Clinical overview
Heavy menstrual bleeding (HMB) is one of the most common reasons women consult primary care, and accounts for a large proportion of gynaecology referrals. The clinical definition has shifted from the old objective threshold (≥80 mL per cycle) to a patient-centred definition: excessive menstrual blood loss that interferes with a woman's physical, emotional, social, and material quality of life. This shift acknowledges that the patient's experience — flooding, double protection, large clots, severe anaemia, time off work — is what matters, not laboratory blood volume.
Management of HMB in 2026 is medical first, with surgical reserved for those who fail or cannot tolerate medical options. The Mirena (LNG-IUS) has revolutionised the management of HMB, and is the first-line intervention in most women with no structural pathology. Hysterectomy rates have fallen dramatically — appropriately. The chapter pairs with heavy-menstrual-bleeding-pathology which addresses the underlying causes; here we cover assessment, classification, investigation, the stepped medical-to-surgical management ladder, and the South African context.
Core knowledge
Definitions
- Heavy menstrual bleeding (HMB): excessive menstrual blood loss interfering with quality of life (NICE NG88 and FIGO definitions).
- Menorrhagia: older term, same meaning; gradually being replaced.
- Metrorrhagia: irregular bleeding between periods (different problem).
- Menometrorrhagia: heavy AND irregular bleeding.
- Intermenstrual bleeding (IMB): bleeding between periods — different aetiology.
- Postcoital bleeding (PCB): bleeding after intercourse — separate workup.
FIGO classification of abnormal uterine bleeding (AUB) — PALM-COEIN
PALM-COEIN separates structural uterine causes from systemic or functional causes of heavy menstrual bleeding.
A systematic classification of causes, not severity. Memorise it.
Structural (PALM):
- Polyp (endometrial or endocervical).
- Adenomyosis.
- Leiomyoma (fibroids — submucosal especially).
- Malignancy and hyperplasia.
Non-structural (COEIN):
- Coagulopathy (von Willebrand disease, platelet disorders, anticoagulants).
- Ovulatory dysfunction (PCOS, hypothyroidism, prolactinoma, perimenopause).
- Endometrial (primary endometrial dysfunction; diagnosis of exclusion).
- Iatrogenic (IUD, hormonal contraception, anticoagulants).
- Not otherwise classified.
This framework structures every assessment.
Assessment
History
- Cycle: length, regularity, duration of bleeding, heaviness (flooding, clots > 1 cm, doubling sanitary protection, nocturnal changes, daytime accidents).
- Pictorial Blood Loss Assessment Chart (PBAC) score >100 suggests true HMB.
- Impact: work, school, exercise, social, intimate life, mood.
- Dysmenorrhoea (often coexists).
- IMB or PCB (different differential — hpv-pathology, polyps, endometrial-carcinoma).
- Pelvic pain or pressure symptoms.
- Reproductive intentions.
- Contraception history.
- Sexual history (rule out cervical/STI causes).
- Bleeding tendency: easy bruising, gum bleeding, family history of bleeding disorders.
- Medications: anticoagulants, antiplatelets, hormonal.
- Comorbidities: thyroid, liver, renal, PCOS, obesity.
- Smear history.
Examination
- General: pallor, signs of anaemia, BMI, signs of androgen excess (PCOS).
- Abdominal: palpable uterus (fibroids), pelvic masses.
- Speculum: cervix (polyp, ectropion, lesion); discharge.
- Bimanual: uterine size, mobility, tenderness; adnexal masses.
Investigations
- FBC — always (anaemia is common; iron studies if anaemia).
- Thyroid function — if cycle abnormality or clinically suggestive.
- Coagulation screen + von Willebrand panel — if family history, heavy bleeding since menarche, postpartum haemorrhage history, bleeding tendency.
- Cervical screen if due.
- Endocervical swab for chlamydia if relevant.
- β-hCG — exclude pregnancy.
- Transvaginal ultrasound — gold standard imaging. Assess endometrial thickness, polyps, fibroids (FIGO classification — submucosal types 0–2 relevant for HMB), adenomyosis features (MUSA), ovarian masses.
- Saline-infusion sonography (SIS) or outpatient hysteroscopy — best for endometrial cavity assessment (polyps, submucosal fibroids, focal lesions). NICE NG88 recommends hysteroscopy ± endometrial biopsy for women with risk factors for endometrial cancer or persistent IMB.
- Endometrial biopsy — indicated for: women ≥45 with HMB, persistent IMB at any age, treatment failure, suspected hyperplasia/cancer. Pipelle outpatient is convenient; specificity high, sensitivity ~80% (misses focal lesions — hysteroscopy preferred for those).
- MRI — for complex fibroid mapping, suspected adenomyosis with surgical implication, suspected malignancy.
Management
A stepped approach. Match treatment to:
- Underlying cause (PALM-COEIN).
- Reproductive intentions (preserve, complete, undetermined).
- Severity / impact / anaemia.
- Patient preference and comorbidities.
First-line: medical
Levonorgestrel-IUS (Mirena) — first-line for most. Reduces blood loss 70–95% at 12 months; ~30% of women achieve amenorrhoea by 12 months. Also contraceptive, also protects endometrium. Suitable for HMB without significant structural pathology, and for HMB with fibroids if cavity is not distorted significantly (FIGO type 0/1 large submucosal fibroids may extrude the device). Indwelling 5–8 years depending on indication; consider extended use to age 55 if inserted ≥45 for HMB.
Non-hormonal:
- Tranexamic acid 1 g PO 8-hourly during menses (up to 1 g 6-hourly for severe cases) — reduces blood loss by ~50%. First-line non-hormonal; useful if pregnancy desired soon.
- NSAIDs (mefenamic acid 500 mg 8-hourly, or ibuprofen) — reduce blood loss ~25–30%; also help dysmenorrhoea.
Hormonal (other):
- Combined hormonal contraception (continuous or cyclical) — reduces blood loss, also contraceptive.
- Progestogens:
- Cyclical norethisterone (5 mg TDS days 5–26) — short-term control; rarely first-line because of side effects and rebound.
- Long-acting progestogens — depot medroxyprogesterone acetate (DMPA), implant; reduce bleeding but irregular bleeding common.
- GnRH agonists — used short-term (3–6 months) for severe HMB, pre-surgical optimisation, or as a bridge to menopause. Use with HRT add-back to mitigate bone loss + menopausal symptoms.
Second-line: surgical (uterus-preserving)
- Hysteroscopic polypectomy for endometrial polyps.
- Hysteroscopic myomectomy for submucosal fibroids (FIGO 0–2).
- Endometrial ablation — for women who have completed family. Reduces bleeding markedly, often amenorrhoea. Various techniques: bipolar radiofrequency (Novasure), thermal balloon (Cavaterm), microwave. Contraindicated: future pregnancy desired (high risk of complications), large uterine cavity (>10 cm depth), submucosal fibroids distorting cavity, hyperplasia, malignancy. ~10–20% require further treatment (often hysterectomy) within 5 years.
Third-line: definitive surgical
- Hysterectomy — definitive treatment. Routes (preferred order):
- Vaginal hysterectomy (least morbidity, fastest recovery).
- Laparoscopic (total or supracervical).
- Open (if anatomical reasons preclude minimally invasive).
- Subtotal hysterectomy (preserves cervix) — slightly less morbidity but ongoing cervical screening required, and ~5% have ongoing cyclical bleeding from residual endometrial cells.
- Oophorectomy decision separate — consider patient age, family history, current ovarian function. Do not remove ovaries routinely under 65 unless indicated (BRCA, ovarian disease).
- Uterine artery embolisation (UAE) — for fibroid-related HMB; preserves uterus; ~10–20% require further treatment.
- Myomectomy — for women wanting fertility preservation with symptomatic fibroids. Open, laparoscopic, or hysteroscopic depending on location.
Iron deficiency and anaemia
- Iron deficiency common — even before HMB causes overt anaemia.
- Oral iron (ferrous sulphate 200 mg TDS or ferrous fumarate) for 3–6 months past correction of anaemia.
- Intravenous iron (ferric carboxymaltose) — for poor tolerance of oral or severe anaemia.
- Transfusion for severe anaemia or haemodynamic compromise.
Special situations
- Adolescents: PCOS common; coagulopathy commoner than in older women — von Willebrand disease ~10–20% in adolescent menorrhagia. COC or tranexamic acid first-line; LNG-IUS appropriate for some.
- Perimenopausal: ovulatory dysfunction common; risk of hyperplasia/cancer rising — biopsy threshold lower; LNG-IUS protects endometrium.
- Postmenopausal bleeding (PMB) — not HMB but always investigated. TVS for endometrial thickness; endometrial biopsy / hysteroscopy if thickness >4 mm or any persistent symptoms.
- Anticoagulants: LNG-IUS, tranexamic acid (cautiously), and ablation are all options. Liaise with haematology.
- Coagulopathy confirmed: liaise haematology; LNG-IUS + tranexamic acid are usually well tolerated.
- HMB in pregnancy: not applicable (different conditions — see antepartum-haemorrhage and postpartum-haemorrhage).
Red flags / pitfalls
- Skipping pregnancy test — always exclude pregnancy.
- Missing endometrial cancer — biopsy ≥45 with HMB; persistent IMB at any age.
- Anchoring on fibroids — fibroids commonly coexist with other causes; address the symptomatic problem.
- Failing to address anaemia — iron studies + supplementation are part of treatment.
- Operating before exhausting medical options — LNG-IUS first-line.
- Hysterectomy without exhaustive counselling — irreversible; explore alternatives.
- Endometrial ablation in younger women without sterilisation discussion — pregnancy after ablation is high-risk.
- Not asking about bleeding history since menarche — diagnosing inherited bleeding disorders.
- Forgetting to screen for thyroid in irregular cycles.
- Treating coagulopathy with hormonal contraception only — primary haematology management is important.
Evidence anchors
- NICE NG88 — Heavy Menstrual Bleeding: Assessment and Management (2018, regularly updated).
- FIGO PALM-COEIN classification (Munro MG et al., FIGO Working Group, 2018 update).
- Cochrane Reviews — LNG-IUS for HMB; tranexamic acid for HMB; endometrial ablation.
- NICE NG88 — recommends LNG-IUS as first-line in absence of structural pathology.
- RCOG GTG 67 — Management of Endometrial Hyperplasia (current).
- Faculty of Sexual and Reproductive Healthcare (FSRH) — IUD/IUS guidance.
- South African EML / NDoH Standard Treatment Guidelines (Hospital level, Adults) — drug availability (tranexamic acid, mefenamic, LNG-IUS).
- Heliövaara-Peippo S, et al. LNG-IUS vs hysterectomy for treatment of HMB. (long-term outcomes).
- Lethaby A, et al. Endometrial resection / ablation techniques for heavy menstrual bleeding. Cochrane Database Syst Rev.