Heavy Menstrual Bleeding (HMB)


For all women referred to secondary care please attach a TV USS


  • Assess nature of bleeding. HMB is Heavy cyclical bleeding. Distinguish between Intermenstrual Bleeding (IMB) and Post-Coital Bleeding (PMB).
  • Impact on patient eg. Physical, emotional, social.
  • Assess for pathology: *Persistent IMB, PCB, pelvic pain and/or pressure symptoms.



  • Physical Examination if HMB with pathology*
  • FBC for all women with HMB
  • Coagulation screen if HMB since peroids started and a personal or FHx suggestive of coagulation disorder.  
  • TV USS if uterus palpable abdominally or tender, history or exam suggests pelvic mass, significant dysmenorrhoea

Do not routinely carry out serum ferritin, female hormone or thyroid testing for women with HMB


Primary care management is suitable for:

  • women with no identified pathology 
  • fibroids <3cm that are not causing distortion of cavity
  • suspected or diagnosed adenomyosis
  • Offer LNG IUS eg Mirena
    If a woman declines LNG IUS or it is not suitable, consider a choice of pharmacological treatments:
  • Non-hormonal: Tranexamic acid or NSAIDs on the bleeding days
  • Hormonal: eg COCP or Progesterone only contraception may supress menstruation which could be beneficial in some women.  


For all women referred to secondary care please attach a recent TV USS to referral

PMB >55yrs or <55yrs with high risk factors such as obesity & Tamoxifen use or suspicious endometrium on TVUSS

Women referred with abnormal bleeding are managed in a one-stop menstrual bleeding clinic which is likely to involve outpatient hysteroscopy and if appropriate, discussion of LNG IUS insertion. Please advise women of this before referral. 

OP Hysteroscopy Paient Information Leaflet

Mirena Patient Information Leaflet

Refer to Menstrual Bleeding Clinic if:  

  • Primary care treatment has been unsuccessful or declined.
  • Severe HMB
  • History of Intermenstrual or Irregular Menstrual bleeding
  • Pathology on USS (eg fibroids >3cm, abnormally thickened endometrium or endometrial polyps),
  • Infreqent heavy bleeding in women who are obese or PCOS.

Please include in referral:

  • Indication of parity
  • Describe symptoms, duration & effect on quality of life
  • Contraception
  • Smear History (The patient will still be seen without this but it speeds up appointment)
  • Relevant past medical and surgical history
  • Current regular medication (if not on proforma)
  • Treatment tried so far (NSAIDs, Tranexamic acid, COCP, Mirena)

Secondary Care Management:

  • Pharmacological options as outlined in primary care management
  • Endometrial ablation
  • Uterine artery embolisation
  • Myomectomy
  • Hysterectomy


References:NICE guideline [NG88] Pulbished date: 14 March 2018 Updated: 31 March 2020

Date:January 2021           Review Date: January 2022

Author:Dr S Burns GP

Contributors:Lisa Verity, Consultant Gynaecologicst, RCHT