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.
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.
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.