2.  Common referral to the menorrhagia clinic  Need to know- what it is - how to diagnose it - recognise red flags - treatments in gp -when to refer  -

3.  Excessive heavy menstrual bleeding over several consecutive cycles, which interferes with the woman's physical, emotional, social and material QOL. (national collaborating centre for women's and children's health 2007)

4.  1/3 women describe their periods as heavy.  40-60% no underlying abnormality.  Causes- Uterine and Ovarian - Systemic - Iatrogenic Complications- IDA

5.  Menstrual history  Gynae hx- red flags - pain - discharge - contraception/family plans - smear status Systemic disease Family history

6.  NICE- suggestion underlying problem - initial treatment ineffective - considering IUS

7.  FBC  TFTs/Clotting if clinically indicated  Opportunistic cx screen if appropriate  TV USS -suggestion of underlying cause -palpable uterus -treatment ineffective - Pelvic mass- urgent ref

8.  Advice and counselling on mens loss and options/ impact future family planning/ written info  Mirena IUS considered 1 st line- provided LT contraception desirable- min 12 months  Tranexamic acid/ NSAIDS/ COC  Oral Norethisterone or long acting progestogens Norethisterone-5-26- not effective contraception Depot provera Switch Add Refer

9.  RED flag symptoms- urgent -persistent IMB/PCB - unexplained vulval or vaginal lump - clinical features of cervical ca.  Heavy bleeding persists  Woman requests surgery  IDA persists despite treatment

10.  Investigations Endometrial biopsy- IMB/ >45/ treatments failed Hysteroscopy- USS inconclusive D+C no longer recommended as diagnostic tool.

11.  GNRH analogues Before surgery Treatment for fibroids - Significant SE

12.  Endometrial ablation 1 st generation- loop diathermy 2 nd generation- thermal balloon, radiowaves Good evidence NICE-impact QOL - drug methods failed/ not suitable - completed family - n uterus/ fibroids < 3cm  Hysterectomy  Uterine Artery embolisation/ myomectomy