Women reporting with heavy menstrual bleeding Full menstrual history. Examination. Full blood count Prolonged Irregular cycles Anaemic Refer specialist Abnormal exam uterine size > 12 wks Abnormal exam uterine size > 12 wks Treat anaemia Treat anaemia Yes No Yes severe No Mild or moderate (80-115g/l) < 80 g/l Algorithm for the Management of Heavy Menstrual Bleeding No
Assess risk of endometrial hyperplasia Bodyweight ≥ 90 kg Age ≥ 45 years Other risk factors Assess risk of endometrial hyperplasia Bodyweight ≥ 90 kg Age ≥ 45 years Other risk factors Assess endometrium Transvaginal ultrasound (TVS) or Endometrial biopsy if endometrium ≥ 12 mm or if TVS not available Assess endometrium Transvaginal ultrasound (TVS) or Endometrial biopsy if endometrium ≥ 12 mm or if TVS not available Hyperplastic endometrium or carcinoma Biopsy Unexplained heavy menstrual bleeding Unexplained heavy menstrual bleeding Normal endometrium Levonorgestrel intrauterine system Tranexamic acid Nonsteroidal anti inflammatory agents Norethisterone (long course) Oc pill Danazol If one medical therapy fails others can be used Levonorgestrel intrauterine system Tranexamic acid Nonsteroidal anti inflammatory agents Norethisterone (long course) Oc pill Danazol If one medical therapy fails others can be used Offer medical therapy Treatment success Evaluation and consideration for surgery Continue medical therapy High risk* NoYes * Referral to specialist could be considered