investigations of heavy menstrual bleeding

Last edited 06/2018

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).

  • laboratoy investigations
    • blood tests
      • full blood count - should be undertaken on all women with heavy menstrual bleeding (HMB)
      • clottting 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


  • 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


  1. NICE (March 2018). Heavy menstrual bleeding