At-a-glance (high-yield primary care)
- Define impact: HMB is about quality-of-life impact, not purely quantified volume.
- Baseline test: FBC (anaemia is common; treat iron deficiency actively).
- First-line treatment for many: LNG-IUS if no contraindications and uterine cavity suitable.
- Non-hormonal options: tranexamic acid and/or NSAIDs are effective, especially when contraception not desired.
- Refer/imaging: suspected structural pathology (fibroids, adenomyosis), persistent symptoms despite treatment, or red flags.
Assessment + investigations (fast, practical)
- History: bleeding pattern, intermenstrual/postcoital bleeding, pain (think adenomyosis/endometriosis), contraception, anticoagulants, pregnancy risk, symptoms of anaemia, and family history.
- Examination: abdominal/pelvic exam if indicated (particularly if pain, pelvic mass, or abnormal bleeding).
- Core tests: FBC; pregnancy test when relevant; consider STI testing if indicated.
- When to consider imaging: bulky/tender uterus, suspected fibroids, persistent pain, treatment failure, or atypical bleeding pattern.
- Safety: follow local suspected cancer pathways for postmenopausal bleeding or high-risk features.
Stepwise treatment (NICE NG88 — simplified)
- First-line (if appropriate): LNG-IUS.
- If LNG-IUS unsuitable/declined:
- Non-hormonal: tranexamic acid and/or NSAIDs (take during menses).
- Hormonal: combined hormonal contraception or cyclical oral progestogens (align with patient goals and contraindications).
- Persistent symptoms: reassess for structural cause, anaemia, adherence; escalate to imaging/referral depending on findings and local pathways.
- Medication safety note: follow current MHRA/NICE safety updates where relevant for specific agents (and use local formulary guidance).
Frequently asked questions
What is the usual first-line treatment for HMB?
For many people without contraindications and where the uterus is suitable, LNG-IUS is a common first-line option because it is highly effective at reducing bleeding.
Which non-hormonal treatments are most useful?
Tranexamic acid and NSAIDs are both effective and can be used when contraception is not desired or hormonal options are unsuitable.
What’s the minimum blood test I should do?
An FBC is the key baseline test to assess for anaemia; treat iron deficiency proactively and reassess symptoms and haemoglobin response.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.