Red flag symptoms: Heavy menstrual bleeding

Red flags associated with menorrhagia and when urgent referral is required.

Red flags

  • Persistent intermenstrual or postcoital bleeding.
  • An unexplained vulval lump or vulval bleeding due to ulceration.
  • A palpable abdominal mass that is not obviously uterine fibroids.

Menorrhagia is an excessive menstrual blood loss (more than 80ml/cycle) over several consecutive cycles, which interferes with a woman's physical, emotional, and social quality of life.

About 30% of patients describe their periods as `heavy’. Menstrual disorders are the second most common gynaecological condition, resulting in 12% of all gynaecology referrals1.

40 – 60% of women with menorrhagia have dysfunctional uterine bleeding and do not have any underlying cause. Other possible causes are listed in box 1.

Box 1: possible causes
  • Uterine and ovarian pathologies: uterine fibroids, endometriosis and adenomyosis
  • Pelvic inflammatory disease and pelvic infection
  • Endometrial polyps, hyperplasia or carcinoma
  • Polycystic ovary syndrome
  • Systemic diseases and disorders: hypothyroidism, liver or renal disease
  • Coagulation disorders such as von Willebrand disease
  • Anticoagulant therapy
  • Chemotherapy
  • Intrauterine contraceptive device (blood loss may be increased by 40 – 50% over 6–12 months compared with pre-insertion values)


When taking a history, ask about:

  • Age of menarche
  • Length of the menstrual cycle
  • Excessive bleeding
  • Clots
  • Persistent inter-menstrual bleeding
  • Postcoital bleeding
  • Underlying systemic disorders
  • Family history of endometriosis or coagulation disorder
  • Cervical smear status
  • Contraceptive use and family planning
  • Impact on quality of life.


A pelvic examination should include vulval examination for evidence of external bleeding and signs of infection, and a speculum examination of vagina and cervix. High vaginal, endocervical, and chlamydia swabs should be obtained if infection is suspected. Bimanual palpation should be undertaken to identify uterine or adnexal enlargement or tenderness.

Look for systemic signs of underlying disease (including endocrine disease) such as hirsutism, striae, thyroid enlargement, nodularity or skin pigmentation. Bruises or petechiae may suggest coagulation disorders.


Full blood count and ferritin should be performed to rule out iron deficiency anaemia. Thyroid function testing should only be carried out if symptoms or signs are suggestive of thyroid disease.

Test for bleeding disorders (for example von Willebrand disease) if there are suggestive features in the history or on examination. Cervical screening and transvaginal pelvic ultrasound may also be undertaken.


The treatment of choice is the Mirena levonorgestrel-releasing intrauterine system2,3. Second choices include tranexamic acid, nonsteroidal anti-inflammatory drugs (NSAIDs) although these should be avoided in renal disease and those with gastrointestinal ulcers, and combined oral contraception.

A third choice could be oral norethisterone or long-acting progestogens. Depot medroxyprogesterone acetate (Depo-Provera) is the recommended long-acting progestogen.

Danazol, gestrinone, and etamsylate are not recommended for the treatment of menorrhagia.

Gonadotropin-releasing hormone analogues (for example leuprorelin or buserelin) are not recommended for use in primary care, but are an option in secondary care.

Rapid management of heavy bleeding

Oral norethisterone, 5 mg three times a day for 10 days, usually stops bleeding within 1-3 days1. A withdrawal bleed occurs 2-4 days after stopping treatment.

If bleeding is exceptionally heavy ('flooding'), 10 mg three times a day may provide better results but they need to understand this treatment carries an increased thromboembolic risk. This should then be tapered down to 5 mg three times a day for about a week once bleeding has stopped.

When to refer

Routine referral (according to local protocols), is needed when there is persistent heavy bleeding that affects the woman's quality of life, despite adequate trials of pharmaceutical treatment, or iron deficiency anaemia that has failed to respond to treatment and requires further investigations. Some patients may wish to consider surgery rather than medical treatment.

Urgent referral is warranted (within two weeks) if there is a suspicious abdominal or vulval mass. Alarm symptoms suggesting a possible malignancy include persistent intermenstrual or post-coital bleeding.

  • Dr Somalanka is a GP in Surrey

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  1. BMJ Clin Evid 2015 Sep 18; 2015.
  2. NICE Clinical Knowledge Summaries Menorrhagia. August 2015.
  3. Gupta JK, Daniels JP, Middleton LJ et al. NIHR 2015 Health Technology Assessment, No. 19.88

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