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Algorithm for the Management of Heavy

Menstrual Bleeding
Women reporting with heavy menstrual bleeding

Full menstrual history . Examination . Full blood


count
Yes

Prolonged
Irregular
cycles
No

Refer
specialist

Yes

Abnormal
exam
uterine size
> 12 wks

No
severe
< 80 g/l

Anaem
ic
No

Mild or
moderat
Treat
e
anaemia
(80115g/l)

Assess risk of
endometrial
hyperplasia
Bodyweight 90
kg
Age 45 years
Other risk factors
High risk*

Unexplained
heavy
menstrual
bleeding

Assess endometrium
Transvaginal
ultrasound (TVS) or
Endometrial biopsy
if endometrium
12 mm or if TVS not
available
Hyperplastic
endometrium or
carcinoma

Biopsy
* Referral to specialist could be

Offer medical
therapy

Normal
endometri
um

Levonorgestrel
intrauterine system
Tranexamic acid
Nonsteroidal anti
inflammatory
agents
Norethisterone
(long course)
Oc pill
Danazol

If one medical therapy fails


others can be used

No
Evaluation
and
considerati
on for
surgery

Treatm
ent
success

Ye
s
Continue
medical
therapy

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