Investigations of heavy menstrual bleeding

Consider starting pharmacological treatment for HMB without investigating the cause if the woman's history and/or examination suggests a low risk of fibroids, uterine cavity abnormality, histological abnormality or adenomyosis (1).

If cancer is suspected then consult urgent gynaecological cancer guidance (linked below).

• laboratory investigations
  • blood tests
    • full blood count - should be undertaken on all women with heavy menstrual bleeding (HMB)
    • clotting studies - testing for coagulation disorders such as von Willebrand's disease should be considered in women who have had HMB since menarche and have personal or family history suggesting a coagulation disorder
    • serum ferritin test should not routinely be carried out on women with HMB - undertaken if the woman has been found to be anaemic on full blood count
    • female hormone testing should not be carried out on women with HMB
    • TFTs should be undertaken only when other signs and symptoms of thyroid disease are present (1)
  • cervical smear if indicated
  • HVS, chlamydia screen if infection suspected
    
    
• structural and histological investigations
  • for suspected cancer guidance then see linked item
    • if appropriate, a biopsy should be taken to exclude endometrial cancer or atypical hyperplasia
      • indications for a biopsy include, for example, persistent intermenstrual bleeding, and, in women aged 45 and over, treatment failure or ineffective treatment
    • imaging studies are indicated in various circumstances:
      • if the uterus is palpable abdominally
      • vaginal examination reveals a pelvic mass of uncertain origin
      • failure of pharmaceutical treatment
      • ultrasound is the first-line diagnostic tool for identifying structural abnormalities
• hysteroscopy - used as a diagnostic tool only when ultrasound results are inconclusive, for example, to determine the exact location of a fibroid or the exact nature of the abnormality
• dilatation and curettage alone should not be used as a diagnostic tool

Note:

• pregnancy test
  • pregnancy should be considered as a cause for an acute onset unexplained HMB
• take into account the woman's history and examination when deciding whether to offer hysteroscopy or ultrasound as the first-line investigation
  • Women with suspected submucosal fibroids, polyps or endometrial pathology
    • outpatient hysteroscopy should be offered to women with HMB if their history suggests submucosal fibroids, polyps or endometrial pathology because:
      • they have symptoms such as persistent intermenstrual bleeding or
      • they have risk factors for endometrial pathology:
        • women with persistent intermenstrual or persistent irregular bleeding, and
        • women with infrequent heavy bleeding who are obese or have polycystic ovary syndrome
        • women taking tamoxifen women for whom treatment for HMB has been unsuccessful
      • endometrial biopsy should be considered at the time of hysteroscopy for women who are at high risk of endometrial pathology
    • for women who decline hysteroscopy, consider pelvic ultrasound, explaining the limitations of this technique for detecting uterine cavity causes of HMB
      
      
  • Women with possible larger fibroids
    • pelvic ultrasound should be offered to women with HMB if any of the following apply:
      • their uterus is palpable abdominally
      • history or examination suggests a pelvic mass
      • examination is inconclusive or difficult, for example in women who are obese
        
        
  • Women with suspected adenomyosis
    • transvaginal ultrasound (in preference to transabdominal ultrasound or MRI) should be offered to women with HMB who have:
      • significant dysmenorrhoea (period pain) or
      • a bulky, tender uterus on examination that suggests adenomyosis
    • if a woman declines transvaginal ultrasound or it is not suitable for her, consider transabdominal ultrasound or MRI, explaining the limitations of these techniques
    • be aware that pain associated with HMB may be caused by endometriosis rather than adenomyosis

Reference:

1. Heavy menstrual bleeding: assessment and management. NG88. NICE Guideline (March 2018 - updated May 2021)