Heavy menstrual bleeding

Heavy menstrual bleeding is defined as excessive menstrual blood loss which interferes with the woman's physical, emotional, social and material quality of life, and which can occur alone or in combination with other symptoms. All interventions should aim to improve quality of life rather than focussing on menstrual blood loss alone. An accurate history may indicate the cause of the bleeding. Indications for endometrial biopsy include persistent intermenstrual bleeding as well as heavy menstrual bleeding, in women aged 45 and over and those where there is evidence of treatment failure. First line treatment includes tranexamic acid or non-steroidal anti-inflammatory drugs or combined oral contraceptives.Second line treatment options include, levonorgestrel-releasing intrauterine system (provided long-term use is anticipated), oral norethisterone or injectable long-acting progestogens.In women with HMB alone who have failed to respond to the above treatment options: with uterus no bigger than a 10-week pregnancy, endometrial ablation should be considered in preference to hysterectomy. Where hysterectomy is indicated, the route of hysterectomy should be considered in the following order: first-line vaginal; second-line abdominal/laparoscopic.