When should I consider referring a patient with heavy menstrual bleeding to secondary care?

Consider referring a patient with heavy menstrual bleeding (HMB) to secondary care if:

• The woman has iron deficiency anaemia that has not responded to treatment and other causes have been excluded.
• Menorrhagia has not improved despite initial treatments.
• She has fibroids measuring 3 cm or more in diameter.
• There is a pelvic mass associated with other features suggestive of cancer (e.g., unexplained bleeding, weight loss), or physical examination identifies ascites or a pelvic/abdominal mass not obviously due to fibroids.
• The woman is aged 55 years or older with postmenopausal bleeding or if the cervix appears consistent with cervical cancer on examination.
• Symptoms are severe, or pharmacological treatment is declined or unsuccessful.
• There is suspicion of submucosal fibroids, polyps, or endometrial pathology requiring further investigation such as hysteroscopy.
• There are compressive symptoms or uncertain diagnosis related to fibroids.

Referral urgency depends on clinical judgement and the presence of suspected malignancy may require urgent (2-week) referral.

While awaiting referral or treatment, tranexamic acid and/or NSAIDs can be offered to manage symptoms.

For full assessment and management, consider the woman’s preferences, comorbidities, fertility desires, and associated symptoms such as pain or pressure.

These recommendations are based on NICE guidelines on heavy menstrual bleeding and suspected cancer pathways.

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