Synopsis
Choose and prescribe evidence-based HMB treatment in NICE priority order, give usable regimens and safety advice, incorporate contraception and fertility goals, and recognise when anatomy or non-response requires specialist intervention.
- Before treatment, establish pregnancy status where relevant, full blood count, bleeding pattern, structural and endometrial risk, fertility goals, contraceptive need, comorbidity and medicine contraindications.
- For HMB with no pathology, fibroids under 3 cm without cavity distortion, or adenomyosis, NICE recommends considering a levonorgestrel intrauterine system first when acceptable.
- A 52 mg LNG-IUS is inserted once after pregnancy exclusion and suitability assessment and is licensed for idiopathic menorrhagia for five years; advise that irregular bleeding is common initially and benefit may take six cycles.
- If the LNG-IUS is declined or unsuitable, NICE options are tranexamic acid, an NSAID, combined hormonal contraception or cyclical oral progestogens; progestogen-only contraception may also suppress menstruation.
- Tranexamic acid is taken only during bleeding: 1 g orally three times daily for up to four days from onset, with renal adjustment and thrombotic safety review.
- Mefenamic acid is 500 mg orally three times daily with or after food from the first day of excessive bleeding, using the shortest necessary course and stopping for diarrhoea or gastrointestinal bleeding.
- Norethisterone 5 mg orally three times daily for 10 days is licensed to arrest dysfunctional bleeding; prevention in the cited SmPC uses 5 mg twice daily on days 19 to 26 for two subsequent cycles.
- Combined hormonal contraception can reduce bleeding and pain while providing contraception, but use an FSRH eligibility assessment for thrombotic, migraine, smoking, blood-pressure, postpartum and interacting-medicine risks.
- For submucosal fibroids discuss hysteroscopic removal; for fibroids at least 3 cm refer for specialist discussion of medicines, GnRH antagonists, embolisation, myomectomy or hysterectomy.
- Review after adequate correct use with bleeding, pain, quality-of-life and haemoglobin outcomes; investigate or escalate if the pattern changes, adherence is confirmed and benefit remains inadequate.
Key red flags
Persistent intermenstrual, postcoital or postmenopausal bleeding, suspicious cervix or endometrial risk requires investigation and must not be masked by repeated hormonal treatment.
Pregnancy must be excluded when clinically possible before fitting an intrauterine system or giving a contraindicated hormonal regimen.
Current or previous important thrombosis, migraine with aura, smoking at age 35 or older, severe hypertension, liver disease and breast cancer history can change hormonal eligibility.
Active peptic ulcer, gastrointestinal bleeding, severe kidney disease, NSAID-sensitive asthma or interacting anticoagulation can make an NSAID unsafe.
Visual disturbance, unilateral leg swelling, chest pain, sudden breathlessness, jaundice or new neurological symptoms during treatment requires urgent cessation and assessment as appropriate.
Failure despite correctly used treatment, fibroids at least 3 cm, cavity distortion or progressive anaemia prompts specialist review rather than endless switching without investigation.
Investigation priorities
Measure treatment consequence and diagnose iron deficiency requiring replacement.
Management branches
There is no pathology, only small non-distorting fibroids, or adenomyosis, and the patient accepts intrauterine treatment.
- Exclude pregnancy and concerning bleeding, assess pelvic infection and cavity suitability, explain alternatives and obtain consent for insertion with a chaperone.
- Insert a licensed 52 mg LNG-IUS using current product and FSRH guidance and explain pain, perforation, expulsion and expected early irregular bleeding.
- Review problems promptly and allow up to six cycles for full HMB benefit when bleeding and side effects remain safe and acceptable.