Heavy menstrual bleeding — structured SAQ (15 marks)

(a) Definition of HMB (3 marks)

One mark per point. ^[1][2]

• The modern definition (NICE NG88 1.1.1; FIGO 2018): excessive menstrual blood loss that interferes with the woman's quality of life, regardless of the absolute amount.
• The classical definition (Hallberg 1966): menstrual blood loss of 80 mL or more per cycle, measured by the alkali-haematin method in a Swedish population study — above this, iron-deficiency anaemia became measurably more common.
• The 80 mL threshold is no longer used clinically because: it requires collecting and measuring menstrual blood (impractical); the modern definition captures the woman's lived experience; and NICE NG88 explicitly directs clinicians to improve quality of life, not to chase a millilitre count.^[1][2]

(b) History and investigations (5 marks)

One mark per point, maximum five. Reference NICE NG88. ^[2]

• History (NICE NG88 1.2.1): nature of the bleeding; related symptoms (persistent IMB, pelvic pain, pressure); impact on quality of life (work, sex, mood — now the definition); comorbidities and previous HMB treatment.
• Bleeding disorder screen (1.2.7): consider testing for a coagulation disorder if HMB since menarche AND personal or family history suggesting a coagulation disorder (e.g. von Willebrand disease).
• Examination: before all investigations and before LNG-IUS fitting (1.2.5). FBC for all women in parallel with treatment (1.2.6).
• Do NOT test routinely: female hormone testing (1.2.9); thyroid testing unless other signs of thyroid disease (1.2.10).
• Investigation: consider starting pharmacological treatment WITHOUT investigating if low risk of structural cause (1.3.1). In this woman — no IMB, no pressure symptoms, no abnormal exam — treat without imaging.^[2]

(c) Stepwise pharmacological management (5 marks)

One mark for the first-line choice with justification; one mark each for the four alternatives. ^[2][3][4]

• First-line (NICE NG88 1.5.2): the levonorgestrel-releasing intrauterine system (LNG-IUS), for no identified pathology, fibroids under 3 cm, or suspected adenomyosis. The Cochrane network meta-analysis (Bofill Rodriguez 2022) confirms the LNG-IUS is the best first-line treatment, reducing menstrual blood loss by about 106 mL per cycle.
• If declined or unsuitable (1.5.3):
  • Non-hormonal — tranexamic acid (antifibrinolytic; about 80 mL reduction per cycle) or NSAIDs (reduce prostaglandins; about 41 mL reduction).
  • Hormonal — combined hormonal contraception or cyclical oral progestogens (norethisterone day 5 to day 26).
• Counsel the six-cycle patience: the LNG-IUS may take up to 6 cycles to show benefit (1.4.3).^[2][3][4]

(d) Referral triggers (2 marks)

One mark per trigger (any two from NICE NG88 1.5.6 and 1.5.8). ^[2]

• Treatment is unsuccessful (1.5.6).
• The woman declines pharmacological treatment (1.5.6).
• Symptoms are severe (1.5.6).
• Fibroids 3 cm or more in diameter (1.5.8).^[2]