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<div class="pre-content"><div><div class="bk_prnt"><p class="small">NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.</p></div><div class="bk_msg_box bk_bttm_mrgn clearfix bk_noprnt"><div class="iconblock clearfix"><a class="img_link icnblk_img" title="Table of Contents Page" href="/books/n/niceng88/"><img class="source-thumb" src="/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-niceng88-lrg.png" alt="Cover" height="100px" width="80px" /></a><div class="icnblk_cntnt"><ul class="messages"><li class="info icon"><span class="icon"><a href="/books/n/niceng88/">A new version of this title is available</a></span></li></ul></div></div></div><div class="messagearea bk_noprnt" style="margin-bottom:1.3846em "><ul class="messages"><li class="warn icon"><span class="icon">Update information: In March 2018 NICE updated and replaced this guideline with NICE guideline NG88 on heavy menstrual bleeding. Some of the 2007 recommendations have been retained in the new guideline. This 2007 full guideline includes the evidence supporting the 2007 recommendations. Information that has been replaced by the new guideline has been shaded in grey in the PDF.</span></li></ul></div><div class="bk_prnt"><p style="color:red;"><strong>Update information: In March 2018 NICE updated and replaced this guideline with NICE guideline NG88 on heavy menstrual bleeding. Some of the 2007 recommendations have been retained in the new guideline. This 2007 full guideline includes the evidence supporting the 2007 recommendations. Information that has been replaced by the new guideline has been shaded in grey in the PDF.</strong></p></div></div></div>
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<div class="main-content lit-style" itemscope="itemscope" itemtype="http://schema.org/Book"><div class="meta-content fm-sec"><div class="iconblock whole_rhythm clearfix no_top_margin"><a href="https://www.rcog.org.uk/" title="RCOG Press" class="img_link icnblk_img" ref="pagearea=logo&targetsite=external&targetcat=link&targettype=publisher"><img class="source-thumb" src="/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-nicecg44-lrg.png" alt="Cover of Heavy Menstrual Bleeding" /></a><div class="icnblk_cntnt"><h1 id="_NBK56536_"><span itemprop="name">Heavy Menstrual Bleeding</span></h1><p><i>NICE Clinical Guidelines, No. 44</i></p><p class="contrib-group"><h4>Authors</h4><span itemprop="author">National Collaborating Centre for Women's and Children's Health (UK)</span>.</p><div class="half_rhythm">London: <a href="https://www.rcog.org.uk/" ref="pagearea=meta&targetsite=external&targetcat=link&targettype=publisher"><span itemprop="publisher">RCOG Press</span></a>; <span itemprop="datePublished">2007 Jan</span>.<div class="small">ISBN-13: <span itemprop="isbn">978-1-904752-35-6</span></div></div><div><a href="/books/about/copyright/">Copyright</a> © 2007, National Collaborating Centre for Women's and Children's Health.</div></div></div></div><div class="body-content whole_rhythm" itemprop="text"><div itemprop="description"><p><b>Update Information:</b> In March 2018 we updated and replaced this guideline with NICE guideline NG88 on heavy menstrual bleeding.</p><p>Heavy menstrual bleeding (HMB) has an adverse effect on the quality of life of many women. It is not a problem associated with significant mortality. Many women seek help from their general practitioners and it is a common reason for referral into secondary care.</p><p>In order for women to be treated successfully, it is essential that the underlying problem is understood by both the patient and the healthcare professional. This guideline provides background information as well as covering epidemiology, physiology, investigation and, ultimately, treatment. The aim is to consider the evidence and review it, taking into account both the woman's and the healthcare professional's viewpoints and interests. This is not always easy but it is anticipated that the information contained in the guideline will help women reach an informed and beneficial decision with their doctors. Once they have read the guideline, they will know what questions to ask and what the options available to them are. Constructive dialogue should allow patients to be able to trust the advice given by their practitioner as they will be confident that they have the latest information and will be able to use it to inform this decision-making process.</p><p>Clinical guidelines have been defined as systematically developed statements which assist clinicians and patients in making decisions about appropriate treatment for specific conditions. This guideline has been developed with the aim of providing guidance on HMB. The effectiveness of the various treatments as well as their risks and benefits are discussed in relation to their use in the treatment of HMB but the discussion cannot be extrapolated to the use of particular treatments to relieve other symptoms, such as hysterectomy for cancer or endometriosis. The implications of each treatment in relation to fertility are also clearly stated so that no woman will undergo treatment that renders her infertile unless this is her specific wish.</p></div><div><h2>Contents</h2><ul id="toc_tllNBK56536_toc_nicecg44_fm_s2" class="simple-list toc toc-toggle"><li class="half_rhythm" id="toc_itm_NBK56536_toc_nicecg44_fm_s2"><a class="toc-item" href="/books/n/nicecg44/nicecg44.fm.s2/">Guideline Development Group membership and acknowledgements</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_nicecg44_fm_abbreviations_gl1"><a class="toc-item" href="/books/n/nicecg44/nicecg44.fm.abbreviations.gl1/">Abbreviations</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_nicecg44_fm_glossary_gl2"><a class="toc-item" href="/books/n/nicecg44/nicecg44.fm.glossary.gl2/">Glossary of terms</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch1"><a class="toc-item" href="/books/n/nicecg44/ch1/">1. Introduction</a><ul id="toc_lst_NBK56536_toc_ch1" class="simple-list toc bktoc_lst_exp"><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch1_s1"><a class="toc-item" href="/books/n/nicecg44/ch1/#ch1.s1">1.1. Aim of the guideline</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch1_s2"><a class="toc-item" href="/books/n/nicecg44/ch1/#ch1.s2">1.2. Areas outside of the remit of the guideline</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch1_s3"><a class="toc-item" href="/books/n/nicecg44/ch1/#ch1.s3">1.3. For whom is the guideline intended?</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch1_s4"><a class="toc-item" href="/books/n/nicecg44/ch1/#ch1.s4">1.4. Who has developed the guideline?</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch1_s5"><a class="toc-item" href="/books/n/nicecg44/ch1/#ch1.s5">1.5. Other relevant documents</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch1_s6"><a class="toc-item" href="/books/n/nicecg44/ch1/#ch1.s6">1.6. Guideline development methodology</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch1_s13"><a class="toc-item" href="/books/n/nicecg44/ch1/#ch1.s13">1.7. Schedule for updating the guideline</a></li></ul></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch2"><a class="toc-item" href="/books/n/nicecg44/ch2/">2. Summary of recommendations and care pathway</a><ul id="toc_lst_NBK56536_toc_ch2" class="simple-list toc bktoc_lst_exp"><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch2_s1"><a class="toc-item" href="/books/n/nicecg44/ch2/#ch2.s1">2.1. Key priorities for implementation (key recommendations)</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch2_s9"><a class="toc-item" href="/books/n/nicecg44/ch2/#ch2.s9">2.2. Summary of recommendations</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch2_s29"><a class="toc-item" href="/books/n/nicecg44/ch2/#ch2.s29">2.3. Research recommendations</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch2_s42"><a class="toc-item" href="/books/n/nicecg44/ch2/#ch2.s42">2.4. Care pathway</a></li></ul></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch3"><a class="toc-item" href="/books/n/nicecg44/ch3/">3. Impact of HMB on women</a><ul id="toc_lst_NBK56536_toc_ch3" class="simple-list toc bktoc_lst_exp"><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch3_s1"><a class="toc-item" href="/books/n/nicecg44/ch3/#ch3.s1">3.1. Defining HMB</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch3_s12"><a class="toc-item" href="/books/n/nicecg44/ch3/#ch3.s12">3.2. Risk factors for increased menstrual bleeding</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch3_s29"><a class="toc-item" href="/books/n/nicecg44/ch3/#ch3.s29">3.3. Prevalence of uterine pathology</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch3_s36"><a class="toc-item" href="/books/n/nicecg44/ch3/#ch3.s36">3.4. Impact of HMB on quality of life</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch3_s42"><a class="toc-item" href="/books/n/nicecg44/ch3/#ch3.s42">3.5. Prevalence of HMB</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch3_s47"><a class="toc-item" href="/books/n/nicecg44/ch3/#ch3.s47">3.6. Definition of HMB</a></li></ul></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch4"><a class="toc-item" href="/books/n/nicecg44/ch4/">4. History taking, examination and investigations for HMB</a><ul id="toc_lst_NBK56536_toc_ch4" class="simple-list toc bktoc_lst_exp"><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch4_s1"><a class="toc-item" href="/books/n/nicecg44/ch4/#ch4.s1">Introduction</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch4_s2"><a class="toc-item" href="/books/n/nicecg44/ch4/#ch4.s2">4.1. History taking for HMB</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch4_s10"><a class="toc-item" href="/books/n/nicecg44/ch4/#ch4.s10">4.2. Measurement of menstrual blood loss</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch4_s17"><a class="toc-item" href="/books/n/nicecg44/ch4/#ch4.s17">4.3. Physical examination for HMB</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch4_s22"><a class="toc-item" href="/books/n/nicecg44/ch4/#ch4.s22">4.4. Laboratory tests for HMB</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch4_s30"><a class="toc-item" href="/books/n/nicecg44/ch4/#ch4.s30">4.5. Investigations for structural and histological abnormalities</a></li></ul></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch5"><a class="toc-item" href="/books/n/nicecg44/ch5/">5. Education and information provision</a><ul id="toc_lst_NBK56536_toc_ch5" class="simple-list toc bktoc_lst_exp"><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch5_s1"><a class="toc-item" href="/books/n/nicecg44/ch5/#ch5.s1">Introduction</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch5_s2"><a class="toc-item" href="/books/n/nicecg44/ch5/#ch5.s2">5.1. Education and information provision for women with HMB</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch5_s12"><a class="toc-item" href="/books/n/nicecg44/ch5/#ch5.s12">Implementation advice on improving education and information provision for women with HMB</a></li></ul></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch6"><a class="toc-item" href="/books/n/nicecg44/ch6/">6. Choice</a><ul id="toc_lst_NBK56536_toc_ch6" class="simple-list toc bktoc_lst_exp"><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch6_s1"><a class="toc-item" href="/books/n/nicecg44/ch6/#ch6.s1">Introduction</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch6_s2"><a class="toc-item" href="/books/n/nicecg44/ch6/#ch6.s2">6.1. Patient choice</a></li></ul></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch7"><a class="toc-item" href="/books/n/nicecg44/ch7/">7. Lifestyle interventions for HMB</a><ul id="toc_lst_NBK56536_toc_ch7" class="simple-list toc bktoc_lst_exp"><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch7_s1"><a class="toc-item" href="/books/n/nicecg44/ch7/#ch7.s1">Introduction</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch7_s2"><a class="toc-item" href="/books/n/nicecg44/ch7/#ch7.s2">7.1. Lifestyle interventions for HMB</a></li></ul></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch8"><a class="toc-item" href="/books/n/nicecg44/ch8/">8. Pharmaceutical treatments for HMB</a><ul id="toc_lst_NBK56536_toc_ch8" class="simple-list toc bktoc_lst_exp"><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch8_s1"><a class="toc-item" href="/books/n/nicecg44/ch8/#ch8.s1">8.1. Hormonal treatments for HMB</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch8_s2"><a class="toc-item" href="/books/n/nicecg44/ch8/#ch8.s2">8.2. Intrauterine levonorgestrel-releasing systems (LNG-IUS)</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch8_s9"><a class="toc-item" href="/books/n/nicecg44/ch8/#ch8.s9">8.3. Combined oral contraceptives</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch8_s17"><a class="toc-item" href="/books/n/nicecg44/ch8/#ch8.s17">8.4. Oral progestogens</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch8_s26"><a class="toc-item" href="/books/n/nicecg44/ch8/#ch8.s26">8.5. Other hormonal treatments for HMB</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch8_s34"><a class="toc-item" href="/books/n/nicecg44/ch8/#ch8.s34">8.6. Injected/depot progestogens</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch8_s41"><a class="toc-item" href="/books/n/nicecg44/ch8/#ch8.s41">8.7. Hormone replacement therapy (HRT)</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch8_s48"><a class="toc-item" href="/books/n/nicecg44/ch8/#ch8.s48">8.8. Gonadotrophin-releasing hormone analogue for treatment of HMB associated with uterine fibroids</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch8_s58"><a class="toc-item" href="/books/n/nicecg44/ch8/#ch8.s58">8.9. Non-hormonal pharmaceutical treatments for HMB</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch8_s59"><a class="toc-item" href="/books/n/nicecg44/ch8/#ch8.s59">8.10. Tranexamic acid</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch8_s67"><a class="toc-item" href="/books/n/nicecg44/ch8/#ch8.s67">8.11. Nonsteroidal anti-inflammatory drugs (NSAIDs)</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch8_s75"><a class="toc-item" href="/books/n/nicecg44/ch8/#ch8.s75">8.12. Etamsylate</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch8_s81"><a class="toc-item" href="/books/n/nicecg44/ch8/#ch8.s81">GDG interpretation of evidence on pharmaceutical treatments for HMB</a></li></ul></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch9"><a class="toc-item" href="/books/n/nicecg44/ch9/">9. Surgery as first-line treatment for HMB</a><ul id="toc_lst_NBK56536_toc_ch9" class="simple-list toc bktoc_lst_exp"><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch9_s1"><a class="toc-item" href="/books/n/nicecg44/ch9/#ch9.s1">Introduction</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch9_s2"><a class="toc-item" href="/books/n/nicecg44/ch9/#ch9.s2">9.1. Surgery as first-line treatment for HMB</a></li></ul></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch10"><a class="toc-item" href="/books/n/nicecg44/ch10/">10. Non-hysterectomy surgery for HMB</a><ul id="toc_lst_NBK56536_toc_ch10" class="simple-list toc bktoc_lst_exp"><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch10_s1"><a class="toc-item" href="/books/n/nicecg44/ch10/#ch10.s1">10.1. Indications for non-hysterectomy surgery or interventional radiology</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch10_s8"><a class="toc-item" href="/books/n/nicecg44/ch10/#ch10.s8">10.2. Endometrial ablation/resection</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch10_s31"><a class="toc-item" href="/books/n/nicecg44/ch10/#ch10.s31">10.3. Dilatation and curettage</a></li></ul></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch11"><a class="toc-item" href="/books/n/nicecg44/ch11/">11. Further interventions for uterine fibroids associated with HMB</a><ul id="toc_lst_NBK56536_toc_ch11" class="simple-list toc bktoc_lst_exp"><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch11_s1"><a class="toc-item" href="/books/n/nicecg44/ch11/#ch11.s1">11.1. Uterine artery embolisation</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch11_s8"><a class="toc-item" href="/books/n/nicecg44/ch11/#ch11.s8">11.2. Myomectomy</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch11_s18"><a class="toc-item" href="/books/n/nicecg44/ch11/#ch11.s18">11.3. Other interventions for uterine fibroids</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch11_s19"><a class="toc-item" href="/books/n/nicecg44/ch11/#ch11.s19">Evidence statements on interventions for fibroids</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch11_s20"><a class="toc-item" href="/books/n/nicecg44/ch11/#ch11.s20">GDG interpretation of evidence on interventions for uterine fibroids</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch11_s21"><a class="toc-item" href="/books/n/nicecg44/ch11/#ch11.s21">Implementation advice for interventions for uterine fibroids</a></li></ul></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch12"><a class="toc-item" href="/books/n/nicecg44/ch12/">12. Hysterectomy</a><ul id="toc_lst_NBK56536_toc_ch12" class="simple-list toc bktoc_lst_exp"><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch12_s1"><a class="toc-item" href="/books/n/nicecg44/ch12/#ch12.s1">Introduction</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch12_s2"><a class="toc-item" href="/books/n/nicecg44/ch12/#ch12.s2">12.1. Indications for hysterectomy</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch12_s9"><a class="toc-item" href="/books/n/nicecg44/ch12/#ch12.s9">12.2. Hysterectomy</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch12_s22"><a class="toc-item" href="/books/n/nicecg44/ch12/#ch12.s22">12.3. Pre-treatment for hysterectomy</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch12_s24"><a class="toc-item" href="/books/n/nicecg44/ch12/#ch12.s24">GDG interpretation of evidence on hysterectomy</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch12_s25"><a class="toc-item" href="/books/n/nicecg44/ch12/#ch12.s25">Implementation advice for hysterectomy</a></li></ul></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch13"><a class="toc-item" href="/books/n/nicecg44/ch13/">13. Removal of ovaries at the time of hysterectomy</a><ul id="toc_lst_NBK56536_toc_ch13" class="simple-list toc bktoc_lst_exp"><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch13_s1"><a class="toc-item" href="/books/n/nicecg44/ch13/#ch13.s1">13.1. Oophorectomy</a></li></ul></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch14"><a class="toc-item" href="/books/n/nicecg44/ch14/">14. Competencies</a><ul id="toc_lst_NBK56536_toc_ch14" class="simple-list toc bktoc_lst_exp"><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch14_s1"><a class="toc-item" href="/books/n/nicecg44/ch14/#ch14.s1">Introduction</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch14_s2"><a class="toc-item" href="/books/n/nicecg44/ch14/#ch14.s2">14.1. Competencies</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_ch14_s12"><a class="toc-item" href="/books/n/nicecg44/ch14/#ch14.s12">Implementation advice on competencies</a></li></ul></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_appendixes_app1"><a class="toc-item" href="/books/n/nicecg44/appendixes.app1/">Appendix A. Health economics</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_appendixes_app2"><a class="toc-item" href="/books/n/nicecg44/appendixes.app2/">Appendix B. Competencies</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_appendixes_app3"><a class="toc-item" href="/books/n/nicecg44/appendixes.app3/">Appendix C. Guideline questions</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_appendixes_app4"><a class="toc-item" href="/books/n/nicecg44/appendixes.app4/">Appendix D. Declarations of interest</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_references_rl1"><a class="toc-item" href="/books/n/nicecg44/references.rl1/">References</a></li><li class="half_rhythm" id="toc_itm_NBK56536_toc_evidencetables_s1"><a class="toc-item" href="/books/n/nicecg44/evidencetables.s1/">Evidence Tables</a></li></ul></div><div><p>While every effort has been made to ensure the accuracy of the information contained within this publication, the publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check current indications and accuracy by consulting other pharmaceutical literature and following the guidelines laid down by the manufacturers of specific products and the relevant authorities in the country in which they are practising.</p></div></div></div>
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