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Menorrhagia | Clinical Guidelines in Primary Care | GP | GPST

TOPIC #1: Menorrhagia – abnormally heavy or prolonged menstrual bleeding


RED FLAGS - looking for structural abnormalities or infection.

Note well, none of these would trigger a 2 week cancer referral based on most recent

NICE guidelines:

1. Persistent intermenstrual bleeding

2. Pelvic pain or pressure

3. Dysmenorrhea

4. Post coital bleeding

5. Dyspareunia

6. Vaginal discharge


1. If examination is normal, but the following risk factors are present, you are referring a patient for a hysteroscopy with +/- endometrial biopsy:

a. persistent intermenstrual or irregular bleeding

b. obesity/PCOS (Polycystic Ovary Syndrome) and infrequent, but heavy bleeding

c. on tamoxifem

d. or finally no risk factors, but initial treatments have failed

2. If however these symptoms are present, send patients for an USS, preferably a transvaginal one: a. pelvic pain

b. dysmenorrhea

c. abdominal examination reveals a pelvic mass thought to be a fibroid

d. or the examination was inconclusive for whatever reason


1. All women should have a FBC

2. Up to date smears – every 3 years 25-49 year olds, every 5 years 50-64 year olds

3. Can consider TFTs if hypothyroidism suggested by other symptoms such as fatigue, constipation, cold intolerance, hair and skin changes

4. Consider coagulation tests if heavy bleeding since menarche, evidence of other bleeding problems, there is a positive family history for bleeding disorders


1. First line – Mirena coil

2. Second line – Tranexamic acid, which is an antifibrinolytic. The dose is 1g three times a day for up to 4 days, initiated when menstruation has started; alternatively, mefenamic acid – NSAID (500mg three times a day) is especially helpful if periods are painful.

These two can be combined and are considered “non-hormonal” methods. Second-line, you can also consider combined hormonal contraception if appropriate

3. Third line – Oral progestogen like medroxyprogesterone acetate 10mg or norethisterone 5mg TDS between D5 and D26. These are the same drugs one would prescribe for patients wishing to postpone periods. The former is preferred in patients at risk of VTE (venous thromboembolism). An alternative to these two is long-acting progestogens such as 12 weekly depot injection

The information contained within this publication was obtained from sources believed to be reliable. Whilst every effort has been made to ensure the accuracy of the material, no responsibility for loss, injury or failure whatsoever occasioned to any person acting or refraining from action as a result of information contained herein can be accepted by the author.

Although every effort has been make to ensure that all owners of copyright material have been acknowledged in the publication, we would be pleased to acknowledge in subsequent reprints or editions any omissions brought to our attention.

All readers should be aware that medical sciences are constantly changing and evolving and whilst the author has checked all dosages and guidance are based upon current indications, there may be specific practices and procedures that differ between localities, countries and nations. You should always follow the guidelines laid down by the manufacturers of specific products and the relevant authorities in the country in which you are practicing.

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