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Heavy menstrual bleeding (HMB) — assessment + first-line treatment

A Canadian clinical summary of heavy menstrual bleeding (hmb) — assessment + first-line treatment, with source-attributed priorities and explicit jurisdiction boundaries.

JurisdictionCanada
Source check2026-08-20
Clinical reviewiatroX editorial team · Clinical editorial review · reviewed 2026-08-20 · due 2027-08-20
AudienceHealthcare professionals practising in Canada
This is an iatroX educational summary of named Canada sources, not an official guideline. It does not replace the complete source documents, local policy, specialist advice or clinical judgement. The evidence source is pan-Canadian, but formularies, funded access, referral routes, public-health directions and service availability remain provincial or territorial.

Source and scope

This summary is bounded to the recommendations, population and decisions covered by No. 292: Abnormal Uterine Bleeding in Pre-Menopausal Women. Apply it with the current provincial or territorial pathway where implementation differs.
sources for this section:SOGC 292

Source-attributed clinical priorities

  • Assess bleeding pattern, anemia, pregnancy possibility, medication and bleeding-disorder risk, and structural or malignant features.
  • Use examination, blood work and imaging selectively according to age, symptoms and risk rather than as a fixed panel for everyone.
  • Match medical or procedural treatment to cause, fertility goals, contraindications and patient preference, escalating hemodynamic instability urgently.
  • Quantify impact on life and iron status rather than relying only on an estimated volume of blood loss.
sources for this section:SOGC 292

Practical assessment and management workflow

1
Confirm pregnancy status and describe cycle regularity, intermenstrual or postcoital bleeding, pain and bleeding disorder clues.
2
Examine when structural disease is possible and obtain blood count and targeted imaging or sampling.
3
Select medical treatment by contraception needs, fibroid or adenomyosis features, contraindications and preference.
4
Review bleeding, hemoglobin, adverse effects and the need for procedural or gynecology referral.
sources for this section:SOGC 292

Safety, red flags and urgent escalation

  • Hemodynamic instability, syncope or symptomatic severe anemia requires urgent treatment.
  • Investigate new postmenopausal, persistent intermenstrual or concerning postcoital bleeding promptly.
  • Do not insert an intrauterine system until pregnancy and relevant uterine or infectious contraindications are considered.
sources for this section:SOGC 292

Confirm the local pathway before acting

The evidence source is pan-Canadian, but formularies, funded access, referral routes, public-health directions and service availability remain provincial or territorial.
sources for this section:SOGC 292

Source and implementation boundary

Read this educational summary with the linked source, current Canadian product information where medicines are involved, and the applicable provincial or territorial pathway. Local formularies, reporting duties, referral routes and service availability can differ.
sources for this section:SOGC 292

Source documents

Use the linked source documents for complete recommendations, evidence grading, exclusions and implementation detail.

  1. Society of Obstetricians and Gynaecologists of CanadaNo. 292: Abnormal Uterine Bleeding in Pre-Menopausal WomenDOI 10.1016/j.jogc.2018.03.007 · J Obstet Gynaecol Can 2018;40(5):e391-e415 · accessed 2026-08-20
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