Overview of assessment and management of heavy menstrual bleeding

Approach to investigating and treating heavy menstrual bleeding outlines an approach to investigations for heavy menstrual bleeding.

Intermenstrual bleeding and postcoital bleeding require separate investigation and management; they should not be treated as for heavy menstrual bleeding.

Figure 1. Approach to investigating and treating heavy menstrual bleeding.

[NB1]

History and examination for heavy menstrual bleedingInvestigations for heavy menstrual bleedingIndications for specialist referral for heavy menstrual bleedingIndications for specialist referral for heavy menstrual bleedingInvestigations for heavy menstrual bleedingIndications for specialist referral for heavy menstrual bleedingInvestigations for heavy menstrual bleedingSurgical treatment for heavy menstrual bleedingTranexamic acid (in SRG)Nonsteroidal anti-inflammatory drugs (in SRG)Levonorgestrel-releasing intrauterine contraceptive device (menstral bleeding topic)Combined hormonal contraception (menstral bleeding topic)Depot medroxyprogesterone (menstral bleeding topic)Levonorgestrel-releasing intrauterine contraceptive device (menstral bleeding topic)Tranexamic acid (in SRG)Combined hormonal contraception (menstral bleeding topic)Nonsteroidal anti-inflammatory drugs (in SRG)Oral progestogensDepot medroxyprogesterone (menstral bleeding topic)EndometriosisAdenomyosis
Note:

COC = combined oral contraceptive; DMPA = depot medroxyprogesterone injection; LNG-IUD = levonorgestrel-releasing intrauterine contraceptive device; NSAID = nonsteroidal anti-inflammatory drug; TSH = thyroid stimulating hormone

NB1: Treatments are listed in order of preference.

NB2: While awaiting surgical review, offer options (excluding LNG-IUD as it may affect investigations) guided by the individual's wishes for fertility and contraception.

NB3: NSAIDs reduce dysmenorrhoea but are less effective at controlling blood loss than tranexamic acid.

NB4: LNG-IUD is first-line therapy even when contraception is not required because it is the most effective treatment for heavy menstrual bleeding.

NB5: The contraceptive vaginal ring is likely to be effective but there is less evidence for this than for COCs.