• Discuss the natural variability and range of menstrual blood loss. For some women, reassurance may be all that is required, and treatment may not be needed.
• If reassurance alone is not appropriate, discuss the different treatment options for heavy menstrual bleeding, covering issues such as:
• Effectiveness of treatments.
• Acceptability of treatments, including likelihood of adverse effects.
• Whether contraception will be required.
• Implications of treatment on fertility.
• Give written information such as patient information leaflets, to explain the condition and treatment options, where appropriate.
• Patient information covering heavy menstrual bleeding is published by the National Institute for Health and Clinical Excellence (NICE) and can be found at www.nice.org.uk (pdf) [NICE, 2007a].
• If asked, advise that no specific lifestyle changes benefit menorrhagia.
• If the woman and clinician cannot agree on the most appropriate treatment option, she should be offered the option of a second opinion.

• Pharmaceutical treatment is recommended first-line for woman with menorrhagia who:
• Have no symptoms suggestive of underlying pathology including postcoital bleeding, intermenstrual bleeding, dyspareunia, dysmenorrhoea, vaginal discharge, and pelvic pain and/or pressure (these symptoms may indicate pelvic inflammatory disease, endometriosis, or endometrial carcinoma). See History.
• Are awaiting the results of investigations.

Treatments for menorrhagia should be considered in the following order:

• The levonorgestrel-releasing intrauterine system (LNG-IUS) (Mirena^®) is the preferred first-choice, provided that long-term contraception with an intrauterine device is acceptable (anticipated minimum use of 12 months).
• Tranexamic acid, nonsteroidal anti-inflammatory drugs (NSAIDs), or the combined oral contraceptive pill (COC) should be considered second, if LNG-IUS is unsuitable.
• Tranexamic acid and NSAIDs are suitable if contraception is not desired and are first-choice drugs while investigations or definitive treatment is being organized.
• If dysmenorrhoea is present, NSAIDs may be preferred, as they provide relief of menstrual pain.
• CKS recommends that if an NSAID is to be used, mefenamic acid, naproxen, or ibuprofen should be prescribed.
• The COC offers more readily reversible contraception than the LNG-IUS. It also has the benefit of regulating cycles and reducing dysmenorrhoea.
• Oral norethisterone or long-acting progestogens should be considered third choice if the other treatments are unsuitable.
• Oral norethisterone should be taken during the follicular and luteal phases (days 5 to 26). It is not an effective form of contraception. However, a dose that is effective in decreasing menstrual blood loss is also likely to inhibit ovulation, and so its use is not appropriate in women wishing to conceive.
• Depot medroxyprogesterone acetate (Depo-Provera^®) is the recommended long-acting progestogen. It is taken as an intramuscular injection once every 12 weeks.
• Danazol, gestrinone, and etamsylate are not recommended for the treatment of menorrhagia.
• Gonadotropin-releasing hormone analogues (e.g. leuprorelin or buserelin) are not recommended for use in primary care, but are an option in secondary care. For more information, see Management in secondary care.

For more information on prescribing drugs to treat menorrhagia, see Prescribing information sections on Levonorgestrel-releasing intrauterine system, Tranexamic acid, Nonsteroidal anti-inflammatory drugs, Combined oral contraceptives, Oral norethisterone, and Long-acting progestogens.

• If initial treatment fails to produce an adequate reduction in menstrual bleeding (and treatment was complied with), consider three options:
• Switch to an alternative pharmaceutical treatment. Oral norethisterone or depot medroxyprogesterone are often suitable if initial treatment was ineffective.
• Add on an additional drug. Typically, tranexamic acid can be combined with a nonsteroidal anti-inflammatory drug (NSAID), or an NSAID can be combined with the combined oral contraceptive.
• Refer to a specialist.

• Consider stopping heavy menstrual bleeding by prescribing oral norethisterone.
• Oral norethisterone, 5 mg three times daily, usually stops bleeding in 24–48 hours.
• If bleeding is exceptionally heavy ('flooding'), 10 mg three times daily may provide better results (get informed consent). This should then be tapered down to 5 mg three times daily for about a week once bleeding has stopped.

• Refer the woman to a specialist if:
• There are alarm symptoms suggesting a possible malignancy. Urgent referral is required (within 2 weeks).
• Heavy bleeding persists that negatively affects the woman's quality of life, despite adequate trials of pharmaceutical treatment. A routine referral should be made, according to local protocols.
• The woman wishes to consider surgery rather than persist with medical treatment. A routine referral should be made, according to local protocols.
• The woman has iron deficiency anaemia that has failed to respond to treatment, and other causes have been excluded. The timing of referral should reflect clinical judgement.

• An endometrial biopsy for histological examination should be taken to exclude endometrial cancer or atypical hyperplasia, if appropriate, for example in women:
• With persistent intermenstrual bleeding.
• Aged 45 years and over.
• Whose treatment has failed or is ineffective.
• Hysteroscopy allows direct visualisation of the uterine cavity and the opportunity to take an endometrial biopsy. It is used as a diagnostic tool when ultrasound results are inconclusive, to determine the exact location of a fibroid or the exact nature of an abnormality.
• Dilatation and curettage (D and C) is no longer recommended as a diagnostic tool for heavy menstrual bleeding.

[National Collaborating Centre for Women's and Children's Health, 2007]

• CKS recommends that therapy with gonadotrophin-releasing hormone (GnRH) analogues (e.g. leuprorelin and buserelin) should not be initiated in primary care.
• They produce a profound hypogonadal effect through downregulation, resulting in no ovulation and no menses.
• They may be used under specialist supervision before surgery or when all other treatment options for uterine fibroids, including surgery or uterine artery embolization, are contraindicated. They may also be used to produce temporary endometrial thinning and relief of bleeding before fibroid surgery.
• GnRH analogues are effective at treating menorrhagia. Evidence from two randomized controlled trials has shown:
• They are effective at reducing menstrual blood loss (RR 1.39, 95% CI 1.12 to 1.72).
• They cause amenorrhoea in most women (89%).
• GnRH analogues can cause significant adverse effects that often limit their use. These are principally perimenopausal in nature, including hot flushes, increased sweating, and vaginal dryness (due to oestrogen deficiency).
• GnRH analogues are given by subcutaneous or intramuscular injection, or intranasally, and they are usually used for less than 6 months. If treatment with these drugs is required for more than 6 months or if adverse affects are experienced, 'add-back' treatment with supplemental oestrogens and progestogens is recommended.

[National Collaborating Centre for Women's and Children's Health, 2007]

• Surgical treatments are almost always used as second-line options in the treatment of menorrhagia, despite the long-term effectiveness (and irreversible nature) of surgery. A systematic review found that surgery improved control of bleeding compared with pharmaceutical treatments after 5 years (OR 1.99, 95% CI 0.84 to 4.73). However, this does not take into account the reversibility of pharmaceutical treatments and other risks with surgery.
• Surgery should be reserved for:
• Use on the woman's request (following full counselling on the advantages and disadvantages).
• Difficult-to-treat cases where pharmaceutical treatment has failed to be sufficiently effective or is contraindicated.

[National Collaborating Centre for Women's and Children's Health, 2007]