Document type
Clinical pathways
Hertfordshire and West Essex ICB
Output type
Clinical Pathways
Heavy Menstrual Bleeding (HMB) - Primary Care

Heavy Menstrual Bleeding (HMB) - Primary Care

Pathway Publish Date: October 2023
Pathway Next Review Date: October 2025 

Please see pathway for primary care management and identification of red flags.  The following text applies to non-red flag patients

Investigation of treatment depends on whether an enlarged uterus is found on examination

Uterus not enlarged

  • Perform FBC, smear if overdue
  • Treatment should be pharmacological in the first instance in the following order:

1. Levonorgestrel-releasing intrauterine system − provided long-term (at least 12 months) use is anticipated

2. Tranexamic acid (consider simultaneous use with levonorgestrel-releasing intrauterine system), non-steroidal anti-inflammatory drugs (which can be used long term), or combined oral contraceptives

3. Norethisterone from days 5 to 26 of the menstrual cycle, or injected long-acting progestogens

  • If bleeding is very heavy ('flooding'), consider stopping it abruptly by giving tranexamic acid/oral norethisterone. Inform the woman that a withdrawal bleed will occur two to four days after stopping treatment.
  • NB: the use of norethisterone for this indication outside of the standard licensed dose is outside of its marketing authorisation (product licence) in the UK.
  • If hormonal treatments are not acceptable to the woman, then either tranexamic acid or NSAIDs can be used.As pain may be due to the passage of clots tranexamic acid can be used in combination.
  • Monitor and review effectiveness, move to second or third line treatment in accordance with pathway if necessary, consider adding in NSAID and/or tranexamic acid or COC
  • If symptoms don't improve after above treatments refer for USS
  • Refer if abnormality on USS as appropriate. 
  • Consider referral to gynaecology if:
    • heavy bleeding persists despite adequate trials of pharmaceutical treatment
    • the woman wishes to consider surgery
    • the woman has iron deficiency anaemia that has failed to respond to treatment

Enlarged uterus

  • Investigations:
    • FBC and smear as above
    • USS if uterus palpable abdominally or VE reveals pelvic mass of uncertain origin
  • Whilst waiting for investigations tranexamic acid or NSAIDs can be tried
  • If USS normal manage as per non-enlarged uterus
  • If red flag on USS refer urgently/2WW pathway as appropriate
  • In the case of fibroids >3cm, consider referring to secondary care when:
    • fibroids are palpable abdominally
    • intra-cavity fibroids are present
    • uterine length as measured by ultrasound or hysteroscopy is greater than 12cm
  • In the case of fibroids <3cm (and are not causing distortion of the interuterine cavity), consider trial of pharmacological therapy in the first instance, as per non-enlarged uterus.
  • Refer to a specialist if symptoms persist as per non-enlarged uterus as above

Referral letter should include the following:

  • Nature of the bleeding,
  • Associated symptoms, such as intermenstrual bleeding, post-coital bleeding, pelvic pain, pressure symptoms, bladder and bowel symptoms
  • Impact on quality of life
  • Conservative management trialled so far
  • Current contraception
  • Smear History: regular, irregular, including date and result of last smear
  • Details of previous colposcopy, any treatments such as LLETZ/cold coagulation/laser
  • Relevant past medical/surgical/obstetric history (including haematological/ coagulation disorders)
  • Current regular medication
  • Pelvic/ abdominal examination findings
  • Speculum findings (e.g. normal, ectropion, cervicitis, cervical polyp)
  • Investigation results