Heavy Menstrual Bleeding
Current Guidance Update
First-Line Medical Therapy
Tranexamic acid and non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line medical treatments for heavy menstrual bleeding.
LNG-IUS Recommendation
The levonorgestrel-releasing intrauterine system (LNG-IUS) is the most effective medical treatment for heavy menstrual bleeding and should be offered before surgical options.
GnRH Therapy
GnRH agonists or antagonists provide effective short-term uterine preparation before surgical procedures and can significantly reduce menstrual bleeding.
Early Management
Women experiencing persistent heavy menstrual bleeding should undergo timely evaluation and receive individualized medical management before considering surgery.
Introduction
Heavy Menstrual Bleeding (HMB): Assessment & Management
Common Causes
- Polyp (uterine or endocervical)
- Adenomyosis
- Leiomyoma (submucosal fibroids)
- Malignancy (especially over age 45)
- Coagulopathy (including von Willebrand disease)
- Ovulatory dysfunction (PCOS, thyroid disease)
- Endometrial disorders
- Iatrogenic causes (Copper IUD, anticoagulants)
Clinical Assessment
- Full blood count (FBC) and ferritin
- Thyroid function and coagulation studies
- Pelvic ultrasound examination
- Endometrial biopsy for women over 45 or high-risk patients
- Hysteroscopy for direct uterine cavity assessment
Medical Management
- Levonorgestrel IUS – reduces blood loss by 71–95%
- Tranexamic acid – reduces bleeding by approximately 40%
- NSAIDs – reduce prostaglandin-mediated blood loss by 20–30%
- Combined oral contraceptive pill
- Norethisterone for short-term management
Surgical Management
- Endometrial ablation for HMB without structural pathology
- Myomectomy for women wishing to preserve fertility
- Hysterectomy as definitive treatment after family completion
Frequently Asked Questions
How much blood loss is heavy?
Clinical assessment focuses on impact on quality of life — flooding, clot passage, rapid soaking, anaemia, or significant interference with daily activities qualify.
Is heavy bleeding a sign of cancer?
Most HMB has benign causes, but endometrial cancer must be excluded in women over 45 or with risk factors.
Conclusion
Heavy menstrual bleeding is a treatable condition with multiple effective medical and surgical options. There is no reason for women to endure excessive blood loss without seeking specialist assessment.
Sources & References
This article draws on guidance current at the time of writing from the following bodies and publications:
- NICE NG88 (updated 2023)
- RCOG (2023)
- ACOG (2022, updated 2024)
General reference bodies for women's health guidance:
RCOG
rcog.org.ukACOG
acog.orgFIGO
figo.orgWHO
who.intNICE
nice.org.uk⚠ IMPORTANT DISCLAIMER
This article is provided for general knowledge and reference purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. No medication, treatment, or change to your healthcare should be undertaken based on this content without first consulting a qualified doctor. Always seek the advice of your physician or another qualified health provider with any questions you may have regarding a medical condition.
