Rotherham Care Pathway
Heavy Menstrual Bleeding
Based on NICE Clinical Guideline 44
Issued January 2007
NOTES
1. HISTORY Risk factors for malignancy include:
Age, BMI, Diabetes, Hypertension, Family History, Smear History (eg
dyskaryosis, glandular atypia)
2. INVESTIGATIONS Blood tests:
Full blood count (all woman presenting with HMB)
[Clotting screen – only if indicated by history or systemic examination]
[Thyroid function – only if signs & symptoms of thyroid disease present]
3. PHYSICAL EXAMINATION Not always necessary if HMB only symptoms, no
pathology suspected and suggested treatment will not be IUS
4. PHARMACEUTICAL TREATMENT in following order:
I. LNG-IUS (levonorgestrel releasing intrauterine system)
II. Tranexamic acide or NSAIDs (Mefenamic acid) or combined oral
contraceptives
III. Norethisterone or injected long-acting progesterones
5. ENDOMETRIAL BIOPSY
Consider referral to primary or secondary care specialist centre
(NB Low sensitivity / High specificity or endometrial aspirate)
Woman presents with HMB
Take history
Take full blood count
Investigations
Physical examination
Provide information to woman
(Information booklet provided by NICE)
No structural abnormality suspected
No suspicion of malignancy
Pharmaceutical treatment
Fibroids less than 3cm in diameter
Uterus is palpable
abdominally or pelvic mass
Consider imaging, first-line
ultrasound (usual transvaginal)
[Offer immediate referral to specialist
if uterus abdominally palpable or pelvic mass]
And / or suspicion of malignancy
[Immediate referral to secondary care]
Consider endometrial biopsy for
persistent intermenstrual bleeding,
and in woman over 45
treatment failure or ineffective treatment
Consider second pharmaceutical
treatment if first falls
Discuss treatment options
Severe impact on quality
of life + no desire to
conceive + normal uterus
+ small fibroids
(<3 cm diameter)
Endometrial ablation
 Other treatments have failed, are
contraindicated or declined
 Desire for amenorrhoea
 Fully informed woman requests it
 No desire to retain uterus and fertility
Hysterectomy
Don’t remove healthy ovaries
Myomectomy
Severe impact on
quality of life
Fibroids (>3cm diameter)
Uterine artery
embolisation