Rationale and impact

Investigations for the cause of HMB

Recommendations 1.3.1 to 1.3.14

Why the committee made the recommendations

Before starting investigations

The committee agreed that investigation is not necessary before starting treatment when history and examination do not suggest structural abnormalities or endometrial pathology.


The choice of first-line investigation should depend on the woman's history and examination findings. The committee made recommendations for using hysteroscopy or ultrasound that were based on the available evidence for diagnostic accuracy.

Women with suspected submucosal fibroids, polyps or endometrial pathology

Outpatient hysteroscopy is recommended for women with HMB if uterine cavity abnormalities or endometrial pathology are suspected because:

  • the evidence showed that it is more accurate (higher sensitivity and specificity) in identifying them than pelvic ultrasound

  • it is safe and has a low risk of complications

  • it is acceptable to women if done according to best practice guidelines

  • women can have submucosal fibroids and polyps removed during the procedure, and targeted biopsy if needed

  • it is cost-effective as part of a diagnosis and treatment strategy.

For women who decline outpatient hysteroscopy, the committee agreed that hysteroscopy under general or regional anaesthetic should be offered, because the benefits of accurate identification outweigh the risks of anaesthesia.

Pelvic ultrasound can be considered for women who decline hysteroscopy, provided that they understand and accept that it is less accurate in detecting uterine cavity abnormalities and endometrial pathology.

Endometrial biopsy should only be taken in the context of hysteroscopy and only from women who a have a high risk of endometrial pathology, to avoid unnecessary and painful biopsies. 'Blind' endometrial biopsy is not recommended because it may not identify treatable lesions.

Women with possible larger fibroids

Hysteroscopy is not able to detect abnormalities outside the uterine cavity, such as subserous or intramural fibroids, or adenomyosis. If an examination suggests a large fibroid or several fibroids, pelvic ultrasound (transvaginal or transabdominal) is recommended instead of hysteroscopy and is likely to be particularly cost-effective in this context.

The committee agreed that if abdominal or vaginal examination is difficult to perform or inconclusive (for example, because the woman is obese), pelvic ultrasound would be helpful to identify any abnormalities that might have otherwise been suggested by examination.

Women with suspected adenomyosis

The evidence showed that transvaginal ultrasound is more accurate than transabdominal ultrasound or MRI for detecting adenomyosis. Although transvaginal ultrasound is more intrusive than the other investigations, the committee's experience suggests that many women find it acceptable. It is also widely available in secondary care, and sometimes in primary care.

Transvaginal ultrasound may not be acceptable to or suitable for some women, such as women who have not been sexually active or women with female genital mutilation. The committee agreed that transabdominal ultrasound or MRI can be considered for these women, provided that they understand and accept that they are less accurate for detecting adenomyosis.

How the 2018 recommendations might affect practice


Hysteroscopy, in preference to pelvic ultrasound, is recommended for women with HMB who are suspected of having submucosal fibroids, polyps or endometrial pathology based on their history and examination. This change in practice will have a resource impact on service organisation and training.

Ultrasound is available through direct booking in primary care, whereas hysteroscopy is not. Changes to services will be needed to allow direct access booking into one-stop hysteroscopy services and ideally to increase delivery in community-based clinics. Specialists could offer more services in the community, or GPs and nurses could be trained to perform hysteroscopy in primary care. However, there should be ongoing savings because the number of unnecessary investigations is reduced and women are offered effective treatment as a result of more accurate diagnosis.

To ensure that outpatient hysteroscopy is acceptable to women, it is essential that the procedure is done according to best practice guidelines, including techniques and equipment to minimise discomfort and pain in women; adequately sized, equipped, and staffed facilities; staff with necessary training, skills and expertise; and the need for audit and benchmarking of outcomes.


Transvaginal and transabdominal ultrasound are already widely available in secondary care and sometimes in primary care.

The committee noted that clinicians might need additional training and experience in interpreting transvaginal ultrasound scans to identify signs of adenomyosis.

For full details of the evidence and the committee's discussion see evidence review A: diagnostic test accuracy in investigation for women presenting with heavy menstrual bleeding.

Management of HMB

Recommendations 1.5.1 to 1.5.15

Why the committee made the recommendations

The committee emphasised the importance of talking to the woman about her needs and preferences when deciding on treatments for HMB. This includes any plans for pregnancy and whether she wants to retain her uterus or fertility. The committee also highlighted that the cause of HMB and other symptoms should be taken into account. This is to ensure that the most appropriate management strategy is offered to the woman.

Treatments for women with no identified pathology, fibroids less than 3 cm in diameter, or suspected or diagnosed adenomyosis

In current practice LNG-IUS is a first-line treatment for HMB in these women. Evidence supported this, showing that it is as effective as, or more effective than, other treatments in improving health-related quality of life and satisfaction with treatment. It also offered the best balance of benefits and costs. However, the committee agreed that more research is needed to determine the benefit to women of investigations before treatment with LNG-IUS as a management strategy (see research recommendation 1).

The available evidence did not show clinically important differences in effectiveness and acceptability among the other pharmacological treatments, so there are several options that may be considered if a woman declines LNG-IUS or it is not suitable.

For women with severe symptoms and those for whom initial treatment is unsuccessful, the committee agreed that referral to specialist care may be considered, because some women may benefit from further investigations (in particular those who started treatment without investigations) or from specialist management.

There was a lack of evidence about second-line treatment, so a choice of pharmacological and surgical options can be considered.

The committee agreed that women who decline pharmacological treatment and ask for surgery as a first treatment may be referred to specialist care for consideration of further investigations and surgical treatment. The evidence showed that reduction in blood loss and satisfaction with treatment was greater for hysterectomy and second-generation endometrial ablation techniques than for first-generation endometrial ablation.

No evidence was found about hysteroscopic removal of submucosal fibroids, but the committee agreed that it is an effective treatment that is acceptable to many women. It can be done at the same time as diagnostic hysteroscopy if facilities are available.

Treatments for women with fibroids of 3 cm or more in diameter

The committee emphasised the importance of taking into account the size, number and location of fibroids, and severity of symptoms, when treating fibroids of 3 cm or more in diameter. This is because women with fibroids that are substantially greater than 3 cm in diameter may benefit from more invasive treatment, such as uterine artery embolisation or surgery. Therefore, referral to specialist care to discuss all treatment options with the woman should be considered.

There was limited evidence that did not favour any one treatment over others for women with fibroids of 3 cm or more in diameter. However, the evidence for pharmacological treatment options was mainly for fibroids not substantially greater than 3 cm in diameter, whereas the evidence for interventional or surgical treatments was mainly for fibroids substantially greater than 3 cm in diameter. The committee agreed that pharmacological treatment is not always the best option for fibroids that are substantially greater than 3 cm in diameter because of their physical effect on the uterine cavity. In addition, some women may prefer not to have pharmacological treatment. Therefore uterine artery embolisation and surgery are included as first-line treatment options.

Evidence on ulipristal acetate was not reviewed as part of this guideline update, but the committee agreed that it is an option for these women.

The committee agreed that second-generation endometrial ablation may be suitable for some women with fibroids that are substantially greater than 3 cm in diameter in the absence of associated pressure-related fibroid symptoms. They were unable to define criteria for eligibility, because these differ for the different techniques (in terms of the size, shape, uniformity and integrity of the uterine cavity) and are specified by the manufacturers.

There was a lack of evidence about specific second-line treatments, so the committee agreed that alternative pharmacological and surgical options should be considered if initial treatment is unsuccessful, after reviewing whether further investigation is needed.

How the 2018 recommendations might affect practice

The committee noted that the recommendations should reinforce current best practice and help to reduce variation in clinical practice for the treatment of HMB.

In current practice, hysterectomy is a second-line treatment strategy for heavy menstrual bleeding, for which women need to have tried first-line treatment strategies, and for these to be unsuccessful, before being offered a hysterectomy. Offering hysterectomy as a first-line treatment option may result in an increase in hysterectomies. However, only a small group of women are expected to choose the procedure as first-line treatment.

For full details of the evidence and the committee's discussion see evidence review B: management of heavy menstrual bleeding.