Heavy menstrual bleeding (menorrhagia)

NICE published an update to its guideline on heavy menstrual bleeding (menorrhagia) in March 2018. There are a couple of changes:

  • Hysteroscopy is now the first line investigation for most women who need investigating for heavy menstrual bleeding, rather than ultrasound.
  • There is no mention of age '45' now. In the old menorrhagia guideline, being over 45 was seen as being at higher risk and hence an indication for hysteroscopy. As that is now the first line investigation for most women, I guess being over 45 was less relevant.
  • Hysterectomy is a bit higher up the treatment pathway, but they don't expect there to be a sudden jump in numbers done.

As I've not summarised this heavy menstrual bleeding guideline before and it is such a common condition, I'll do a bit of a summary. This isn't an exhaustive summary, just the most useful bits.

Menorrhagia diagnosis is nicely laid out in a single side flow sheet.

Management is also laid out too on a separate sheet. Good ones to have in the 'folder'.


Not everyone needs an internal examination for heavy menstrual bleeding. Do an internal examination if:

  • Planning menorrhagia investigations (other than bloods I guess).
  • Using an IUS (intrauterine system, eg Mirena)
  • Other symptoms (eg dysmenorrhoea, persistent IMB, persistent irregular bleeding, on tamoxfen or infrequent bleeding with PCOS or obesity).

Investigations for heavy menstrual bleeding menorrhagia

All women with heavy menstrual bleeding (menorrhagia) need a full blood count.

Some women need no other investigations. Consider starting treatment without investigation if the history +/- exam suggests that there is a low risk of fibroids, uterine cavity abnormality, histological abnormality or adenomyosis.

Otherwise, use the history and examination to decide whether to do hysteroscopy or ultrasound first line.

Hysteroscopy first line investigation for heavy menstrual bleeding if you suspect small fibroids, polyps or endometrial pathology:

  • Persistent intermenstrual bleeding.
  • Persistent irregular bleeding.
  • Infrequent bleeding with PCOS or obesity.
  • Tamoxifen.
  • Treatment for menorrhagia has been ineffective.

Ultrasound first line either if they decline hysteroscopy, or if you suspect larger fibroids:

  • Uterus palpable.
  • History or exam suggests a pelvic mass.
  • Exam is difficult (eg obesity).
  • Adenomyosis is suspected (eg significant dysmenorrhoea or a bulky tender uterus on exam).

Treatment of menorrhagia

IUS (eg mirena) first line for at least 6m, if there is:

  • No identified pathology.
  • Fibroids < 3cm not causing distortion.
  • Suspected or confirmed adenomyosis.

Second line:

  • Tranexamic acid / NSAIDs
  • Hormonal - eg COC, cyclical progesterones. POP may suppress ovulation, which may be helpful.


Refer patients with heavy menstrual bleeding to secondary care if:

  • Treatment is unsuccessful or is declined.
  • Symptoms are severe.
  • Fibroids of 3cm or more. Offer tranxamic acid +/- NSAIDs whilst awaiting referral.

This article first appeared in The Sessional GP magazine.

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