NICE guidance on heavy menstrual bleeding highlights importance of patient choice

NICE recommends that women should be provided with sufficient information for them to be able to make their own choice about treatment options, explains Dr Anne Connolly. This article is supported by Hologic.

Dr Anne Connolly
Dr Anne Connolly

NICE defines heavy menstrual bleeding (HMB) 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’.1

One in five women suffer with heavy periods2 and one in 20 women, aged between 30-49 years, consult their GP about the issue each year.1 Of all referrals to gynaecology services, 12% are for menstrual disorders.1

Wear White Again

Wear White Again aims to raise awareness of heavy periods, break down the taboo and provide useful information about the condition, enabling women to have informed conversations with their GP and discuss the available treatment options.

This article is funded by Hologic for GP Connect

Despite the prevalence, the psychological impact of HMB is often underestimated. A recent survey of women with the condition found that, of those asked:

  • 74% experienced anxiety due to HMB.
  • 67% suffered with depression due to HMB.
  • 62% reported the HMB had an impact on their physical wellbeing.3

Perhaps unsurprisingly then, the updated version of the NICE guidelines, published in March 2018,1 encourages clinicians to recognise the major impact of HMB on a women’s quality of life and to ensure interventions improve this, rather than focusing on blood loss alone. 

Choice of treatment options

The latest update of the NICE guidelines recommends that women should be provided with sufficient information for them to be able to make their own choice about treatment options and to be able to access these in a timely manner.

Most women presenting with HMB can be managed in primary care, by following NICE's recommendations. It is therefore, important for primary care practitioners to take the time to understand the updated NICE guidelines, talk to patients about HMB, understand their preferred choice and signpost them to relevant information resources.4

Detailed information on the pattern of bleeding and the individual endometrial risk factors will determine which, if any, examination and investigations are required, such as hysteroscopy (NICE recommends a hysteroscopy is performed in the outpatient setting with the option of including LNG-IUS insertion or endometrial polyp morcellation, e.g. Myosure®, as a one-stop procedure in women where indicated and chosen).

However, in the majority of cases of women with HMB no cause is identified, and individualised treatment options are dependent on their ongoing fertility requirements, treatment efficacy and risks, social impact associated with post-procedure recovery and, of course, the patient’s choice.1,4

Recommended treatments

Recommended treatments today fall into three groups: hormonal, non-hormonal or surgical.


  • LNG-IUS, e.g. levongesterel, IUD
  • Combined hormonal contraception
  • Long-cycle progestogens

Non-hormonal medical management:

  • Tranexamic acid
  • Non-steroidal anti-inflammatory drugs


  • Second generation endometrial ablation e.g. NovaSure®
  • Hysterectomy1

The RCGP in conjunction with Endometriosis UK and the Royal College of Obstetricians and Gynaecologists, is developing a menstrual well-being toolkit to achieve the ambition of these latest guidelines.5 The toolkit will include healthcare professional education, patient information and commissioning resources.

Likewise, the Wear White Again website, which has been developed by Hologic, is a useful resource for healthcare professsionals and patients looking for more information and/or support on HMB.

  • Dr Connolly is a GPSI in gynaecology and accredited as a hysteroscopist, colposcopist and FSRH trainer. She has been involved with commissioning since 2006 as clinical lead for maternity, women’s and sexual health for Bradford and Airedale. Dr Connolly is one of the founder members and chair of the Primary Care Women’s Health Forum.

Useful resources


  1. NICE. Heavy menstrual bleeding: assessment and management. NG88. March 2018
  2. Centers for Disease Control and Prevention. Bleeding disorders in women: heavy menstrual bleeding. 2015 [Accessed June, 2018].
  3. Opinium Research. Online survey of 1002 women aged 18+ years who currently experience menorrhagia/heavy periods or have experienced them within the last 3 years.
  4. Patient Info. Heavy Periods. March 2018. [Accessed October 2018]
  5. RCGP. RCGP launches Menstrual Wellbeing clinical spotlight project. 2018. [Accessed October 2018]

Supported by Hologic

Date of preparation: October 2018; ADS-02300-GBR-EN Rev 001

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