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A 35-year-old woman (para 2) presents with heavy menstrual bleeding for 8 months. PBAC score is 145 (normal under 100).[3] She feels tired; Hb is 102 g/L. Pelvic ultrasound shows a normal uterus with no fibroids or polyps.
Questions
a) What is the diagnosis and FIGO classification? (2 marks)
Heavy menstrual bleeding (HMB), likely due to primary endometrial disorder (COEIN category: Endometrial — primary haemostatic dysfunction). No structural cause identified on ultrasound (PALM excluded). PBAC over 100 confirms HMB. Anaemia (Hb 102) secondary to chronic blood loss.[2][3]
b) What is the first-line treatment? (2 marks)
Levonorgestrel IUS 52mg (Mirena) — first-line per NICE NG88 (no identified pathology, fibroids under 3 cm not distorting the cavity, or adenomyosis). Reported blood-loss reductions of up to 90% (Cochrane); significant reduction within 3–6 months (Mirena SPC). Also provides contraception (8 years licensed for contraception; 5 years for HMB). If declined/unsuitable (NG88): non-hormonal — tranexamic acid 1g TDS during menses for up to 4 days (max 4g/day) or NSAIDs (mefenamic acid 500mg TDS); hormonal — combined hormonal contraception or cyclical oral progestogens. Also: iron supplementation (oral; IV if intolerant or unresponsive) for anaemia.[1][2]
c) If medical treatment fails, what are the surgical options? (3 marks)
- Second-generation endometrial ablation (e.g. bipolar radiofrequency, thermal balloon, microwave — NICE NG88/TA78) — for completed family; satisfaction at 1 year similar to hysterectomy, but ~13% risk of further surgery for treatment failure (Cochrane 2021); contraception still needed
- Hysterectomy (vaginal preferred > laparoscopic > abdominal) — definitive cure; 0% re-operation after hysterectomy.[1]
d) What investigations should be done before starting treatment? (3 marks)
- FBC — for all women with HMB (NICE NG88); ferritin to confirm iron deficiency
- Coagulation screen (e.g. von Willebrand screen) — NG88: consider when HMB since menarche plus personal/family history of bleeding disorder
- Do NOT routinely test female hormones or thyroid function in HMB unless other signs/symptoms of thyroid disease (NG88)
- Endometrial biopsy at hysteroscopy — for high-risk groups only (persistent intermenstrual/irregular bleeding; infrequent heavy bleeding with obesity or PCOS; tamoxifen; failed treatment — NG88)
- TVS/hysteroscopy — already normal here; biopsy not indicated at 35 without risk factors.[1]
References3ShowHide
- [1]National Institute for Health and Care Excellence Heavy menstrual bleeding: assessment and management (NICE guideline NG88) NICE, 2026.Source
- [2]Bofill Rodriguez M, Lethaby A, Jordan V. Progestogen-releasing intrauterine systems for heavy menstrual bleeding Cochrane Database Syst Rev, 2020.PMID 32529637
- [3]Higham JM, O'Brien PM, Shaw RW. Assessment of menstrual blood loss using a pictorial chart Br J Obstet Gynaecol, 1990.PMID 2400752