Heavy Menstrual Bleeding Pathway

Please refer to the Summary of Product Characteristics (SPC) of any drug considered. This pathway has been developed from published guidance in collaboration with local gynaecologists. This guidance is to assist GPs in decision making and is not intended to replace clinical judgement

Patient presents with heavy regular menstrual bleeding with no history of intermenstrual or postcoital bleeding. Definition: Regular excessive menstrual blood loss which interferes with the woman s physical, emotional, social and material quality of life (QoL). Perceptions of blood loss vary

Investigations: History: Examination:  FBC  and LMP  Abdominal palpation – check if  Chlamydia test (at risk patients) -  Degree of blood loss (pads used, clots, flooding) palpable vulvovaginal self collection  Irregular bleeding – IMB, PCB  Bimanual examination – if palpable  Consider testing for coagulation  Pain - abdominal or pelvic uterus disorders in women who:  Pressure symptoms (causing bladder / bowl Consider pharmacological - have had HMB since menarche & symptoms) treatment without investigating the - have a personal / family history  Symptoms of anaemia (SOB, palps, lethargy) cause if the women's history and/or suggesting a coagulation disorder.  Impact on life examination suggests a low risk of  Cervical screening if appropriate  Current/ recent contraception fibroids, uterine cavity abnormality, (refer to guidance) histological abnormality or  Do not routinely carry out serum ferritin, female hormone testing or TFTs (unless signs/ symptoms of thyroid disease)

Red flags: Symptoms Consider direct Signs of infection, Uterus enlarged/ pelvic Anaemia with Ovarian: or suggestive of ovarian access to , mass symptoms pelvic/abdominal cancer: assess for endometrial discharge or fever Hb<10g/L mass not obviously Unexplained weight cancer in women aged Inconclusive or difficult fibroids loss, or 55 and over with: examination e.g. in changes in bowel - Unexplained obese women. Endometrial: Post habit or persistently symptoms of vaginal menopausal bleeding or frequently (more discharge who: Tender uterus on (unexplained vaginal than 12 times per  Are presenting with examination suggesting bleeding more than month): these symptoms for adenomyosis or 12 months after abdominal the first time, or significant menstruation has distension/,  Have dysmenorrhoea stopped because of Feeling full or loss of thrombocytosis, or referral the ) appetite, pelvic or  Report haematuria, Pelvic scan, hysteroscopy or or or transvaginal ultrasound as Cervical: increased urinary - Visible haematuria, clinically indicated (See NICE Appearance of cervix urgency and/or and guidance) consistent with frequency  Low haemoglobin Abnormal cervical cancer levels, or Normal Vaginal: Unexplained  Thrombocytosis, or Normal result Abnormal result. palpable mass in or  High blood glucose Screen for Ovarian /mass, multiple/ Fibroids <3cm in at entrance to vagina levels infections large fibroids. Uterine polyp diameter (not Ca 125 and pelvic distorting the uterine Vulval: Unexplained If pharmacological treatment is ultrasound scan Pelvic ultrasound Treat if infection cavity), or suspected vulval lump, needed while investigations and scan found (see NICE/PHE or diagnosed ulceration or definitive treatment are being antimicrobial guidance – adenomyosis bleeding managing common organised, offer tranexamic infections) acid and/or NSAIDs.

Ovarian or Patient trying to conceive: Patient NOT trying to conceive: Endometrial: Scan 1st line: Tranexamic acid 1g tds from day 1st line : Levonorgestrel IUD trial for at suggestive of 1 of cycle for 4 days least 6 months (Levosert® or Mirena® ) ovarian or 2nd line NSAIDs (may be preferred if 2nd line: Combined oral contraceptive, endometrial cancer dysmenorrhoea present): tranexamic acid, NSAIDs (naproxen 500mg or Ca 125 35IU/ml Naproxen 500mg initially, followed by initially, followed by 250mg 6-8 hrly OR 250mg 6 – 8 hrly OR mefenamic acid (less mefenamic acid (less cost effective than cost effective than naproxen) 500mg tds naproxen) 500mg tds whilst bleeding whilst bleeding heavily. heavily.) Try for 3 menstrual cycles- continue if 3rd line: injectable long acting progestogen symptoms well controlled OR oral norethisterone 5mg tds day 5 – 26 Poor response – try 2nd line treatment for of cycle 3 cycles as appropriate Try for 3 menstrual cycles- continue if symptoms well controlled Poor response – try 2nd/ 3rd line treatment for 3 cycles as appropriate

2 week referral 2 week referral Failed treatment or women declines pharmacological treatment. Refer to Gynaecology

Pathway created by NCL led by Camden CCG Clinical Cabinet + GB July 2016 Links: Pathway updated and approved by Clinical Cabinet July 2019. Queries to: [email protected] NICE guideline (NG88): : Assessment and management.

NHS Choices Heavy Periods, Menorrhagia Refer to current BNF or SPC for full medicines information Review due – May 2022