close

Log in

Access to premium content is restricted to healthcare professionals / registered members. Login with your email address to continue.

Forgot Your Password?

Don't have an account? Sign up

By signing in or creating an account, you agree to our Terms and conditions and Privacy notice

This site is intended for Healthcare Professionals only
Back to CKS

Women's health

Menorrhagia (heavy menstrual bleeding)

Last revised in July 2026

Menorrhagia is excessive (heavy) menstrual blood loss which occurs regularly (every 24 to 35 days)

Menorrhagia (heavy menstrual bleeding): Summary

  • Menorrhagia (or heavy menstrual bleeding) is defined as excessive menstrual blood loss which interferes with a woman's physical, social, emotional, and/or material quality of life. It can occur alone or in combination with other symptoms.
  • Menstrual disorders make up about 12% of all referrals to gynaecology services. About 1 in 20 women aged between 30–49 years consult their GP each year because of heavy periods or menstrual problems.
  • In almost 50% of women with menorrhagia, no underlying cause is found. Possible causes include uterine fibroid, uterine cancer, endometriosis, systemic disorders (such as coagulation disorders and hypothyroidism), and medications (such as anticoagulants).
  • Diagnosis of menorrhagia includes taking a detailed clinical history and considering the need for physical examination and investigations.  
    • If the woman has a history of menorrhagia with other related symptoms (such as persistent intermenstrual bleeding, pelvic pain, and/or pressure symptoms), a physical examination should be offered. If there are no related symptoms, pharmacological treatment may be considered without carrying out a physical examination (unless the treatment chosen is the levonorgestrel-releasing intrauterine system [LNG IUS]).
    • If the woman's history and/or examination suggest a low risk of fibroids, uterine cavity abnormality, histological abnormality, or adenomyosis, pharmacological treatment may be considered without investigating the cause of bleeding.
    • A full blood count is indicated in all women with menorrhagia to rule out iron deficiency anaemia. Other investigations should be guided by the history and clinical findings.
  • For women with no identified pathology, fibroids less than 3 cm in diameter, or suspected or diagnosed adenomyosis:
    • An LNG-IUS should be offered.
    • If this is declined or unsuitable, other pharmacological treatments should be considered, such as tranexamic acid, a nonsteroidal anti-inflammatory drug (NSAID), or hormonal treatments (combined hormonal contraception or cyclical oral progestogens).
    • If treatment is unsuccessful, the woman declines pharmacological treatment, or symptoms are severe, referral to a specialist should be considered for further investigations and consideration of alternative treatment options.
  • For women with fibroids of 3 cm or more in diameter, specialist referral should be considered for additional investigations and consideration of treatment options.
    • If pharmacological treatment is needed while the woman is awaiting treatment or referral, tranexamic acid and/or an NSAID should be offered.
  • Referral should also be arranged if:
    • Physical examination identifies ascites and/or a pelvic or abdominal mass (which is not obviously due to uterine fibroids).
    • The woman has a pelvic mass associated with any other features of cancer (such as unexplained bleeding or weight loss).
    • There are complications, such as compressive symptoms from large fibroids (for example, dyspareunia, pelvic pain or discomfort, constipation, or urinary symptoms).
    • The woman has iron deficiency anaemia that has failed to respond to treatment and other causes have been excluded. 

 

Have I got the right topic?

From age 12 years onwards (Female).

This CKS topic covers the management of menorrhagia (heavy menstrual bleeding) in primary care.

This CKS topic does not cover the management of intermenstrual or irregular bleeding, postcoital bleeding, postmenopausal bleeding, or menopausal symptoms. It also does not cover in detail the secondary care management of menorrhagia.

There are separate CKS topics on Amenorrhoea, Anaemia - iron deficiency, Dysmenorrhoea, Endometriosis, Gynaecological cancers - recognition and referral, Infertility, and Menopause. 

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

July 2026 — minor update. The recommendation advising against routine serum ferritin testing has been removed in line with NICE guideline NG88.

Previous changes

November 2024 — minor update. The drug interactions section for tranexamic acid has been updated.

February 2024 — minor update. A link has been added to the NHS England Decision support tool: making a decision about managing heavy periods.

January 2024 — minor update. Added information on Mirena®licensing for treatment of idiopathic menorrhagia for 5 years in line with an update to the manufacturer's summary of product characteristics. 

March 2023  — reviewed. The topic title has been changed from 'Menorrhagia' to 'Menorrhagia (heavy menstrual bleeding)'. A literature search was conducted in January 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No changes to clinical recommendations have been made.

  • In May 2021, the committee for the National Institute for Health and Care Excellence (NICE) guideline Heavy menstrual bleeding: assessment and management [NICE, 2021] amended the recommendations on the use of ulipristal acetate (Esmya®) for the management of uterine fibroids, in line with a Medicines and Healthcare products Regulatory Agency (MHRA) Drug Safety Update [MHRA, 2021]. Ulipristal acetate has been associated with cases of serious liver injury and liver failure (requiring transplantation in some cases), and the licence was temporarily suspended in March 2020 to allow a further review of these risks.
  • The use of ulipristal acetate (Esmya®) is outside the scope of this CKS topic, as it is initiated and supervised in secondary care.
  • For detailed information on the MHRA recommendations, see the Drug Safety Update Ulipristal acetate 5mg (Esmya): further restrictions due to risk of serious liver injury [MHRA, 2021].

December 2018 — minor update. The sections on Diagnosis (particularly the section on Investigations) and Management have been updated to reflect new recommendations in the 2018 National Institute for Health and Care Excellence (NICE) guideline Heavy menstrual bleeding: assessment and management [NICE, 2018]. The management section has been restructured to simplify use.

December 2017 — minor update. Information on fetal malformations and effectiveness of hormonal contraceptives as an effect of topiramate have been added.

June to July 2017 — reviewed. A literature search was conducted in June 2017 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of the topic. 

August 2015 — minor update. The prescribing information on mefenamic acid has been updated to reflect expert opinion and an NHS Regional Drugs and Therapeutics Centre Bulletin.

February 2013 — minor update. The 2013 Quality, Innovation, Productivity, and Prevention (QIPP) options for local implementation have been added to this topic.

October 2012 — minor update. The 2012 QIPP options for local implementation have been added to this topic.

September 2012 — minor update. The Black triangle status has been removed from Qlaira® tablets.

August 2012 — reviewed. A literature search was conducted in July 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. No changes to clinical recommendations have been made.

June 2011 — minor update. Information on Qlaira®, a quadraphasic combined oral contraceptive pill, has been added to the section on Prescribing information. The 2010/2011 QIPP options for local implementation have been added to this topic. 

January 2011 — minor update. The dosage and usage instructions for tranexamic acid have been amended. The prescription has also been amended. 

October 2010 — the topic structure has been revised to ensure consistency across CKS topics. No changes to clinical recommendations have been made.

September 2010 — minor update. A prescription for Rigevidon®, a new ethinylestradiol plus levonorgestrel combined oral contraceptive pill, has been added. 

June 2010 — minor update. A prescription for Levest®, a new ethinylestradiol plus levonorgestrel combined oral contraceptive pill, has been added. 

March 2009 — minor update to the combined oral contraceptive pill prescriptions. The upper age limit for use has been reduced to 50 years. 

June to September 2007 — converted from CKS guidance to CKS topic structure. The evidence base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. The most important change to the recommendations is that the levonorgestrel-releasing intrauterine system is now recommended first line for most women with heavy menstrual bleeding.

November 2005 — minor technical update. 

July 2005 — minor update. The topic has been updated to incorporate the Referral guidelines for suspected cancer published by the National Institute for Health and Care Excellence (NICE). 

February 2005 — minor update. The topic has been updated to include prescribing advice from the Committee on Safety of Medicines on the effect of depot medroxyprogesterone acetate contraception on bones. 

May 2004 — reviewed. Validated in September 2004 and issued in November 2004.

April 2002 — minor update. The topic has been updated to incorporate referral advice from NICE.

June 2001 — reviewed. Validated in July 2001 and issued in October 2001.

October 1998 — written.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 January 2023.

HTAs (Health Technology Assessments)

No new HTAs since 1 January 2023.

Economic appraisals

No new economic appraisals relevant to England since 1 January 2023.

Systematic reviews and meta-analyses

No new systematic reviews and meta-analyses since 1 January 2023.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 January 2023.

New policies

No new national policies or guidelines since 1 January 2023.

New safety alerts

No new safety alerts since 1 January 2023.

Changes in product availability

No changes in product availability since 1 January 2023.

Goals and outcome measures

Goals

To support primary healthcare professionals to: 

  • Assess women with menorrhagia.
  • Offer appropriate treatment, taking into account the woman's priorities and preferences. 
  • Refer to a specialist where appropriate, for example, if surgical treatment is indicated or where there is diagnostic uncertainty.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP — Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

In 2020 the quality standard was updated, and statements prioritised in 2013 were updated or replaced [NICE, 2020]: 

  • People presenting with symptoms related to heavy menstrual bleeding have a focused history taken that includes the impact on their quality of life. 
  • People with heavy menstrual bleeding and suspected submucosal fibroids, polyps or endometrial pathology are offered outpatient hysteroscopy.
  • People with heavy menstrual bleeding have a discussion with their healthcare professional about all their treatment options.

Statements from the 2013 version that are still supported by the evidence may still be useful at a local level [NICE, 2013]:

  • Women with heavy menstrual bleeding who have a suspected uterine cavity abnormality, histological abnormality, adenomyosis or fibroids have a physical examination before referral for further investigations.
  • Women with heavy menstrual bleeding who are undergoing further investigations or awaiting definitive treatment are offered tranexamic acid and/or non-steroidal anti-inflammatory drugs at the initial assessment.

Background information

What is it?

  • The National Institute for Health and Care Excellence (NICE) defines menorrhagia (heavy menstrual bleeding) as excessive menstrual blood loss which interferes with a woman's physical, social, emotional, and/or material quality of life, and which can occur alone or in combination with other symptoms [NICE, 2021a].
    • Menstruation is the cyclic shedding of the uterine lining in response to the interactions of hormones produced by the hypothalamus, pituitary, and ovaries [Reed, 2018].
    • A normal menstrual cycle is 21–35 days long, with bleeding lasting an average of 5–7 days and blood loss of between 25–80 ml [Shaw, 2022].
    • Menorrhagia has been defined, in research and clinical settings, as blood loss of more than 80 ml and/or a duration of more than 7 days [National Collaborating Centre for Women’s and Children’s Health, 2020; CDC, 2022; Kaunitz, 2023]. However, this definition is no longer considered useful because measurement of menstrual blood loss is rarely undertaken in routine clinical practice and women's self-assessment of blood loss has been widely demonstrated to differ from measured blood loss [Chimbira, 1980; Fraser, 1984; Wyatt, 2001; Warner, 2004].
    • Menorrhagia is highly subjective, and what is considered heavy bleeding to one woman may be normal for another. Studies show that many women who seek treatment for menorrhagia do not have blood loss severe enough to be clinically defined as menorrhagia [Wyatt, 2001; Warner, 2004; Magnay, 2014]. 
    • The NICE definition accounts for women who do not meet the standard criteria for menorrhagia (more than 80 ml and/or duration of more than 7 days) but for whom menstrual blood loss has a significant impact on quality of life [Sriprasert, 2017].

How common is it?

  • Menorrhagia is one of the most common reasons for referral to a gynaecologist.
    • Menstrual disorders make up about 12% of all referrals to gynaecology services [NICE, 2021a]. 
    • About 1 in 20 women aged between 30–49 years consult their GP each year because of heavy periods or menstrual problems [NICE, 2021a].
    • The prevalence of menorrhagia in the adolescent population has been reported as up to 37% [Dhillon-Smith, 2020]. 

What are the causes of menorrhagia?

  • In about 50% of women with menorrhagia, no cause is identified [CDC, 2022]. Possible causes of menorrhagia include [BMJ, 2022; CDC, 2022]:
    • Uterine and ovarian pathologies, such as:
    • Systemic conditions, such as:
      • Coagulation disorders (for example, von Willebrand disease).
      • Hypothyroidism. For more information, see the CKS topic on Hypothyroidism.
      • Diabetes mellitus. For more information, see the CKS topics on Diabetes - type 1 and Diabetes - type 2.
      • Hyperprolactinaemia. 
      • Liver or renal disease.
    • Other causes, including:
      • Medications such as anticoagulants, antiplatelets, nonsteroidal anti-inflammatory drugs (NSAIDs), selective serotonin reuptake inhibitors (SSRIs), oral contraceptive pill, and herbal supplements (such as ginseng, ginkgo, and soya) [BMJ, 2022].
      • Intrauterine contraceptive device. For more information, see the CKS topic on Contraception - IUS/IUD.

What are the complications?

  • Heavy menstrual bleeding may negatively affect a woman's physical, social, emotional, and/or material quality of life [NICE, 2021a].
  • Other complications include: 
    • Iron deficiency anaemia. 
    • Complications of secondary care interventions, such as [National Collaborating Centre for Women’s and Children’s Health, 2020]:
      • Endometrial ablation — vaginal discharge, increased period pain or cramping, infection, and perforation.
      • Hysterectomy — infection, thrombosis, urinary dysfunction, and damage to other abdominal organs (such as the urinary tract or bowel).
      • Uterine artery embolization — infection, persistent vaginal discharge, premature ovarian failure (particularly in women over 45 years old), haematoma, and haemorrhage.

Diagnosis

How should I assess a woman with menorrhagia?

  • Take a detailed clinical history. 
    • Ask about the nature of the bleeding, including:
      • Onset (for example, peri-menarcheal, sudden, or gradual).
      • Frequency/pattern (cyclic or non-cyclic).
      • Duration (acute or chronic).
      • Temporal association (for example, postcoital or postpartum). 
      • Related symptoms (such as persistent intermenstrual bleeding, pelvic pain, and/or pressure symptoms) — may suggest uterine cavity abnormality, histological abnormality, adenomyosis, or fibroids. 
    • Ask about her menstrual history, including:
      • Age of menarche.
      • Gravidity and parity.
      • Normal menstrual cycle and any variation of this pattern (including regularity, duration, and number of pads/tampons per day).
      • Last menstrual period (the start date of the most recent menstrual period). 
    • Ask about: 
      • Medical history, including recent medical procedures and comorbidities (such as endometriosis or history of coagulation disorders [for example, von Willebrand disease]).
      • Drug history, including current medications and previous treatment for menorrhagia.
      • Sexual history, including current contraceptive use (hormonal contraceptives may cause irregular bleeding), contraceptive plans, and future plans for a family (as this may impact the choice of treatment). 
      • Cervical screening history — to confirm she has attended as scheduled and results were normal. For more information, see the CKS topic on Cervical screening.
      • Signs and symptoms of anaemia, such as dyspnoea, fatigue, headache, and sore tongue. For more information, see the CKS topic on Anaemia - iron deficiency.
      • The impact of the bleeding on the woman's quality of life.
  • If the woman has a history of menorrhagia without other related symptoms, consider starting pharmacological treatment without carrying out a physical examination (unless the treatment chosen is the levonorgestrel-releasing intrauterine system [LNG-IUS]).
  • If the woman has a history of menorrhagia with other related symptoms, offer a physical examination (as appropriate) to exclude an underlying cause.
    • Perform an abdominal examination — to assess for large fibroids and other masses. 
    • Perform a bimanual pelvic examination, including a speculum examination of the cervix (except in young girls who are not sexually active) — to exclude an underlying cause, such as ascites, fibroids, or gynaecological cancer. For more information, see the CKS topics on Fibroids, Cervical cancer and HPV, and Gynaecological cancers - recognition and referral.
    • Look for features of an underlying systemic disease, for example:
      • Hypothyroidism — goitre. For more information, see the CKS topic on Hypothyroidism.
      • Coagulation disorders (for example, von Willebrand disease) — bruises or petechiae. For more information, see the CKS topic on Bruising.
      • Polycystic ovary syndrome — acne, hirsutism. For more information, see the CKS topic on Polycystic ovary syndrome.
  • Arrange investigations as appropriate to exclude an underlying cause. 
    • Arrange a full blood count in all women — to rule out iron deficiency anaemia (which is a strong indicator of excessive menstrual bleeding). For more information, see the CKS topic on Anaemia - iron deficiency.
    • Arrange other investigations as suggested by history and clinical findings, for example:
      • A pregnancy test — in all women of reproductive age who have any deviation from their normal pattern of menstrual bleeding. 
      • A vaginal or cervical swab — if an infection is suspected.
      • Thyroid function tests — if there are features of hypothyroidism. For more information, see the CKS topic on Hypothyroidism.
      • Tests for coagulation disorders (for example, von Willebrand disease) — in women who have had heavy menstrual bleeding since menarche and a personal or a family history of a coagulation disorder. 
    • Do not:
      • Carry out female hormone testing for women with menorrhagia. 
      • Measure blood loss to diagnose menorrhagia.
  • If the woman's history and/or examination suggests a low risk of fibroids, uterine cavity abnormality, histological abnormality, or adenomyosis, consider starting pharmacological treatment for menorrhagia without investigating the cause.
  • If the woman's history and/or examination suggests a high risk of fibroids, uterine cavity abnormality, histological abnormality, or adenomyosis, arrange further investigations to determine the cause of menorrhagia. 

Basis for recommendation

These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guideline Heavy menstrual bleeding: assessment and management [National Collaborating Centre for Women’s and Children’s Health, 2020; NICE, 2021a].

  • The recommendations on clinical history taking and are also based on expert opinion in a review article [BMJ, 2022] and on what CKS considers to be good clinical practice.  
  • The recommendation to offer a pregnancy test to all women of reproductive age who have any deviation from their normal pattern of menstrual bleeding is based on expert opinion in a review article [BMJ, 2022]. 

How should I investigate for the cause of menorrhagia?

  •  Suspected submucosal fibroids, polyps, or endometrial pathology
    • Offer referral for outpatient hysteroscopy to women with menorrhagia if their history suggests submucosal fibroids, polyps, or endometrial pathology because they have:
      • Symptoms such as persistent intermenstrual bleeding or
      • Risk factors for endometrial pathology.
    • Explain what the procedure involves, and discuss the possible alternatives.
      • If the woman declines outpatient hysteroscopy, offer a referral for hysteroscopy under general or regional anaesthesia. 
      • If the woman declines hysteroscopy under general or regional anaesthesia, consider referral for a pelvic ultrasound, explaining the limitations of this technique for detecting uterine cavity causes of menorrhagia. 
    • Endometrial biopsy should be considered at the time of hysteroscopy for women who are at high risk of endometrial pathology, such as:
      • 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 menorrhagia has been unsuccessful.
  • Possible larger fibroids
    • Offer a pelvic ultrasound to women with menorrhagia 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. 
  • Suspected adenomyosis
    • Offer a transvaginal ultrasound (in preference to a transabdominal ultrasound or MRI [magnetic resonance imaging]) to women with menorrhagia who have significant dysmenorrhoea (period pain) or a bulky, tender uterus on examination that suggests adenomyosis.
      • If a transvaginal ultrasound is declined or unsuitable, consider a transabdominal ultrasound or MRI, explaining the limitations of these techniques. 
      • Be aware that pain associated with menorrhagia may be caused by endometriosis rather than adenomyosis. For more information, see the CKS topic on Endometriosis.

Basis for recommendation

These recommendations are based on the National Institute for Health and Care Excellence (NICE) guideline Heavy menstrual bleeding: assessment and management [NICE, 2021a]. For full details of the evidence and the NICE guideline development committee's discussion, see NICE evidence review A: diagnostic test accuracy in investigation for women presenting with heavy menstrual bleeding. 

  • The NICE guideline development committee agreed that:
    • Investigation is not necessary before starting treatment when history and examination do not suggest structural abnormalities or endometrial pathology. 
    • The choice of first-line investigation should depend on the woman's history and examination findings. The committee made recommendations for using hysteroscopy or ultrasound that were based on the available evidence for diagnostic accuracy. 
  • The NICE guideline development committee noted that these recommendations may impact current practice.
    • Hysteroscopy
      • Hysteroscopy, in preference to pelvic ultrasound, for women with menorrhagia who are suspected of having submucosal fibroids, polyps, or endometrial pathology will have a resource impact on service organization and training.
      • Ultrasound is available through direct booking in primary care, whereas hysteroscopy is not. Therefore, changes to services will be needed to allow direct access booking into one-stop hysteroscopy services and ideally to increase delivery in community-based clinics.
      • To ensure that outpatient hysteroscopy is acceptable to women, it is essential that the procedure is done according to best practice guidelines, including techniques and equipment to minimize discomfort and pain in women; adequately sized, equipped, and staffed facilities; staff with necessary training, skills, and expertise; and the need for audit and benchmarking of outcomes.
    • Ultrasound
      • Transvaginal and transabdominal ultrasound are already widely available in secondary care and sometimes in primary care. However, clinicians might need additional training and experience in interpreting transvaginal ultrasound scans to identify signs of adenomyosis.

Management

Scenario: Management of menorrhagia (heavy menstrual bleeding)

From age 12 years onwards (Female).

When should I refer a woman with menorrhagia?

  • Refer using a suspected cancer pathway referral (for an appointment within 2 weeks) if:
    • The woman has a pelvic mass associated with any other features of cancer (such as unexplained bleeding or weight loss). 
    • The woman is aged 55 years and over with post-menopausal bleeding (unexplained vaginal bleeding more than 12 months after menstruation has stopped because of the menopause).
    • On examination, the appearance of their cervix is consistent with cervical cancer.
  • Refer urgently to gynaecology if physical examination identifies ascites and/or a pelvic or abdominal mass (which is not obviously due to uterine fibroids).
    • If the woman's history and/or examination suggests a high risk of fibroids, uterine cavity abnormality, histological abnormality, or adenomyosis, arrange further investigations to determine the cause of menorrhagia.
  • Refer for specialist management (urgency depending on clinical judgement) if:
    • The woman has iron deficiency anaemia which has failed to respond to treatment, and other causes have been excluded. 
    • Menorrhagia has not improved despite initial treatments.
  • Consider specialist referral for women with fibroids of 3 cm or more in diameter. For more information, see the section on Primary care management. 
  • If pharmacological treatment is needed while the woman is awaiting treatment or referral appointment, offer tranexamic acid and/or a non-steroidal anti-inflammatory drug. 

Basis for recommendation

These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guidelines Suspected cancer: recognition and referral [NICE, 2021b] and Heavy menstrual bleeding: assessment and management [NICE, 2021a].

How should I manage women with menorrhagia in primary care?

If referral is not indicated:

  • Provide appropriate information and advice on menorrhagia, for example:
  • Discuss the natural variability and range of menstrual blood loss with the woman.
    • For some women, reassurance may be all that is required, and treatment may not be needed.
    • If the woman feels she does not fall within the normal range, offer appropriate treatment taking into account:
      • The woman's priorities and preferences. 
      • Any comorbidities.
      • The presence or absence of fibroids (including size, number, and location), polyps, endometrial pathology, or adenomyosis.
      • Associated symptoms, such as pressure and pain.
    • Discussions should cover the benefits and risks of the various options, suitable treatments if she is trying to conceive, and whether she wants to retain her fertility and/or her uterus.
  • For women with menorrhagia and no identified pathology; fibroids less than 3 cm in diameter, which are not causing distortion of the uterine cavity; or suspected or diagnosed adenomyosis:
    • Consider a levonorgestrel intrauterine system (LNG-IUS) as the first-line treatment.
      • Explain to the woman about anticipated changes in bleeding pattern, particularly in the first few cycles and maybe lasting longer than 6 months. Advise that she should wait for at least 6 cycles to see the benefits of the treatment.
      • Note that this is an off-label use for some brands of LNG-IUS.
      • For prescribing information on the LNG-IUS, see the CKS topic on Contraception - IUS/IUD.
    • If an LNG-IUS is declined or unsuitable, consider other pharmacological treatment options.
    • If treatment is unsuccessful, the woman declines pharmacological treatment, or symptoms are severe, consider specialist referral for:
      • Additional investigations, taking into account any investigations the woman has already had.
      • Consideration of alternative treatments, such as pharmacological options not already tried or surgical treatment (second-generation endometrial ablation or hysterectomy). Hysteroscopic removal may be considered for women with submucosal fibroids.
  • For women with fibroids of 3 cm or more in diameter, consider specialist referral for additional investigations and consideration of treatment options.
    • If pharmacological treatment is needed while the woman is awaiting treatment or referral appointment, offer tranexamic acid and/or an NSAID.
      • Advise the woman to continue the treatment(s) for as long as they are found to be beneficial.
      • Note that this is an off-label use for NSAIDs. 
    • Secondary care treatment will depend on the size, location, and number of fibroids as well as the severity of symptoms. Treatment options include:
      • Non-hormonal treatment: NSAIDs (off-label use) or tranexamic acid.
      • Hormonal treatment: LNG-IUS (off-label use for some brands), CHC, or cyclical oral progestogens. Ulipristal acetate (Esmya®) may be considered for some premenopausal women in line with advice issued by the Medicines and Healthcare products Regulatory Agency (MHRA).
      • Uterine artery embolization.
      • Surgical treatment: myomectomy, hysterectomy, or second-generation endometrial ablation.

Additional information on treatment options for menorrhagia

  • Hormonal treatments 
    • The levonorgestrel-releasing intrauterine system (LNG-IUS) is an intrauterine device that releases a daily dose of 20 micrograms of levonorgestrel (an androgenic progestogen). The effects of the LNG-IUS are local and hormonal, including prevention of endometrial proliferation and thickening of cervical mucus. It may also suppress ovulation. Mirena®is licensed for the treatment of idiopathic menorrhagia for 5 years. 
    • Oral progestogens are synthetic forms of progesterone (a physiological hormone produced during the luteal phase of the menstrual cycle). Progesterone is responsible for the secretory transformation of the endometrium, and bleeding occurs after endogenous levels of oestrogen and progesterone fall (if fertilization does not occur). The mechanisms by which oral progestogens reduce menorrhagia are not fully understood. Oral progestogens are effective, but their clinical usefulness may be limited by tolerability. Norethisterone is the most commonly used oral progestogen in the treatment of menorrhagia. 
    • Combined oral contraceptives (COCs) contain oestrogen and progestogen in combination. They act on the hypothalamo–­pituitary axis to suppress ovulation and fertility. COCs are generally used in 21-day treatment cycles followed by a 7-day break, during which time endometrial breakdown and loss will occur. Such withdrawal bleeding is physiologically different from the bleeding that occurs after a natural ovulatory cycle. Most brands of COC are monophasic, being of the same strength throughout the 21-day treatment phase. Some brands vary to mimic the endogenous changes they replace. 
  • Non-hormonal treatments 
    • Tranexamic acid is a competitive inhibitor of plasminogen activation, thus acting as an antifibrinolytic agent. The binding of plasminogen to fibrin induces fibrinolysis (an enzymatic process that prevents the accumulation of fibrin and enables the removal of thrombi). By occupying the necessary binding sites, tranexamic acid prevents the dissolution of fibrin, thereby stabilizing the clot and preventing bleeding [DrugBank, 2023]. As menstrual bleeding involves the liquefaction of clotted blood from spiral endometrial arterioles, reduction in this process is believed to be the mechanism of reduced menstrual loss. 
    • Nonsteroidal anti-inflammatory drugs (NSAIDs), such as mefenamic acid, reduce prostaglandin synthesis by inhibition of cyclooxygenase. Prostaglandins affect local tissue reactivity and are implicated in inflammatory response, pain pathways, uterine bleeding, and uterine cramps. Menorrhagia can be associated with increased prostaglandin levels. 
  • Surgical treatments
    • Endometrial ablation is a procedure that surgically destroys the lining of the uterus. Second-generation endometrial ablation techniques include:
      • Microwave endometrial ablation — a probe is inserted into the uterus through the vagina and cervix. This probe produces microwaves that destroy the lining of the womb. 
      • Thermal balloon endometrial ablation — a deflated balloon is moved into the uterus through the vagina and cervix. Once in place, the balloon is filled with a heated liquid. The heat destroys the lining of the womb. 
    • Uterine artery embolization is a procedure to remove uterine fibroids. Small particles are injected into the blood vessels that take blood to the uterus. This impairs the blood supply to fibroids, causing them to shrink.  
    • Myomectomy is a procedure to remove uterine fibroids while preserving the uterus. Fibroids are removed via a number of routes: abdominal, vaginal, laparoscopic, and hysteroscopic. The choice of route is determined by the size and position of the fibroids.
    • Hysterectomy is the partial or total surgical removal of the uterus. It may also involve removal of the cervix, ovaries, and other surrounding structures.

 [National Collaborating Centre for Women’s and Children’s Health, 2020]

Basis for recommendation

These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guideline Heavy menstrual bleeding: assessment and management [NICE, 2021a]. 

  • NICE reviewed the evidence on treatments for heavy menstrual bleeding [NICE, 2021a].  
    • Women with no identified pathology, fibroids less than 3 cm in diameter, or suspected or diagnosed adenomyosis
      • In current practice, the levonorgestrel intrauterine system (LNG-IUS) is the first-line treatment for menorrhagia in these women. Evidence identified by NICE suggests that it is as effective as, or more effective than, other treatments in improving health-related quality of life and satisfaction with treatment. In addition, it offers the best balance of benefits and costs, is widely used in clinical practice, and is routinely available in primary care. 
      • The evidence did not show clinically important differences in effectiveness and acceptability among the other pharmacological treatments, so the NICE guideline committee agreed that if the LNG-IUS is declined or unsuitable, other pharmacological treatments can be considered.
      • For women with severe symptoms and those for whom initial treatment is unsuccessful, the committee agreed that referral to specialist care may be considered because some women may benefit from further investigations (in particular those who started treatment without investigations) or from specialist management.
      • There was a lack of evidence on second-line treatment, so the committee agreed that a choice of pharmacological and surgical options can be considered.
      • The committee agreed that women who decline pharmacological treatment and ask for surgery as a first treatment may be referred to specialist care for consideration of further investigations and surgical treatment.
    • Women with fibroids of 3 cm or more in diameter
      • The NICE guideline committee emphasized the importance of taking into account the size, number, and location of fibroids as well as the severity of symptoms when treating fibroids of 3 cm or more in diameter. This is because women with fibroids that are substantially greater than 3 cm in diameter may benefit from more invasive treatment, such as uterine artery embolization or surgery. Therefore, referral to specialist care to discuss all treatment options with the woman should be considered. 
    • For full details of the evidence and the NICE guideline development committee's discussion, see NICE evidence review B: management of heavy menstrual bleeding. 
  • CKS identified a subsequent Cochrane systematic review on treatments for heavy menstrual bleeding (search date: July 2021) [Bofill Rodriguez, 2022].
    • Nonsteroidal anti-inflammatory drugs (NSAIDs), antifibrinolytics (tranexamic acid), combined oral contraception (COC), combined vaginal ring (CVR), long‐cycle and luteal oral progestogens, LNG‐IUS, ethamsylate, and danazol (included to provide indirect evidence) were compared with placebo.
    • Evidence from 26 studies (n=1770) suggested that:
      • LNG‐IUS results in a large reduction of menstrual blood loss (low certainty evidence).
      • Antifibrinolytics probably reduce menstrual blood loss (moderate certainty evidence).
      • Long‐cycle progestogen reduces menstrual blood loss (low certainty evidence).
      • NSAIDs slightly reduce menstrual blood loss (low certainty evidence).
    • Conclusions could not be made about:
      • The true effect of the remaining interventions and the sensitivity analysis for reduction of menstrual blood loss, as the evidence was rated as very low certainty.
      • The effect of these treatments on the perception of improvement and satisfaction, as the evidence was rated as very low certainty.

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) or the British National Formulary (BNF).

Tranexamic acid

  • Tranexamic acid is licensed for the treatment of menorrhagia.
  • The recommended dosage is 1 g three times daily for up to four days, to be initiated when menstruation has started. The dose may be increased to a maximum of 4 g daily.
  • Tranexamic acid is contraindicated in women with severe renal impairment. A dose reduction is recommended for women with mild to moderate renal impairment [ABPI, 2018]:
    • Serum creatinine 120–249 micromoles/litre: 15 mg/kg twice daily.
    • Serum creatinine 250–500 micromoles/litre: 15 mg/kg once daily. 

[ABPI, 2018; BNF, 2023]

Contraindications and cautions

  • Do not prescribe tranexamic acid to women with:
    • Fibrinolytic conditions following disseminated intravascular coagulation.
    • History of convulsions.
    • Severe renal impairment (risk of accumulation).
    • A history of (or active) thromboembolic disease (for example, deep vein thrombosis or pulmonary embolism).
  • Prescribe tranexamic acid with caution to:
    • Women with: 
      • Irregular menstrual bleeding — the cause of bleeding should be established before initiating treatment.
      • Massive haematuria — in case of haematuria of renal origin (especially in haemophilia), there is a risk of mechanical anuria due to the formation of a ureteral clot.
      • Mild to moderate renal impairment — a dose reduction is recommended.
      • A previous thromboembolic event and a family history of thromboembolic disease (women with thrombophilia) — tranexamic acid should be used only if there is a strong medical indication and under strict medical supervision.
      • Hereditary angioneurotic oedema — regular eye examinations (for example, visual acuity, slit lamp, intraocular pressure, or visual fields) and liver function tests should be performed during long-term treatment.
    • Women taking certain medications, including oral contraceptives and oral anticoagulants.
    • Children under 15 years of age — clinical experience is not available.

[ABPI, 2018; BNF, 2023]

Adverse effects

  • Gastrointestinal adverse effects, such as nausea, vomiting, and diarrhoea, may occur but disappear when the dosage is reduced.
  • Impaired colour vision and other visual disturbances have been rarely reported. If these occur, discontinue treatment with tranexamic acid.
  • Other possible adverse effects of tranexamic acid include: 
    • Uncommon — allergic dermatitis, indigestion, and headache.
    • Rare — thromboembolic events and allergic skin reactions.
    • Very rare — arterial or venous thrombosis at any sites and hypersensitivity reactions, including anaphylaxis.
    • Frequency unknown —  convulsions.

[ABPI, 2018; National Collaborating Centre for Women’s and Children’s Health, 2020; BNF, 2023] 

Drug interactions

  • Anticoagulants — concurrent use with oral anticoagulants (such as warfarin) is expected to antagonise the effects of tranexamic acid. Concurrent use is contraindicated.
  • Combined hormonal contraceptives — concurrent use might result in additive clotting effects. 

[Preston, 2024]

Oral norethisterone

Contraindications and cautions

  • Do not prescribe norethisterone to:
    • Women with:
      • Previous idiopathic or current venous thromboembolism (deep vein thrombosis or pulmonary embolism).
      • Active or recent arterial thromboembolic disease (for example, angina or myocardial infarction).
      • Severe or active liver disease.
      • History during pregnancy of idiopathic jaundice, severe pruritus, or pemphigoid gestationis.
      • Undiagnosed vaginal bleeding.
      • Acute porphyria.
      • Current breast cancer (unless progestogens are being used in the management of this condition).
    • Pregnant women. 
  • Prescribe norethisterone with caution to women with:
    • Hypertension.
    • Diabetes — progestogens can decrease glucose tolerance.
    • History of breast cancer — seek specialist advice before use.
    • Liver tumours — seek specialist advice before use.
    • Multiple risk factors for cardiovascular disease (CVD), such as a personal or family history of CVD and severe obesity (body mass index more than 30 kg/m2).
    • Positive antiphospholipid antibodies.
    • Rheumatoid arthritis.
    • Risk factors for venous thromboembolism.
    • Systemic lupus erythematosus.
    • Malabsorption syndromes.
    • Conditions that can be aggravated by fluid retention, including: 
      • Epilepsy.
      • Migraine.
      • Asthma.
      • Cardiac dysfunction.
      • Renal impairment.
      • Asthma.

[ABPI, 2017; BNF, 2023]

Adverse effects

  • Menstrual cycle irregularities, including breakthrough bleeding, spotting, and amenorrhoea, are common adverse effects of norethisterone.
  • Other possible adverse effects include:
    • Uncommon — breast tenderness.
    • Rare — depression.
    • Frequency not known — appetite change, depression, fatigue, gastrointestinal disorder, headaches, hepatic cancer, hypertension, libido disorder, nervousness, rash, thromboembolism, and weight change.
  • Discontinue treatment with norethisterone if the following occur:
    • Jaundice or deterioration in liver function.
    • Significant increase in blood pressure.
    • New onset of migraine-type headache.
  • Ophthalmological evaluation (to exclude papilloedema or retinal vascular lesions) is recommended if the following occur:
    • Acute impairment of vision.
    • Proptosis.
    • Diplopia.
    • Migraine headache. 

[ABPI, 2017; BNF, 2023]

Drug interactions

  • Ciclosporin — increased ciclosporin concentrations have been seen in some people taking norethisterone.
    • Be aware of the potential for an interaction in the case of an unexpected response to treatment.
  • Ulipristal — norethisterone may decrease the efficacy of ulipristal, and ulipristal might decrease the efficacy of norethisterone.
    • Avoid concurrent use or advise the woman to use additional contraceptive precautions.
  • The effects/efficacy of norethisterone may be decreased during concurrent treatment with several drugs, including:
    • Carbamazepine.
    • Lamotrigine.
    • Modafinil.
    • Phenobarbital.
    • Phenytoin.
    • Primidone.
    • Rifabutin.
    • Rifampicin.
    • St John's wort.
    • Topiramate.
  • See the British National Formulary (BNF) for a list of other possible drug interactions with norethisterone.

[ABPI, 2017; BNF, 2023]

Supporting evidence

This CKS topic is largely based on the National Institute for Health and Care Excellence (NICE) guideline Heavy menstrual bleeding: assessment and management [National Collaborating Centre for Women’s and Children’s Health, 2020; NICE, 2021a].

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of menorrhagia.

Search dates

August 2017 - January 2023

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • exp Menorrhagia/, menorrhagia.tw., heavy menstrual bleeding.tw.

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • ABPI (2017) SPC for Norethisterone 5 mg tablets. Electronic Medicines Compendium. Datapharm Communications Ltd. http://www.medicines.org.uk [Free Full-text]
  • ABPI (2018) SPC for Tranexamic Acid 500 mg film coated tablets. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • BMJ Best Practice (2022) Abnormal uterine bleeding. BMJ Publishing Group. http://bestpractice.bmj.com
  • BNF (2023) British National Formulary. National Institute for Health and Care Excellence. https://bnf.nice.org.uk
  • Bofill Rodriguez, M., Dias, S., Jordan, V. et al. (2022) Interventions for heavy menstrual bleeding; overview of Cochrane reviews and network meta‐analysis (Cochrane Review/Cochrane Intervention Protocol). Issue 05. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
  • CDC (2022) Heavy Menstrual Bleeding. Centers for Disease Control and Prevention. http://www.cdc.gov [Free Full-text]
  • Chimbira, T. H., Anderson, A. B. and Turnbull, A.C (1980) Relation between measured menstrual blood loss and patient's subjective assessment of loss, duration of bleeding, number of sanitary towels used, uterine weight and endometrial surface area. British Journal of Obstetrics and Gynaecology 87(7), 603-609. [Abstract]
  • Dhillon-Smith, R and Latthe, P (2020) Guideline for the management of Heavy Menstrual Bleeding (HMB) in adolescents. British Society for Paediatric & Adolescent Gynaecology. http://britspag.org [Free Full-text]
  • DrugBank (2023) Tranexamic acid. http://drugbank.com [Free Full-text]
  • Fraser, I. S., McCarron, G. and Markham, R (1984) A preliminary study of factors influencing perception of menstrual blood loss volume. American Journal of Obstetrics and Gynecology 149(7), 788-793. [Abstract]
  • Irvine, G. A., Campbell-Brown, M. B., Lumsden, M. A. et al. (1998) Randomised comparative trial of the levonorgestrel intrauterine system and norethisterone for treatment of idiopathic menorrhagia. British journal of obstetrics and gynaecology 105(6), 592-598. [Abstract]
  • Kaunitz, A.M (2023) Patient education: Heavy or prolonged menstrual bleeding (menorrhagia) (Beyond the Basics). UpToDate, Inc. http://www.uptodate.com [Free Full-text]
  • Lethaby, A., Irvine, G. and Cameron, I (2008) Cyclical progestogens for heavy menstrual bleeding (Cochrane Review/Cochrane Intervention Protocol). Issue 01. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
  • Magnay, J. L., Nevatte, T. M., O'Brien, S. et al. (2014) Validation of a new menstrual pictogram (superabsorbent polymer-c version) for use with ultraslim towels that contain superabsorbent polymers. Fertility and sterility 10(2), 515-522. [Abstract] [Free Full-text]
  • Maybin, J. A. and Critchley, H. O (2016) Medical management of heavy menstrual bleeding. Women's health 12(1), 27-34. [Free Full-text]
  • National Collaborating Centre for Women’s and Children’s Health (2020) Heavy menstrual bleeding. National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
  • National Institute for Health and Clinical Excellence (2013) Quality standard: Heavy menstrual bleeding. NICE. http://www.nice.org.uk [Free Full-text]
  • NICE (2020) Quality standard: Heavy menstrual bleeding. National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
  • NICE (2021a) Heavy menstrual bleeding:assessment and management. National Institite for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
  • NICE (2021b) Suspected cancer: recognition and referral. National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
  • Preston, C.L (2024) Stockley's Drug Interactions. Medicines Complete. Pharmaceutical Press. https://www.medicinescomplete.com
  • Reed, B.G and Carr, B.R (2018) The Normal Menstrual Cycle and the Control of Ovulation. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.
  • Shaw, J.A (2022) Menorrhagia. Medscape. http://emedicine.medscape.com [Free Full-text]
  • Sriprasert, I., Pakrashi, T., Kimble, T. et al. (2017) Heavy menstrual bleeding diagnosis and medical management. Contraception and reproductive medicine 2, 20. [Abstract]
  • Warner, P. E., Critchley, H. O., Lumsden, M. A. et al. (2004) Menorrhagia I: measured blood loss, clinical features, and outcome in women with heavy periods: a survey with follow-up data. American journal of obstetrics and gynecology 190(5), 1216-1223. [Abstract]
  • Wyatt, K. M., Dimmock, P. W., Walker, T. J. et al. (2001) Determination of total menstrual blood loss. Fertility and sterility 76(1), 125-131. [Abstract] [Free Full-text]
Change privacy settings