Women's health toolkit

This Women’s Health Hub is categorised into sections best representing the needs of women at different stages of their lives.

Top tips for managing heavy menstrual bleeding in primary care

  1. Heavy menstrual bleeding is common; one in five women experience heavy periods with one in 20 women aged 30-49 presenting to primary care each year.
  2. HMB affects a woman’s physical, psychological and social health and wellbeing.
  3. The history of the problem and any co-morbidities determine if examination and investigations are required.
  4. HMB occurring in women with obesity or any condition causing unopposed oestrogen excess requires investigation to exclude endometrial hyperplasia and cancer, rates of which are rising in the UK.
  5. Treat without further need to examine or investigate if there are no additional symptoms and low risk for endometrial pathology.
  6. Basic laboratory investigations include:
  • FBC for all
  • Testing for coagulation disorders only if HMB since menarche or personal/FH of coagulation disorder
  • Consider sexual health screen
  • Cytology if due
  • No indication for testing thyroid function, hormone levels or ferritin without the presence of additional symptoms.
  1. Recommended investigations for women with HMB:

Pelvic ultrasound scan (trans-vaginal preferably) for possible larger fibroids or adenomyosis:

  • Enlarged uterus/ pelvic mass/ pelvic pressure symptoms
  • Dysmenorrhea

Hysteroscopy for possible endometrial pathology (hyperplasia/polyps/submucosal fibroids). Persistent irregular and/or intermenstrual bleeding:

  • Infrequent heavy bleeding plus obesity or PCOS
  • Late menopause (over 55)
  • Use of tamoxifen
  • FH Breast/bowel/ovary cancer
  • Abnormal ultrasound scan findings
  • If previous treatment unsuccessful
  1. Treat with tranexamic acid +/- analgesia at first visit, including while waiting for further investigations or referral.
  2. Future treatments depend on investigation findings, imminent fertility requirements, risk assessment and informed patient choice:

Hormonal:

i. Levonorgestrel intra-uterine system

ii. Combined hormonal contraception

iii. Long-cycle or continuous progestogens

Non-hormonal:

i. Tranexamic acid (1.5g three or four times daily)

ii. Plus/or NSAID of choice

Surgery referral:

i. Fibroid resection or embolization

ii. Endometrial ablation

iii. Hysterectomy

  1. Following endometrial ablation women require reliable contraception and combined HRT preparations for menopausal symptoms even if amenorrhoeic.