NICE NG88: Heavy Menstrual Bleeding: Assessment and Management
Initial Assessment
Take a history covering the nature of the bleeding, associated symptoms (e.g. pain, pressure symptoms, intermenstrual or postcoital bleeding), impact on quality of life, and other factors that may affect treatment choice (e.g. fertility plans, comorbidities). Offer a physical (including pelvic) examination if the history suggests related symptoms, before starting treatment, unless the woman has not been sexually active and symptoms suggest an uncomplicated picture, or she chooses pharmacological treatment without examination and there are no risk factors for pathology.
Carry out a full blood count for all women with heavy menstrual bleeding (HMB), and start this in parallel with any HMB treatment offered rather than waiting for the result.
Investigation Pathway: When to Image or Biopsy
- Pelvic ultrasound should be offered if the uterus is palpable abdominally, examination reveals a pelvic mass of uncertain origin, or pelvic examination is difficult or inconclusive (e.g. in women with a raised BMI).
- Outpatient hysteroscopy should be offered when history suggests submucosal fibroids, polyps, or endometrial pathology — particularly with persistent intermenstrual bleeding or risk factors for endometrial pathology — since these are unlikely to be reliably identified or excluded by history and examination alone.
- Endometrial biopsy should be considered (typically taken at the time of hysteroscopy) in women at high risk of endometrial pathology: those with persistent intermenstrual or persistent irregular bleeding, women taking tamoxifen, and women in whom pharmacological treatment for HMB has been unsuccessful.
Imaging and endoscopic assessment are therefore reserved for women with clinical features suggesting structural or histological pathology, not offered routinely to every woman presenting with HMB.
Management Ladder
First-line pharmacological treatment: Consider a levonorgestrel intrauterine system (LNG-IUS) as first-line for women with HMB who have no identified pathology, fibroids <3 cm in diameter that are not distorting the uterine cavity, or suspected/diagnosed adenomyosis — regardless of whether heavy bleeding is the woman's only symptom.
Second-line pharmacological treatment (if LNG-IUS is declined, not tolerated, or unsuitable): non-hormonal options — tranexamic acid, NSAIDs; hormonal options — combined hormonal contraception, or cyclical oral progestogens (e.g. norethisterone).
Surgical treatment: Considered when pharmacological treatment fails, is unsuitable, or symptoms are severe. Options include second-generation endometrial ablation, myomectomy or uterine artery embolisation for fibroids ≥3 cm, and hysterectomy — the latter reserved for women in whom other treatments have failed, are contraindicated, or who wish for amenorrhoea/definitive treatment and have completed their family.
High-Yield Exam Points
- LNG-IUS is first-line pharmacological treatment for HMB — before tranexamic acid, NSAIDs, or COCP — in women with no pathology, small non-distorting fibroids (<3 cm), or adenomyosis. This is one of the most commonly tested facts in Part 2.
- Do not delay treatment while awaiting FBC results — treat and investigate in parallel.
- Routine pelvic ultrasound is not required for every woman with HMB; it is triggered by a palpable uterus, suspected mass, or inconclusive examination.
- Hysteroscopy and endometrial biopsy are targeted at women with risk factors for structural/endometrial pathology (persistent intermenstrual bleeding, tamoxifen use, treatment failure) — not first-line investigations for straightforward HMB.
- Fibroids ≥3 cm shift management toward surgical/procedural options (myomectomy, uterine artery embolisation) rather than LNG-IUS first-line.
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Source: National Institute for Health and Care Excellence (NICE) (7 July 2026 (originally published 14 March 2018))
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MRCOG AI is an independent educational tool. It is not affiliated with, endorsed by, or connected to the Royal College of Obstetricians and Gynaecologists (RCOG).