultrasound first when the uterus is palpable abdominally, a pelvic mass is suspected or examination is inconclusive or difficult; prefer transvaginal ultrasound for suspected adenomyosis.
- Agree whether the priority is bleeding reduction, pain control, contraception, fertility preservation or definitive treatment, then set a review point rather than escalating without reassessment.
Key red flags
Bleeding with a positive or uncertain pregnancy test, unilateral pain, shoulder-tip pain or collapse may be ectopic pregnancy or pregnancy loss and needs urgent location assessment.
Persistent intermenstrual bleeding, postcoital bleeding, postmenopausal bleeding, a suspicious cervix or endometrial cancer risk shifts assessment towards urgent direct investigation.
A palpable abdominal or pelvic mass, marked distension, pressure symptoms or new urinary or bowel dysfunction requires structural imaging and specialist review.
Heavy bleeding since menarche plus personal or family bleeding history suggests an inherited coagulation disorder and warrants directed testing with haematology input.
Severe symptomatic anaemia, cardiovascular compromise or rapidly falling haemoglobin requires urgent stabilisation; a laboratory number cannot replace physiological assessment.
Investigation priorities
Exclude pregnancy-related bleeding before assigning a non-pregnant uterine pathway or prescribing relevant treatment.
Management branches
A patient describes periods as heavy, prolonged or increasingly disruptive.
- Check physiology and acute blood loss, establish pregnancy possibility, and elicit cycle pattern, flooding, associated bleeding, pain, pressure and quality-of-life impact.
- Review medicines, contraception, fertility priorities, endometrial risk and bleeding-disorder history, then examine when symptoms or the proposed treatment requires it.
- Arrange full blood count in parallel with initial safe treatment and give clear urgent return advice for collapse, severe pain or uncontrolled flooding.