Heavy menstrual bleeding for GP Education 8th March 2011

Flow chart for the management of heavy menstrual bleeding

Woman presenting with HMB

Full history
Take full blood count

No structural or histological Structural or histological

abnormality suspected abnormality possible

Physical examination

Exclude Chlamydia
No Check cervical cytology up to date
Start pharmaceutical abnormality/fibroids Consider endometrial biopsy for
treatment less than 3cm diameter persistent bleeding and in women
syndrome over 45 treatment failure or
ineffective treatment

Physical examination
Uterus is
palpable
abdominally or
pelvic mass

Consider second
pharmaceutical treatment if Consider ultrasound imaging
first fails

Other treatments have failed, are

contraindicated or declined Severe impact on quality of
Severe impact on quality Desire for amenorrhoea life
of life & normal size Fully informed woman requests it Fibroids >3cm diameter
uterus No desire to retain uterus or fertility
Myomectomy
Endometrial ablation Hysterectomy Uterine artery embolization
Produced by Caroline Overton MBBS MD FRCOG FHEA, Consultant Gynaecologist, St Michael’s
Hospital UHBristol carolineoverton@uk-consultant.co.uk
Adapted from the National Institute for Health and Clinical Excellence Clinical guideline CG44 January
2007: Heavy Menstrual Bleeding