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.
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.
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.
Key medicines
Levonorgestrel 52 mg intrauterine systemInsert one 52 mg intrauterine system after pregnancy exclusion and suitability assessment; the cited product is licensed for idiopathic menorrhagia for five years.
Tranexamic acid tabletsTake 1 g orally three times daily from the onset of heavy bleeding for up to four days, with renal dose reduction and the product maximum observed.