HEAVY MENSTRUAL BLEEDING PATHWAY
Women presenting with HMB
(for IMB and PCB see alternative pathways)
History, Abdo and PV exam. FBC
Ultrasound - not part of the routine examination
History and physical exam are normal - manage in primary care with medical
treatment (unless contraindicated) – based on NICE Guidelines (CG44)
Uterus palpable
abdominally /
pelvic mass >
12 weeks
gestation on
bimanual
examination
Provide patient with written information on medical /
pharmacological treatment options:
st
1 line – Mirena (x 6 months unless contraindications)
nd
2 line - Tranexamic acis / NSAIDs / COCs (x 3 months)
rd
3 line – Norethisterone / long acting progestogens (x 3 months)
See CCG Clinical Threshold Policy for further info on treatment
options.
Severe
anaemia
(Hb level
<8 g/dl).
Increased risk of
endometrial cancer:
PCOS in over 40
Excess Oestrogen
Family history and/or
anemia
Discuss preferred treatment option with patient.
Allow pt time to reflect. Begin treatment.
Consider
ultrasound
Treatment fails try next line. All medical treatment options to be
explored (unless contraindicated) prior to onward referral.
Consider diagnostic
Hysteroscopy / biopsy
YOU ARE NOW REFERRING YOUR PATIENT INTO SECONDARY CARE FOR SURGERY
Treatment will depend on ultrasound results / desire to preserve fertility and uterus. Treatment options suggested below are
based on NICE Guidance but ARE NOT for patients who primarily have pressure symptoms - they should be shared with your
patient prior to referral. The consultant will discuss and agree the best option with the patient.
•
•
Ultrasound shows normal
uterus/small fibroids
Severe impact on quality
of life
Hysteroscopy prior to treatment
1st line treatment (unless contraindications)
Endometrial ablation when:
• No desire to preserve fertility
• No fibroid in cavity
•
•
•
•
Large fibroids
Large uterus
Ultrasound shows possible adenomyosis
Severe impact on quality of life
MRI
Uterine artery embolisation
– retention of uterus and
possible fertility
Diagnostic Hysteroscopy /
biopsy
Consider Myomectomy –
retention of uterus and
possible fertility
Hysterectomy should not be used as a first-line treatment solely for HMB as per NICE Guidance. Women offered
hysterectomy should have a full discussion of the implication of the surgery before a decision is made.
Hysterectomy
• Do not remove healthy overies
• No desire to preserve fertility
• Other treatments have failed, are contraindicated or declined
• Fully informed women requests surgical treatment