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The following Guidelines summary is for assessing and managing heavy menstrual bleeding (menorrhagia). It aims to help healthcare professionals investigate the cause of heavy periods that are affecting a woman’s quality of life and to offer the right treatments, taking into account the woman’s priorities and preferences.

It includes updated recommendations on: investigations for the cause of heavy menstrual bleeding and the management of heavy menstrual bleeding.

It also includes recommendations on: history, physical examination and tests and useful information for women.

This guideline replaces NICE CG44, and is the basis of NICE QS47.

MHRA advice on ulipristal acetate (Esmya): In March 2020, the MHRA updated its advice on the use of ulipristal acetate (Esmya) to say that healthcare professionals should contact patients currently taking Esmya for uterine fibroids as soon as possible and advise them to stop their treatment. The licence for Esmya has been suspended to protect public health while a safety review is conducted after a case of liver injury. 

This summary has been abridged for print. View the full summary at guidelines.co.uk/454104.article

Impact of heavy menstrual bleeding on women

  • Recognise that heavy menstrual bleeding (HMB) has a major impact on a woman’s quality of life, and ensure that any intervention aims to improve this rather than focusing on blood loss

History, physical examination and laboratory tests


  • Take a history from the woman that covers:
    • the nature of the bleeding
    • related symptoms, such as persistent intermenstrual bleeding, pelvic pain and/or pressure symptoms, that might suggest uterine cavity abnormality, histological abnormality, adenomyosis or fibroids
    • impact on her quality of life
    • other factors that may affect treatment options (such as comorbidities or previous treatment for HMB)
  • Take into account the range and natural variability in menstrual cycles and blood loss when diagnosing HMB, and discuss this variation with the woman. If the woman feels that she does not fall within the normal ranges, discuss care options
  • If the woman has a history of HMB without other related symptoms, consider pharmacological treatment without carrying out a physical examination (unless the treatment chosen is levonorgestrel-releasing intrauterine system [LNG IUS][A])

Physical examination

  • If the woman has a history of HMB with other related symptoms offer a physical examination
  • Carry out a physical examination before all investigations or LNG-IUS[A] fittings

Laboratory tests

  • Carry out a full blood count test for all women with HMB, in parallel with any HMB treatment offered
  • Testing for coagulation disorders (for example, von Willebrand’s disease) should be considered for women who:
    • have had HMB since their periods started and
    • have a personal or family history suggesting a coagulation disorder
  • Do not routinely carry out a serum ferritin test for women with HMB
  • Do not carry out female hormone testing for women with HMB
  • Do not carry out thyroid hormone testing for women with HMB unless other signs and symptoms of thyroid disease are present.

Investigations for the cause of heavy menstrual bleeding

Algorithm 1: Heavy menstrual bleeding: diagnosis

NICE Alg 1 Heavy menstrual bleeding- management

Before starting investigations


  • Take into account the woman’s history and examination when deciding whether to offer hysteroscopy or ultrasound as the first-line investigation

Women with suspected submucosal fibroids, polyps or endometrial pathology

  • Offer outpatient hysteroscopy to women with HMB if their history suggests submucosal fibroids, polyps or endometrial pathology because:
    • they have symptoms such as persistent intermenstrual bleeding or
    • they have risk factors for endometrial pathology
  • Ensure that outpatient hysteroscopy services are organised and the procedure is performed according to best practice, including:
    • advising women to take oral analgesia before the procedure
    • vaginoscopy as the standard diagnostic technique, using miniature hysteroscopes (3.5mm or smaller)
  • Ensure that hysteroscopy services are organised to enable progression to ‘see-and-treat’ hysteroscopy in a single setting if feasible
  • Explain to women with HMB who are offered outpatient hysteroscopy what the procedure involves and discuss the possible alternatives
  • If a woman declines outpatient hysteroscopy, offer hysteroscopy under general or regional anaesthesia
  • For women who decline hysteroscopy, consider pelvic ultrasound, explaining the limitations of this technique for detecting uterine cavity causes of HMB
  • Consider endometrial biopsy at the time of hysteroscopy for women who are at high risk of endometrial pathology, such as:
    • women with persistent intermenstrual or persistent irregular bleeding, and women with infrequent heavy bleeding who are obese or have polycystic ovary syndrome
    • women taking tamoxifen
    • women for whom treatment for HMB has been unsuccessful
  • Obtain an endometrial sample only in the context of diagnostic hysteroscopy. Do not offer ‘blind’ endometrial biopsy to women with HMB

Women with possible larger fibroids

  • Offer pelvic ultrasound to women with HMB if any of the following apply:
    • their uterus is palpable abdominally
    • history or examination suggests a pelvic mass
    • examination is inconclusive or difficult, for example in women who are obese

Women with suspected adenomyosis

  • Offer transvaginal ultrasound (in preference to transabdominal ultrasound or MRI) to women with HMB who have:
    • significant dysmenorrhoea (period pain) or
    • a bulky, tender uterus on examination that suggests adenomyosis
  • If a woman declines transvaginal ultrasound or it is not suitable for her, consider transabdominal ultrasound or MRI, explaining the limitations of these techniques
  • Be aware that pain associated with HMB may be caused by endometriosis rather than adenomyosis (see NICE’s guideline on endometriosis)

Other diagnostic tools

  • Do not use saline infusion sonography as a first-line diagnostic tool for HMB
  • Do not use MRI as a first-line diagnostic tool for HMB
  • Do not use dilatation and curettage alone as a diagnostic tool for HMB.

Information for women about heavy menstrual bleeding and treatments

  • Provide women with information about HMB and its management. Follow the principles in the NICE guideline on patient experience in adult NHS services in relation to communication, information and shared decision-making
  • Provide information about all possible treatment options for HMB and discuss these with the woman (see Management of HMB). Discussions should cover:
    • the benefits and risks of the various options
    • suitable treatments if she is trying to conceive
    • whether she wants to retain her fertility and/or her uterus

Levonorgestrel-releasing intrauterine system (LNG-IUS)

  • Explain to women who are offered an LNG-IUS:[A]
    • about anticipated changes in bleeding pattern, particularly in the first few cycles and maybe lasting longer than 6 months
    • that it is advisable to wait for at least 6 cycles to see the benefits of the treatment

Impact of treatments on fertility

  • Explain to women about the impact on fertility that any planned surgery or uterine artery embolisation may have, and if a potential treatment (hysterectomy or ablation) involves loss of fertility then opportunities for discussion should be made available
  • Explain to women that uterine artery embolisation or myomectomy may potentially allow them to retain their fertility

Endometrial ablation

  • Advise women to avoid subsequent pregnancy and use effective contraception, if needed, after endometrial ablation


  • Have a full discussion with all women who are considering hysterectomy about the implications of surgery before a decision is made. The discussion should include:
    • sexual feelings
    • impact on fertility
    • bladder function
    • need for further treatment
    • treatment complications
    • her expectations
    • alternative surgery
    • psychological impact
  • Inform women about the increased risk of serious complications (such as intraoperative haemorrhage or damage to other abdominal organs) associated with hysterectomy when uterine fibroids are present
  • Inform women about the risk of possible loss of ovarian function and its consequences, even if their ovaries are retained during hysterectomy

Management of heavy menstrual bleeding

Algorithm 2: Heavy menstrual bleeding: management

NICE Alg 2 amended Heavy menstrual bleeding- management

  • When agreeing treatment options for HMB with women, take into account:
    • the woman’s preferences
    • any comorbidities
    • the presence or absence of fibroids (including size, number and location), polyps, endometrial pathology or adenomyosis
    • other symptoms such as pressure and pain

Treatments for women with no identified pathology, fibroids less than 3 cm in diameter, or suspected or diagnosed adenomyosis

  • Consider an LNG-IUS[A] as the first treatment for HMB in women with:
    • no identified pathology or
    • fibroids less than 3 cm in diameter, which are not causing distortion of the uterine cavity or
    • suspected or diagnosed adenomyosis
  • If a woman with HMB declines an LNG-IUS or it is not suitable, consider the following pharmacological treatments:
    • non-hormonal:
      • tranexamic acid
      • non-steroidal anti-inflammatory drugs (NSAIDs)[B]
    • hormonal:
      • combined hormonal contraception[C]
      • cyclical oral progestogens
  • Be aware that progestogen-only contraception may suppress menstruation, which could be beneficial to women with HMB
  • If treatment is unsuccessful, the woman declines pharmacological treatment, or symptoms are severe, consider referral to specialist care for:
    • investigations to diagnose the cause of HMB, if needed (see Investigations for the cause of HMB) taking into account any investigations the woman has already had and
    • alternative treatment choices, including:
      • pharmacological options not already tried
      • surgical options:
        • second-generation endometrial ablation
        • hysterectomy
  • For women with submucosal fibroids, consider hysteroscopic removal

Treatments for women with fibroids of 3 cm or more in diameter

  • Consider referring women to specialist care to undertake additional investigations and discuss treatment options for fibroids of 3 cm or more in diameter
  • If pharmacological treatment is needed while investigations and definitive treatment are being organised, offer tranexamic acid and/or NSAIDs[B]
  • Advise women to continue using NSAIDs[B] and/or tranexamic acid for as long as they are found to be beneficial
  • For women with fibroids of 3 cm or more in diameter, take into account the size, location and number of fibroids, and the severity of the symptoms and consider the following treatments:
    • pharmacological:
      • non-hormonal:
        • tranexamic acid
        • NSAIDs[B]
      • hormonal:
        • LNG-IUS[A]
        • combined hormonal contraception[C]
        • cyclical oral progestogens
    • uterine artery embolisation
    • surgical:
      • myomectomy
      • hysterectomy
  • Be aware that the effectiveness of pharmacological treatments for HMB may be limited in women with fibroids that are substantially greater than 3 cm in diameter


[A] Note that this is an off-label use for some LNG-IUSs. See prescribing medicines for more information. See the General Medical Council’s Prescribing guidance: prescribing unlicensed medicines for further information.

[B] Note that this is an off-label use for NSAIDs. See the General Medical Council’s Prescribing guidance: prescribing unlicensed medicines for further information.

[C] Note that this is an off-label use for NSAIDs and some combined hormonal contraceptives. See the General Medical Council’s Prescribing guidance: prescribing unlicensed medicines for further information.


© NICE 2020. Heavy menstrual bleeding: assessment and management. Available from: www.nice.org.uk/guidance/NG88. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.

Published date: 14 

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