Heavy menstrual bleeding (HMB) is one of the most frequent gynaecological presentations in both primary and secondary care. UK clinicians rely on guidance from multiple authoritative bodies, especially NICE (NG88) and the Royal College of Obstetricians and Gynaecologists (RCOG). This page provides an in-depth, clinically usable comparison of those recommendations, showing where they align, where emphasis differs, and how to apply them in day-to-day practice.
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The goal is to help GPs, gynaecologists, trainees, nurse practitioners, and pharmacists quickly understand how to navigate initial assessment, investigations, first-line medical therapy, procedural decision-making, and special situations. Links to official sources are provided for rapid verification and deeper reading.
Guideline scope at a glance
NICE NG88 sets out a full pathway for diagnosis and management of HMB in primary and secondary care. RCOG issues multiple, more procedural-focused documents that assume secondary-care or specialist-led involvement. The table below summarises the scope.
| Guideline | Scope | Target setting | Last update |
|---|---|---|---|
| NICE NG88 | Diagnosis & management of HMB | Primary & secondary care | Published 2018, reviewed 2021 (current 2025) |
| RCOG guidance | Specialist-led management, procedures, fertility considerations | Secondary care | Multiple documents; check RCOG site for latest |
Diagnostic approach: emphasis and flow
NICE (NG88) encourages a symptom-led, GP-led initial assessment. Diagnosis is based on patient-reported impact rather than measured blood loss. Pelvic examination is selective (e.g., suspected structural pathology, failed medical management). Transvaginal ultrasound is first-line imaging if the uterus is enlarged or symptoms suggest fibroids.
RCOG places earlier emphasis on pelvic examination and imaging in secondary care. Framing often considers fibroids, adenomyosis, and endometrial pathology sooner, with a specialist lens on differential diagnoses and onward procedures.
Key difference: NICE prioritises primary-care feasibility and symptom burden; RCOG assumes specialist access to imaging and procedural planning.
First-line management: LNG-IUS alignment
Both NICE and RCOG agree the levonorgestrel intrauterine system (LNG-IUS) is preferred first-line for HMB when acceptable to the patient.
| Aspect | NICE | RCOG |
|---|---|---|
| First-line | LNG-IUS preferred | LNG-IUS preferred (procedure-aware) |
| If LNG-IUS unsuitable | Tranexamic acid, NSAIDs, COCP; cyclical oral progestogens | Same drugs, with more discussion of procedural alternatives |
| Hormonal options | COCP, cyclical progestogens | Similar, with broader commentary on regimens and specialist follow-up |
Alignment: Strong. Both back LNG-IUS first-line where appropriate. RCOG commentary is more procedure-aware and may incorporate earlier specialist review if medical therapy is unlikely to succeed.
Procedural and surgical options
NICE sets a pathway: attempt medical therapy, consider endometrial ablation when appropriate, and reserve hysterectomy for cases where less invasive options fail or are unacceptable. Shared decision-making is emphasised, especially around fertility wishes and surgical risks.
RCOG offers greater procedural granularity: techniques for endometrial ablation, myomectomy considerations, hysterectomy approaches, and perioperative risk stratification. There is richer discussion of fertility preservation and tailoring to fibroid burden or adenomyosis.
Key difference: RCOG provides procedural detail and surgical nuance; NICE provides stepwise prioritisation of care pathways.
Special situations and comorbidities
Fertility preservation: NICE flags fertility but offers limited procedural detail; RCOG discusses fertility-sparing surgical options and when to refer to reproductive specialists.
Adolescents: NICE applies broadly; RCOG often addresses adolescents in separate guidance. Clinicians should ensure age-appropriate counselling and safeguarding.
Anaemia: Both recommend investigation and correction alongside HMB treatment. RCOG procedural discussions emphasise optimisation before intervention.
Fibroids & adenomyosis: RCOG offers more detailed procedural considerations; NICE guides when to image and when to refer or escalate.
Practical clinical takeaways
- Use NICE NG88 for GP-led diagnosis, initial medical therapy, and deciding when to image or refer.
- Use RCOG guidance for surgical decision-making, secondary-care planning, and fertility-sensitive cases.
- Both bodies are largely concordant; differences reflect care setting rather than conflicting recommendations.
- LNG-IUS remains first-line when acceptable; if unsuitable, tranexamic acid, NSAIDs, or COCP are reasonable alternatives.
- Consider endometrial ablation when medical therapy fails; reserve hysterectomy for cases where less invasive options are ineffective or unacceptable.
- Always address anaemia and quality-of-life impacts; document shared decision-making and contraindications.
Stepwise approach you can lift into practice
- Initial assessment (NICE-led): Symptom history, impact on quality of life, pregnancy status, anaemia screening, selective pelvic exam.
- First-line treatment: Offer LNG-IUS if acceptable; if not, consider tranexamic acid, NSAIDs, or COCP. Review response at 3 months.
- Imaging trigger: Consider transvaginal ultrasound if enlarged uterus, fibroid symptoms, failed first-line therapy, or red flags.
- Escalation: If medical therapy fails or is unsuitable, consider endometrial ablation in appropriate candidates; discuss surgical options (myomectomy, hysterectomy) with fertility and risk in mind.
- Specialist care (RCOG depth): For complex fibroids, adenomyosis, or fertility preservation, follow RCOG procedural recommendations and risk stratification.
- Follow-up: Reassess symptoms, anaemia, and contraception needs; ensure patient understands options and when to return.
FAQs: fast answers for clinic
Is measured blood loss required? No. NICE focuses on patient-reported impact; objective measurement is rarely needed.
When should I not fit an LNG-IUS? Contraindications include suspected or known pregnancy, pelvic infection, uterine cavity distortion from large fibroids, and certain malignancies. Discuss alternatives.
When to refer? Diagnostic uncertainty, structural pathology, failed medical therapy, or when procedural options are being considered.
Do both guidelines agree on tranexamic acid? Yes. Both endorse it when LNG-IUS is unsuitable or declined.
How do I handle fertility concerns? Document preferences early. Use RCOG procedural guidance for fertility-sparing options; avoid irreversible surgery unless fully counselled.
Source links (official)
- NICE NG88 – Heavy menstrual bleeding
- RCOG – Gynaecology guidance (see HMB-related Green-top resources)
- NICE guidelines hub (CliniSearch)
- NHS clinical guidelines overview
Why this matters for clinicians
HMB is a quality-of-life issue with significant impacts on anaemia, work, and wellbeing. By aligning the strengths of NICE (primary-care pathway, pragmatism) and RCOG (procedural depth, specialist nuance), clinicians can streamline care, set expectations, and move efficiently from initial management to definitive treatment when needed. Clear linking to official sources supports transparency and reduces the risk of using outdated copies.
How to use this page with CliniSearch
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