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Referral
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Heavy Menstrual Bleeding Without Histological or Structural Abnormality
Key Messages
Scope
Heavy Menstrual Bleeding (HMB) without histological or structural abnormality.
Referral for specialist advice and surgery, if appropriate, is only commissioned in women without significant fibroids or structural or histological abnormalities, if they have failed treatment with appropriate pharmacotherapy including the levonorgestrel-IUD (LNG-IUD). Heavy Menstrual Bleeding - Referral for Surgical Management - South & West
NICE guidance from March 2018 (Overview | Heavy menstrual bleeding: assessment and management | Guidance | NICE) suggests it is reasonable to start treatment for HMB "without investigating the cause if the woman's history and/or examination suggest a low risk of fibroids, uterine cavity abnormality, histological abnormality or adenomyosis". This guidance outlines what treatment and investigation should be considered in such circumstances and when, if pharmacological treatment including IUS fails, it might be suitable to refer. Referral for specialist advice and surgery, if appropriate, is only commissioned in idiopathic HMB if certain criteria are met. See referral section.
Out of Scope
Patients with:
- Post-coital bleeding – see Post Coital Bleeding - South & West
- Intermenstrual bleeding – see Inter-menstrual bleeding - South & West
- Dyspareunia/dysmenorrhoea/pelvic pain - under development
- Post menopausal bleeding – see Postmenopausal Bleeding - South & West
- Suspicion of gynaecological malignancy – see Urgent Suspected Cancer Gynaecology - South & West
History
- Menorrhagia is defined as:
- excessive menstrual blood loss which interferes with the woman’s physical, emotional, social and material quality of life, alone or in combination with other symptoms.
- Check risk factors for endometrial pathology (impact on threshold for investigation/referral):
- BMI greater than 40
- Family History/genetic predisposition (Lynch/Cowden syndrome)
- Unopposed oestrogen
- PCOS
- Diabetes
- Tamoxifen
Please specify any risk factors in the clinical referral details as they may influence the prioritisation of the referral
Examination
- Pelvic and speculum examination:
- if the history is suggestive of structural or histological abnormality (e.g. IMB, PCB or pain),
- or a Levonorgestrel-IUD is the chosen treatment
- Perform smear if overdue
- Abdominally palpable pelvic mass - see Urgent Suspected Cancer Gynaecology - South & West
- Suspicious lesions of the lower genital tract detected - see Urgent Suspected Cancer Gynaecology - South & West
- Post coital bleeding – see Post Coital Bleeding - South & West
- Intermenstrual bleeding – see Inter-menstrual bleeding - South & West )
- Post menopausal bleeding – see Postmenopausal Bleeding - South & West
- Systemic disorders causing excessive bleeding
- Risk factors for endometrial pathology (impact on threshold for investigation/referral):
- BMI greater than 40
- Family History/genetic predisposition (Lynch/Cowden syndrome)
- Unopposed oestrogen
- PCOS
- Diabetes
- Tamoxifen
Please specify any risk factors in the clinical referral details as they may influence the prioritisation of the referral
- Pelvic (transvaginal if available) ultrasound scan:
- if structural abnormality is suspected
- the uterus is palpable abdominally
- or if there is failure of pharmacological treatment.
- Full blood count (FBC)
- recommended for all women with HMB
- Investigations that may be considered but are generally not indicated:
- ferritin, gonadotrophin levels, thyroid function test (only if other signs or symptoms suggest thyroid disease), coagulation studies (e.g. von Willebrand’s) only if HMB since menarche, personal or family history suggestive of coagulation disorder.
Management
Treatment aims are to improve quality of life and alleviate associated symptoms, not necessarily to cure heavy bleeding.
All patients should be strongly encouraged to keep BMI in health range; obesity contributes to high circulating oestrogens and heavy menstrual bleeding. Surgical management is likely to be declined if BMI is over 35. Please see Adult weight management pathway - South & West (devonformularyguidance.nhs.uk)
Discuss treatment options taking into account the woman’s choices and preferences including the desire to retain fertility/uterus, the benefits and harms of treatment and the clinical considerations (comorbidities, multiple pathologies, size of uterus)
The following treatment options are appropriate when:
- there is no identified pathology
- there are fibroids of less than around 3cm that do not distort the uterine cavity significantly
- adenomyosis is suspected.
Adenomyosis that is suspected on USS can be managed in primary care using any of the following options. This finding does not require a referral to secondary care.
It is appropriate to try one option and consider an alternative after 3 cycles if unsuccessful.
First Line
Levonorgestrel-IUD
- Women should persevere for at least 6 cycles to see benefit
- Can be used in conjunction with non-hormonal treatment (and sometimes hormonal treatment – unlicensed)
Please note that sexual health services are only able to offer LNG-IUD for contraception. They are not commissioned to provide LNG-IUD fitting for heavy menstrual bleeding alone. If fitting of LNG-IUD is not available in your surgery please send a written referral to your local gynaecology service or if the patient is under 55 and a resident of North Devon, East Devon or Torbay consider referral to non-contraceptive LARC service.
South & West - Non contraceptive LARC fitting - LNG-IUD fits
North & East - Non contraceptive LARC fitting - LNG-IUD fits
Formulary chapter 7.3.2 Progestogen-only contraceptives:
- 7.3.2 Progestogen-only contraceptives - South & West
- 7.3.2 Progestogen-only contraceptives - North & East
Second Line
- NSAIDs may be 1st choice where dysmenorrhoea co-exists
- Combined Oral contraceptive, for a minimum trial 3 months, unless UKMEC contraindicated
- Tranexamic acid
UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) | FSRH
COCP: 7.3.1 Combined hormonal contraceptives (CHC) - South & West
TXA: 2.11 Antifibrinolytic drugs and haemostatics - South & West )
NSAIDS: 10.1.1 Non-steroidal anti-inflammatory drugs (NSAIDs) - South & West
Third Line
- Progesterones
Progestogens: 6.4.1 Female sex hormones and their modulators - South & West
Referral Criteria
Required in referral letter (referrals submitted without this information may be returned):
1) Treatments in general practice
i. details of treatments tried or reasons why not appropriate should be recorded in the referral letter
ii. please specify if there is a clinical reason why a LNG-IUD is not appropriate for the patient
iii. desire to retain uterus/fertility
2) Findings of pelvic and speculum examination
3) BMI
4) Pelvic (transvaginal if available) ultrasound scan
5) Up to date smear, as per local guideline (however it is not necessary to perform additional smears as this is not an investigation for bleeding of any kind)
6) Full Blood Count (FBC)
To ensure all the required information is attached, a referral proforma is available to download: HMB-Referral-Template-No-Merge-fields
Please note, the referral proforma is not mandatory.
Referral Instructions
For Referral to Gynaecology
e-Referral Service selection:
- Specialty: Gynaecology
- Clinic Type: Menstrual Disorders
- Service: DRSS-Western-Gynaecology-Devon ICB-15N
Referral Form
Patient Information
MyHealth patient information - HMB
Evidence
Pathway Group
This guideline has been signed off on behalf of NHS Devon.
Publication date: November 2018
Updated: December 2024
