1. HELP – HMB: Evidence-based Learning for Best Practice
Module 3: Best practice in the diagnosis of HMB
Updated May 2017
This slide module has been developed with the assistance of the HELP Global Expert Group for heavy menstrual bleeding (HMB), comprising an international group of experts in the diagnosis and management of HMB.
The HELP group is a panel of independent physicians with an expert interest in HMB. Formation of the HELP group and its ongoing work is supported by Bayer AG

2. What is the most frequent cause of HMB amongst your patients?
No pathological cause
Ovulatory dysfunction
Fibroids
Other
Notes:
HMB is a specific type of abnormal bleeding which may result from structural and non-structural abnormalities defined within the PALM-COEIN classification.1 However, the majority of women with HMB do not have any structural or histologically identifiable abnormalities and there is no identifiable cause of HMB.2
References:
Munro MG, et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynecol Obstet 2011;113:3-13
National Collaborating Centre for Women's and Children's Health. Heavy Menstrual Bleeding Clinical Guideline 44. London: RCOG Press for NICE; 2007

3. Testing for coagulation disorders Thyroid function None of the above
Thinking about your practice, which laboratory tests do you undertake for women that present with heavy or prolonged bleeding?
Full blood count
Testing for coagulation disorders
Thyroid function
None of the above
Notes:
Laboratory tests and investigations can help exclude a pathological cause of HMB. However, these tests are ONLY needed if indicated by structured medical history or physical examination, and should not present a barrier for the diagnosis and treatment of HMB.1
COMPLETE BLOOD COUNT: Required for all women
THYROID FUNCTION: If endocrine cause suspected
INHERITED COAGULATION DISORDERS: If indicated by structured history
ULTRASOUND SCAN: To rule out structural cause of HMB
ENDOMETRIAL BIOPSY: If endometrial pathology suspected
References:
1. Munro MG, et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynecol Obstet 2011;113:3-13

4. When would you consider initiating treatment for a patient presenting with symptoms of HMB?
At initial presentation having confirmed the presence of HMB
As interim treatment while waiting further investigation or test results to identify a possible cause of HMB
Following completion of all investigations into the cause of HMB
I discuss initiating treatment in all these scenarios
After confirmation of HMB, but where further investigations are required, it may be appropriate to consider interim treatment to manage symptoms, as we will discuss later.1
Royal College of Obstetrics and Gynaecology. Advice for Heavy Menstrual Bleeding (HMB) Services and Commissioners. 2017, RCOG Press

5. Module content The challenge of diagnosis
Using a step-by step diagnostic checklist to identify heavy menstrual bleeding
Using a structured medical history and a physical examination to identify potential risk factors
Tests and investigations to help rule out a pathological cause of HMB
Offering immediate interim treatment of HMB and anemia (if present) while awaiting results
Module objective:
To simplify the diagnosis of HMB.
Notes:
A number of key questions and actions are proposed that will lead HCPs along a clear pathway to establishing whether a patient’s HMB is of pathological origin and further investigation is required, or whether treatment can be initiated immediately.
Please note that slides 7 to 13 are meant to always be used together as they represent a continuous diagnostic pathway based on FIGO recommendations and published guidelines for the diagnosis of HMB.
Speaker notes and full references accompany the slides contained in this Module.

6. Diagnosis of HMB can be a challenge for healthcare providers
There is no ‘typical’ patient with HMB1
Confirmation of HMB relies on information from the patient regarding frequency, duration and extent of bleeding and its physical impact BUT
Women have a low awareness and knowledge of HMB2
They adopt lifestyle changes to help manage HMB2
Are reluctant to seek medical advice2,3
Notes:
As discussed in Modules 1 and 2, women can present with HMB at different life stages – from adolescence to menopausal transition.1,4
Healthcare providers rely on information from women about the impact of menstrual bleeding on their everyday life as well as the frequency, duration and volume.
However, women appear to have a low awareness of HMB and are reluctant to seek medical advice.2,3
References:
National Collaborating Centre for Women's and Children's Health. Heavy Menstrual Bleeding Clinical Guideline 44. London: RCOG Press for NICE; 2007
Bitzer J, et al. Women’s attitudes towards heavy menstrual bleeding, and their impact on quality of life. Open Access J Contraception 2013:4 21–28
Fraser I, et al. Prevalence of heavy menstrual bleeding and experiences of affected women in a European patient survey. Int J Gynecol Obstetrics 2015:128:196–200
Kowalczyk Mullins TL, et al. Evaluation and Management of Adolescents with Abnormal Uterine Bleeding. Pediatric Annals 2015;44(9):e218-e222
National Collaborating Centre for Women's and Children's Health. London: RCOG Press for NICE; 2007; 2. Bitzer J, et al. Open Access J Contraception 2013:4 21–28; 3. Fraser I, et al.. Int J Gynecol Obstetrics 2015:128:196–200.

7. A diagnostic checklist for HMB

8. The HELP diagnostic checklist Practical guidance based on the FIGO recommendations1
A step-by step guide to help:
Confirm presence and impact of HMB
Identify relevant medical history, physical symptoms and risk factors that may indicate a pathological cause
Guide the use of investigations and tests to exclude a pathological cause
Notes:
The HELP Global Expert Group developed a diagnostic checklist which helps to confirm the presence and impact of HMB; identifies relevant medical history, physical symptoms and risk factors indicating a pathological cause and guide the use of investigations and tests to exclude a pathological cause of HMB
It is based on FIGO recommendations1 for questions to ask about the type and volume of menstrual bleeding and published guidelines regarding the taking of medical history and additional test and investigations needed.
The aim of the checklist is to identify those women with HMB that has no pathological cause in order that treatment may be initiated immediately.
Once a thorough history, a physical examination and imaging studies (if indicated) are performed, and all potential significant structural causes are excluded, medical management is the first-line approach.2
Even in women where a pathological cause cannot be excluded, medical management can be initiated for symptom relief while they await further investigation.
References:
Munro MG, et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynecol Obstet 2011;113:3–13
Bradley LD, Guye NA. The medical management of abnormal uterine bleeding in reproductive-aged women. Am J Obstet Gynecol 2016;214(1):31-44
Munro MG, et al. Int J Gynecol Obstet 2011;113:3–13

9. Using three key questions to help identify HMB1-3
Answering yes to one or more of these questions and experiencing symptoms for 3+ months indicates that HMB is a problem is impacting negatively on quality of life
Further action is needed to identify cause and appropriate treatment
Notes:
These three key questions are based on a broader range of questions to determine the frequency, duration and extent of bleeding and its physical impact, as well as identify what changes a woman makes to her daily activities to accommodate HMB.1-3
References:
Philipp CS, et al. Development of a screening tool for identifying women with menorrhagia for hemostatic evaluation. Am J Obstet Gynecol 2008;198:163.e1-163.e8
Bushnell DM, et al., Menorrhagia Impact Questionnaire: assessing the influence of heavy menstrual bleeding on quality of life. Curr Med Res Opin 2010; 26(12):
Matteson KA, Clark MA. Questioning our questions: do frequently asked questions adequately cover the aspects of women’s lives most affected by abnormal uterine bleeding? Opinions of women with abnormal uterine bleeding participating in focus group discussions. Women Health 2010; 50(2):
Munro MG, et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynecol Obstet 2011;113:3–13
HMB, heavy menstrual bleeding
Philipp CS, et al. Am J Obstet Gynecol 2008;198:163.e1-163.e8; 2. Bushnell, DM, et a. Curr Med Res Opin 2010; 26(12): ; 3. Matteson KA, Clark MA. Women Health 2010; 50(2):

10. Taking a structured medical history and physical examination can identify potential risk factors1,2
Taking steps to identify:
Factors contributing to presence of HMB1,2
Other physical symptoms relevant to reproductive pathology1
Notes:
A structured medical history is helpful in identifying potential factors that could contribute to the presence of HMB, for example, presence of an inherited blood disorder or concomitant illness or medication.1,2
Other physical symptoms may be present and indicative of reproductive pathology, for example, post-coital bleeding or pelvic pressure.1
References:
National Collaborating Centre for Women's and Children's Health. Heavy Menstrual Bleeding Clinical Guideline 44. London: RCOG Press for NICE; 2007
Bradley LD, Gueye N-A. The medical management of uterine bleeding in reproductive aged women. Am J Obs Gynecol 2016;214(1):31-44
National Collaborating Centre for Women's and Children's Health. London: RCOG Press for NICE; 2007; 2. Bradley LD, Gueye N-A. Am J Obs Gynecol 2016;214(1):31-44

11. And prompt further investigation
A structured medical history can identify factors contributing to the presence of HMB1-5
Age
(>40 years)
Lifestyle
(smoking, high BMI)
Unopposed estrogen
Anovulation
And prompt further investigation
Symptoms of HMB
Hypertension
Medications
Notes:
Other risk indicators for pathology may emerge during the taking of a patient history which may prompt further investigation.1-5
References:
National Collaborating Centre for Women's and Children's Health. Heavy Menstrual Bleeding Clinical Guideline 44. London: RCOG Press for NICE; 2007
Singh S, et al. SOGC Clinical Practice Guideline. Abnormal Uterine Bleeding in Pre-Menopausal Women. J Obstet Gynaecol Can 2013;35(5 eSuppl):S1-S28
Marret H, et al, on behalf of CNGOF. Clinical practice guidelines on menorrhagia: management of abnormal uterine bleeding before menopause. Eur J Obstet Gynecol Reprod Biol 2010;152:
ACOG Practice bulletin. Number 136, July 2013: Management of abnormal uterine bleeding associated with ovulatory dysfunction. Obstet Gynecol 2013;122(1):176-85
Bradley LD, Guye NA. The medical management of abnormal uterine bleeding in reproductive-aged women. Am J Obstet Gynecol 2016;214(1):31-44
Diabetes
Hereditary factors
(inherited blood disorders)
1. National Collaborating Centre for Women's and Children's Health. London: RCOG Press for NICE; 2007; 2. SOGC Clinical Practice Guideline. J Obstet Gynaecol Can 2013;35(5 eSuppl):S1-S28; 3. Marret H, et al, on behalf of CNGOF. Eur J Obstet Gynecol Reprod Biol 101(152): ; 4. ACOG Committee on Practice Bulletins – Gynecology, Bulletin 136. Obstet Gynecol 2013;122:176–85; 5. Bradley LD, Guye NA. Am J Obstet Gynecol 2016;214(1):31-44

12. Physical examination can confirm the source of bleeding and identify anatomic causes1
What does the physical examination involve1,2
Physical examination
General health e.g. pallor, fatigue breathlessness
Abdominal palpation
Visualisation of the cervix
Bimanual (internal) examination
Results can inform treatment and identify the need for further investigations.1
Notes:
The aim of the general examination is to confirm the source of bleeding and look for anatomic causes such as fibroids or cervical polyps to inform treatment and identify the need for further investigations.1
It should include physical examination, general health (signs of fatigue/pallor/breathlessness), abdominal palpation, visualisation of the cervix and bimanual (internal) examination.1,2
Signs of systemic illness, such as fever, ecchymoses, an enlarged thyroid gland.
Evidence of hyperandrogenism such as hirsutism, acne, clitoromegaly, or male pattern balding.
Acanthosis nigricans may be seen in women with polycystic ovarian syndrome (PCOS).
Galactorrhea (bilateral milky nipple discharge) suggests the presence of hyperprolactinemia.
Physical examination is not needed if the history suggests the presence of HMB without structural or histological abnormality.3
References:
National Collaborating Centre for Women's and Children's Health. Heavy Menstrual Bleeding Clinical Guideline 44. London: RCOG Press for NICE; 2007
UpToDate Approach to abnormal uterine bleeding in non-pregnant, reproductive age women. Accessed at
NICE. Heavy menstrual bleeding: assessment and management. NICE clinical guidelines [CG44] Last updated: August Accessed at nice.org.uk/guidance/cg44
Physical examination is not needed if the history suggests the presence of HMB without structural or histological abnormality.3
1. . National Collaborating Centre for Women's and Children's Health. London: RCOG Press for NICE; 2007; 2. UpToDate Accessed at 3. NICE Heavy Menstrual Bleeding Clinical Guideline 44, 2007

13. Presence of any of these symptoms requires further investigation
Other physical symptoms may indicate endometrial cancer or other pathology in women of reproductive age1-5
Evaluating the problem
Evaluating the problem
If suspected organic pathology or risk factors present
Presence of any of these symptoms requires further investigation
Intermenstrual bleeding
Imaging for structural causes
Post-coital bleeding
Pelvic pressure
Endometrial biopsy for histology
Pain
Notes:
A number of risk factors for endometrial cancer have been identified.1-5
These include intermenstrual bleeding, post-coital bleeding, pelvic pressure and pain.1-5
Presence of one or more of these symptoms should prompt further investigation via imaging and /or endometrial biopsy.1-5
Presence of bleeding in a post-menopausal woman should prompt immediate further investigation.1-5
References:
National Collaborating Centre for Women's and Children's Health. Heavy Menstrual Bleeding Clinical Guideline 44. London: RCOG Press for NICE; 2007
Singh S, et al. SOGC Clinical Practice Guideline. Abnormal Uterine Bleeding in Pre-Menopausal Women. J Obstet Gynaecol Can 2013;35(5 eSuppl):S1-S28
Marret H, et al, on behalf of CNGOF. Clinical practice guidelines on menorrhagia: management of abnormal uterine bleeding before menopause. Eur J Obstet Gynecol Reprod Biol 2010;152:
ACOG Practice bulletin. Number 136, July 2013: Management of abnormal uterine bleeding associated with ovulatory dysfunction. Obstet Gynecol 2013;122(1):176-85
1. NICE Heavy Menstrual Bleeding Clinical Guideline 44; 2007; 2. SOGC Clinical Practice Guideline. J Obstet Gynaecol Can 2013;35(5 eSuppl):S1-S28; 3. Marret H, et al, on behalf of CNGOF. Eur J Obstet Gynecol Reprod Biol 101(152): ; 4. ACOG Committee on Practice Bulletins – Gynecology, Bulletin 136. Obstet Gynecol 2013;122:176–85; 5. Spanish Society of Gynecology and Obstetrics 2013, proSEGO.com.

14. HMB may may result from structural and non-structural abnormalities1
FIGO has proposed a standard classification for abnormal uterine bleeding (AUB) to aid diagnosis1
Notes:
The International Federation of Gynecology and Obstetrics (FIGO) Working Group on Menstrual Disorders developed the PALM-COEIN classification system for abnormal uterine bleeding (AUB), defined as menstrual bleeding that is abnormal in duration, volume and frequency.1
This system separates the causes of AUB in reproductive-aged women into structural and non-structural categories.1
The PALM side of the classification refers to structural causes that could be evaluated and diagnosed on imaging or biopsy;1,3
The COEIN slide of the classification allows consideration of underlying medical disturbances that can result in AUB.1,3
HMB is a specific type of abnormal bleeding which may result from structural and non-structural abnormalities defined within the PALM-COEIN classification.1 However, the majority of women with HMB do not have any structural or histologically identifiable abnormalities.2
Management of HMB is justified when this bleeding has an impact on physical health or lifestyle.4
References:
Munro MG, et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynecol Obstet 2011;113:3-13
National Collaborating Centre for Women's and Children's Health. Heavy Menstrual Bleeding Clinical Guideline 44. London: RCOG Press for NICE; 2007
Singh S, et al. SOGC Clinical Practice Guideline. Abnormal Uterine Bleeding in Pre-Menopausal Women. J Obstet Gynaecol Can 2013;35(5 eSuppl):S1-S28
NICE. Heavy menstrual bleeding: assessment and management. NICE clinical guidelines [CG44] Last updated: August Accessed at nice.org.uk/guidance/cg44
For the majority of women, there is no identifiable cause of HMB2
1. Munro MG, et al. Int J Gynecol Obstet 2011;113:3-13; 2. National Collaborating Centre for Women's and Children's Health. London: RCOG Press for NICE; 2007

15. Further tests and investigations may help to exclude pathological cause of HMB1
These tests are ONLY needed if indicated by structured medical history or physical examination
Notes:
The role of investigations is to detect pathology that may be causing symptoms and to detect pathology that may progress to cause significant illness.1
Laboratory tests and investigations can help exclude a pathological cause of HMB. However, it should be noted that there is no identifiable cause of HMB for the majority of women.1
References:
National Collaborating Centre for Women's and Children's Health. Heavy Menstrual Bleeding Clinical Guideline 44. London: RCOG Press for NICE; 2007
Remember, for the majority of women, there is no identifiable cause of HMB1
1. National Collaborating Centre for Women's and Children's Health. London: RCOG Press for NICE; 2007.

16. Additional laboratory tests may be indicated1-3
If…
There are clinical findings suggestive of thyroid or pituitary dysfunction, or hyperandrogenism
There is a history of menstrual bleeding since menarche or a personal or family history of abnormal bleeding
However, for all women with HMB…
a complete blood count is recommended1
the possibility of pregnancy should be ruled out
Notes:
A full blood count is recommended for all women with heavy or prolonged bleeding.1
Additional blood tests are only required in the following situations:1-3
If there is the possibility of pregnancy, a sensitive urine or serum pregnancy test should be performed;
Testing for coagulation disorders is only relevant in women with a history of menstrual bleeding since menarche or a personal or family history of abnormal bleeding.
Thyroid function tests are only indicated if there are clinical findings suggestive of thyroid disease.
References:
Singh S, et al. SOGC Clinical Practice Guideline. Abnormal Uterine Bleeding in Pre-Menopausal Women. J Obstet Gynaecol Can 2013;35(5 eSuppl):S1-S28
Marret H, et al, on behalf of CNGOF. Clinical practice guidelines on menorrhagia: management of abnormal uterine bleeding before menopause. Eur J Obstet Gynecol Reprod Biol 2010;152:
National Collaborating Centre for Women's and Children's Health. Heavy Menstrual Bleeding Clinical Guideline 44. London: RCOG Press for NICE; 2007
1. SOGC Clinical Practice Guideline. J Obstet Gynaecol Can 2013;35(5 eSuppl):S1-S28; 2. Marret H, et al, on behalf of CNGOF. Eur J Obstet Gynecol Reprod Biol ): ; 3. National Collaborating Centre for Women's and Children's Health. London: RCOG Press for NICE; 2007.

17. Up to 20% of women with HMB have an inherited bleeding disorder1
Bleeding symptoms indicative of an inherited bleeding disorder1
Epistaxis (usually bilateral and lasting > 10 minutes duration)
Notable bruising without injury (> 2cm in diameter)
Minor wound bleeding (i.e. from trivial cuts lasting longer than 5 minutes)
Bleeding of the oral cavity or gastrointestinal tract without a lesion
Excessive or prolonged bleeding following dental extraction
Unexpected post-surgical bleeding
Hemorrhage from ovarian cyst or corpus luteum
Post-partum hemorrhage (especially delayed onset > 24 hours)
Notes:
Up to 20% of women with HMB have an inherited bleeding disorder.1
HMB since menarche and a family history are predictive factors but other bleeding symptoms can also help in recognition.1
References:
Davies J, Kadir RA. Heavy Menstrual Bleeding: An update on management. Thrombosis Res 2017;151(Suppl 1)
Bradley LD, Guye NA. The medical management of abnormal uterine bleeding in reproductive-aged women. Am J Obstet Gynecol 2016;214(1):31-44
It is important to have a high index of suspicion in adolescents, as coagulation disorders are a common cause of HMB in this age group2

18. Imaging and endometrial assessment and biopsy is only indicated in specific circumstances1,2
Examination suggests a structural cause of the bleeding
Pharmaceutical treatment has failed
Examination and/or symptoms suggest the risk of malignancy
It is important to have a high index of suspicion in adolescents, as coagulation disorders are a common cause of HMB in this age group2
Notes:
Imaging studies may be indicated when physical examination suggests structural causes of bleeding, conservative management has failed and a risk of malignancy has been identified.1
These include:2
• the uterus is palpable abdominally;
• vaginal examination reveals a pelvic mass of uncertain origin.
They offer valuable additional information in the assessment and treatment of HMB where indicated.1
If imaging is indicated, transvaginal ultrasound is recommended as the first-line imaging modality but hysteroscopy and magnetic resonance imaging (MRI) are also options.1
References:
Singh S, et al. SOGC Clinical Practice Guideline. Abnormal Uterine Bleeding in Pre-Menopausal Women. J Obstet Gynaecol Can 2013;35(5 eSuppl):S1-S28
National Collaborating Centre for Women's and Children's Health. Heavy Menstrual Bleeding Clinical Guideline 44. London: RCOG Press for NICE; 2007
Imaging can be carried out using ultrasound, hysteroscopy and/or Magnetic Resonance Imaging (MRI)
1. SOGC Clinical Practice Guideline. J Obstet Gynaecol Can 2013;35(5 eSuppl):S1-S28; 2. National Collaborating Centre for Women's and Children's Health. London: RCOG Press for NICE; 2007.

19. Treatment can be offered even if further investigations are required1
Notes:
If further investigations are required, it may be appropriate to consider interim treatment to manage symptoms.1
Treatment options can be discussed using the HELP treatment algorithm (see Module 4).
Results from the Complete Blood Count and/or symptoms of anemia, such as fatigue or weakness, indicate the need to provide iron-replacement therapy (see next slide).2,3
Royal College of Obstetrics and Gynaecology. Advice for Heavy Menstrual Bleeding (HMB) Services and Commissioners. 2017, RCOG Press
Fraser I, et al. Prevalence of heavy menstrual bleeding and experiences of affected women in a European patient survey. Int J Gynecol Obstetrics 2015:128:196–200
Singh S, et al. SOGC Clinical Practice Guideline. Abnormal Uterine Bleeding in Pre-Menopausal Women. J Obstet Gynaecol Can 2013;35(5 eSuppl):S1-S28

20. Treating symptoms of anemia
Fatigue and weakness are common symptoms of HMB that can help confirm diagnosis of iron deficiency1
Age or gender group
Hemoglobin (g/dL)
Children (0.5-4)
< 11.0
Children (5-12)
< 11.5
Children (12-15)
< 12.0
Adult men
< 13.0
Non-pregnant women
Pregnant women
Adapted from the WHO global database on anemia2
Iron-deficiency affects >20% of women during their reproductive lives3
Notes:
A internet-based survey was conducted among women (aged years) in five European countries between January and February 2012 found fatigue and weakness to be common symptoms that helped to confirm a diagnosis of anemia in women affected by HMB.
The WHO defines IDA as haemoglobin (Hb) concentration below 12 g/dl in non-pregnant women over 15 years of age, and below 11 g/dl in pregnant women.2
Iron-deficiency affects >20% of women during their reproductive lives3
In women with HMB with Hb levels below the defined WHO levels, iron supplementation (for example, ferrous sulphate 200 mg twice daily) corrects anemia and replenishes body stores.4
Oral iron should be continued for 3 months after correction of iron deficiency in order to replenish iron stores.4
References:
Fraser I, et al. Prevalence of heavy menstrual bleeding and experiences of affected women in a European patient survey. Int J Gynecol Obstetrics 2015:128:196–200
World Health Organization. Worldwide prevalence of anaemia 1993–2005: WHO global database on anaemia, Accessed at:
Percy L, et al. Iron deficiency and iron deficiency anaemia in women. Best Pract Res Clin Obstet Gynaecol 2017;40: doi: /j.bpobgyn Epub 2016 Oct 1
Goddard A, et al. Guidelines for the management of iron deficiency anaemia. Gut 2011;60:
Iron supplementation corrects anemia and replenishes body stores4
Fraser I, et al.. Int J Gynecol Obstetrics 2015:128:196–200; 2. World Health Organization. Worldwide prevalence of anaemia 1993–2005: WHO global database on anaemia, 2008; 3. Percy L, et al. Best Pract Res Clin Obstet Gynaecol 2017;40:55-67; 4.Goddard A, et al. Gut 2011;60:

21. Conclusions
Diagnosis of HMB can be a challenge for healthcare providers
The proposed diagnostic checklist comprises key questions that help to identify menstrual bleeding and obtain information from a structured medical history and physical examination to guide further investigation where needed
For women where no further investigation is needed, discussion should move immediately to treatment
A number of different options are available and selection of the most appropriate is guided by a HELP Treatment Algorithm (see Module 4)
Supporting references for these concluding statements can be found in the notes sections of the slides contained within this Module.

22. Implications for practice
A step-by step diagnostic checklist can be used to confirm the presence of HMB
A structured medical history and physical examination identifies potential risk factors and the need for further investigations1,2
Where indicated, further tests and investigations help rule out a pathological cause of HMB1
Immediate interim treatment of HMB and anaemia (if present) should be provided for patients while awaiting results3
References:
National Collaborating Centre for Women's and Children's Health. Heavy Menstrual Bleeding Clinical Guideline 44. London: RCOG Press for NICE; 2007
Bradley LD, Gueye N-A. The medical management of uterine bleeding in reproductive aged women. Am J Obs Gynecol 2016;214(1):31-44
Royal College of Obstetrics and Gynaecology. Advice for Heavy Menstrual Bleeding (HMB) Services and Commissioners. 2017, RCOG Press
Remember: The majority of women with HMB do not have any structural or histologically identifiable abnormalities and there is no identifiable cause of HMB.1