Key Facts

Heavy menstrual bleeding (menorrhagia) is a common gynaecological complaint that significantly affects quality of life, work, and social functioning. NICE NG88 provides a framework for investigation and management.

Epidemiology

• Affects approximately 1 in 4 women of reproductive age
• Most common between ages 30-50 years
• Accounts for approximately 12% of gynaecology referrals
• Leading cause of iron deficiency anaemia in premenopausal women

Aetiology

• Dysfunctional uterine bleeding (DUB): no structural or systemic cause identified (50% of cases)
• Structural causes (PALM): polyps, adenomyosis, leiomyomata (fibroids), malignancy/hyperplasia
• Non-structural causes (COEIN): coagulopathy (von Willebrand disease in 13% of women with HMB), ovulatory dysfunction, endometrial disorders, iatrogenic (anticoagulants, copper IUD), not yet classified

Pathophysiology

• Normal menstrual blood loss: 5-80 mL per cycle
• HMB results from disruption of normal endometrial haemostasis
• Fibroids: increase endometrial surface area and disrupt endometrial vasculature
• Adenomyosis: ectopic endometrial tissue in myometrium impairs uterine contractility
• Coagulopathy: impaired clotting leads to excessive blood loss

Typical Presentation

• Excessively heavy periods requiring frequent pad/tampon changes (soaking through hourly)
• Passing clots >2.5cm
• Flooding through clothing or bedding
• Need for double protection (pads + tampons)
• Duration >7 days
• Significant impact on quality of life

Associated Symptoms

• Symptoms of iron deficiency anaemia: fatigue, breathlessness, pallor
• Dysmenorrhoea (particularly with adenomyosis or endometriosis)
• Intermenstrual bleeding (polyps, malignancy)
• Pressure symptoms with fibroids (urinary frequency, constipation)

Red Flags

• Intermenstrual bleeding (exclude cervical/endometrial malignancy)
• Postcoital bleeding (cervical pathology)
• Age >45 with new-onset HMB (endometrial pathology)
• Postmenopausal bleeding (endometrial cancer until proven otherwise)
• Severe anaemia (Hb <70 g/L)

Bedside

• Abdominal and pelvic examination
• Speculum examination: cervical inspection, exclude polyps/ectropion
• BMI assessment

Bloods

• FBC: assess for iron deficiency anaemia (NICE NG88 recommends in all women with HMB)
• Ferritin: if anaemia confirmed
• TFTs: if clinical suspicion of thyroid disease
• Coagulation screen and von Willebrand factor: if HMB since menarche, family history of bleeding disorder, or bruising

Imaging

• Pelvic ultrasound (TVS): first-line if structural pathology suspected (fibroids, polyps, adenomyosis)
• MRI pelvis: for fibroid mapping if surgery planned
• Saline infusion sonography: for endometrial cavity assessment

Special Tests

• Endometrial biopsy: Pipelle biopsy if age >45, persistent IMB, treatment failure, risk factors for endometrial cancer
• Hysteroscopy: gold standard for intrauterine pathology assessment (outpatient or inpatient)
• Pictorial blood loss assessment chart (PBAC): semi-objective blood loss quantification (>100 = HMB)

Non-pharmacological

• Reassurance and explanation of the condition
• Iron supplementation (ferrous sulphate 200mg BD-TDS) if iron deficient
• Menstrual cups or period underwear as adjuncts

Pharmacological

• First-line: Mirena IUS (LNG-IUS 52mg): reduces blood loss by 94%; effective for 5 years; also provides contraception
• Second-line (if IUS declined or unsuitable):
  • Tranexamic acid 1g TDS during menses (antifibrinolytic; reduces loss by 40-50%)
  • Mefenamic acid 500mg TDS during menses (reduces loss by 25%; also helps dysmenorrhoea)
  • Combined oral contraceptive: reduces blood loss by 40-50%
• Third-line: norethisterone 5mg TDS days 5-26, or medroxyprogesterone acetate injections
• GnRH analogues (goserelin 3.6mg SC monthly): short-term use before surgery or if other treatments fail; add-back HRT if >6 months

Surgical/Interventional

• Endometrial ablation: second-generation techniques (NovaSure, Thermablate); 80-90% satisfaction; alternative to hysterectomy
• Myomectomy: for fibroids if fertility preservation desired (hysteroscopic for submucosal, laparoscopic/open for intramural/subserosal)
• Uterine artery embolisation (UAE): interventional radiology; reduces fibroid size by 40-60%
• Hysterectomy: definitive treatment; considered when family complete and other treatments failed

Referral Criteria

• Suspected structural pathology (fibroids, polyps): gynaecology referral
• Treatment failure after 3 months of pharmacological management
• Suspected malignancy: urgent 2-week wait referral
• Severe anaemia requiring transfusion

• Mirena IUS: 80-90% of women report significant improvement; 20% achieve amenorrhoea
• Endometrial ablation: 80-90% satisfaction; 15-20% require further surgery within 5 years
• Hysterectomy: 100% cure rate for HMB; significant recovery time (4-8 weeks)
• Untreated HMB: progressive iron deficiency anaemia, impaired quality of life
• Menorrhagia resolves spontaneously at menopause

NICE NG88 Treatment Pathway

PALM-COEIN Classification (FIGO)