Unscheduled bleeding common in first 3-6 months - no action.

>6 months, consider trial off HRT or USS and endometrial biopsy (if endometrium thickened). If investigations normal, consider E2 HRT and IUS.

Asymptomatic polyp with normal appearance and normal cytology - no action.

Symptomatic polyp - remove if <2cm, send for histology.

Refer to secondary care if >2cm or abnormal appearance.

Gynaecology; Menstrual Disorders.

2WW if suspected Cervical Cancer.

FBC, USS: Symptomatic fibroids <3cm/not distorting cavity - IUS/medical management.

Symptomatic fibroids >3cm, consider Esmya, Uterine Artery Embolisation, Myomectomy, GnRH Analogue.

NICE Heavy Menstrual Bleeding

 UHDB Heavy Menstrual Bleeding Diagnosis

 JUCD Heavy Menstrual Bleeding Pathway

FBC (Not TFT/Hormone Tests): USS if history/exam abnormal or failed medical treatment.

Endometrial Biopsy if >45 years or risk factors for endometrial hyperplasia/cancer.

IUS first line hysterectomy only offered in exceptional cases if all other treatments failed.

Consider pregnancy test, chlamydia test.

Review hormonal contraception.

USS if history/exam abnormal or persistent symptoms.

Endometrial biopsy if >45 years.

Examine cervix.

Chlamydia swab; treat and review after 4-6 weeks.

Smear only if due.

<25 years, on hormonal contraception; consider change in method and review if exam/investigations are normal.

Cervical Polyp; consider removal and review.

2WW if suspected Cervical Cancer.

 Colpscopy if >25 years.

 Gynaecology if <25 years, IMB and PCB (any age), polyp/ectropion.

Examine to exclude cervical cause.

 Consider urgent USS if <55 years and no risk factors for endometrial cancer. Risk factors include obesity, DM, PCOS, tamoxifen, unopposed oestrogens.