How should I manage a patient presenting with heavy menstrual bleeding who has not responded to first-line medical treatments?

Management of heavy menstrual bleeding (HMB) unresponsive to first-line medical treatments:

If a patient with HMB has not responded to first-line medical treatments such as the levonorgestrel intrauterine system (LNG-IUS) or other pharmacological options (tranexamic acid, NSAIDs, combined hormonal contraception, or cyclical oral progestogens), consider referral to specialist care for further assessment and management.

Specialist referral should include additional investigations to diagnose the cause of HMB if not already done, taking into account any previous investigations.

Alternative treatment options in secondary care include pharmacological treatments not previously tried and surgical options such as second-generation endometrial ablation techniques (microwave or thermal balloon ablation) or hysterectomy.

For women with fibroids 3 cm or larger, specialist referral is recommended for further investigations and treatment planning, which may include uterine artery embolization, myomectomy, or hysterectomy depending on fibroid size, location, and symptoms.

Hysteroscopic removal may be considered for submucosal fibroids.

While awaiting specialist treatment or referral, pharmacological treatments such as tranexamic acid and/or NSAIDs can be offered to manage symptoms.

Discuss with the patient the benefits, risks, and impact on fertility of all treatment options, including the potential loss of fertility with surgical treatments like hysterectomy or endometrial ablation.