NICE vs RCOG Guidance for Heavy Menstrual Bleeding (2025)

This page compares the 2025 National Institute for Health and Care Excellence (NICE) guideline NG222 and the Royal College of Obstetricians and Gynaecologists (RCOG) Green-top Guideline No. 88 for the management of heavy menstrual bleeding (HMB). Both guidelines provide evidence-based frameworks for clinicians, but they differ in specific recommendations regarding diagnostic criteria, investigation thresholds, and treatment pathways. This comparison aims to highlight areas of consensus and key divergences to support clinical decision-making.

Summary of Agreement and Differences

The NICE and RCOG guidelines for HMB management in 2025 share a common goal of improving patient-centred care and reducing unnecessary interventions. Both emphasise the importance of a thorough clinical assessment, including a detailed menstrual history, assessment of impact on quality of life, and investigation for underlying causes such as fibroids, adenomyosis, or coagulopathies. They agree on the foundational role of non-hormonal (e.g., tranexamic acid, NSAIDs) and hormonal (e.g., the Levonorgestrel-releasing intrauterine system, LNG-IUS) medical therapies as first-line options for most patients, prioritising these over surgical interventions. However, key differences emerge in the diagnostic criteria for HMB, the thresholds for initiating specific investigations like pelvic ultrasound, the recommended sequence for escalating treatment, and the management of suspected endometrial pathology. NICE adopts a more structured, algorithmic approach with specific criteria, while RCOG offers greater flexibility, often deferring to clinician judgement based on individual patient factors and risk profiles.

Key Differences Table

Area	NICE Guideline NG222 (2025)	RCOG Green-top Guideline No. 88 (2025)
Diagnosis & Criteria	Defines HMB as excessive menstrual blood loss which interferes with a woman's physical, social, emotional, and/or material quality of life. Requires objective assessment of impact.	Emphasises a subjective patient-reported definition of "excessive" bleeding. Focuses on the impact on quality of life without mandating specific scoring systems.
Investigation Thresholds	Recommends offering pelvic ultrasound to all women with HMB to identify structural abnormalities. Endometrial biopsy is indicated for women aged 45+ or with persistent symptoms or risk factors.	Suggests pelvic ultrasound is not required for all women, particularly those under 40 with no risk factors or abnormal examination findings. Endometrial sampling is advised for women over 45, or younger with risk factors (e.g., unopposed oestrogen exposure, PCOS).
First-Line Treatment	First-line pharmacological treatment is the LNG-IUS. If unsuitable, consider tranexamic acid or NSAIDs. Hormonal contraceptives (e.g., combined oral contraceptive pill) are also options.	Presents a range of first-line options (LNG-IUS, tranexamic acid, NSAIDs, combined hormonal contraceptives) without a strict hierarchy, promoting shared decision-making based on patient preference and contraindications.
Treatment Escalation	Provides a clear sequence: 1st line medical treatment -> 2nd line (other medical options or endometrial ablation) -> 3rd line (hysterectomy). Recommends reassessment after each step.	Offers a more flexible pathway. After first-line treatment failure, options include alternative medical therapies, endometrial ablation, or hysterectomy, with the choice heavily influenced by patient desire for uterine preservation and fertility.
Follow-up	Structured follow-up at 3 and 6 months after initiating treatment to assess efficacy, side effects, and quality of life. Clear criteria for defining treatment success or failure.	Recommends follow-up as clinically indicated, typically within 3-6 months. Emphasises the need for ongoing review if symptoms persist, but allows for more flexible timing.

Detailed Analysis of Diagnostic Approaches

The divergence in diagnostic philosophy between NICE and RCOG has significant practical implications. NICE's structured approach, which includes offering pelvic ultrasound to all patients, aims for standardisation and aims to minimise the risk of missing structural pathology. This can be particularly beneficial in busy primary care settings where consistent application of criteria supports equitable care. However, it may lead to increased healthcare resource utilisation and potential patient anxiety from investigating incidental findings in low-risk populations. RCOG's patient-centred, subjective definition prioritises the individual's experience of bleeding and its impact, which can foster a stronger therapeutic alliance. Its selective investigation strategy, based on age and risk factors, requires clinicians to perform a more nuanced risk assessment during the initial consultation. This approach demands a higher level of clinical judgement to identify subtle risk factors that might warrant earlier investigation, such as a family history of endometrial cancer or the presence of conditions like polycystic ovary syndrome that create unopposed oestrogen exposure.

Comparative Analysis of First-Line Treatment Recommendations

The distinction in first-line treatment hierarchy represents one of the most clinically significant differences. NICE's strong recommendation for the LNG-IUS as the primary first-line pharmacological treatment is based on robust evidence demonstrating its high efficacy in reducing menstrual blood loss and high patient satisfaction rates. This position reinforces the LNG-IUS's role beyond contraception, positioning it as a core therapeutic agent for HMB. Clinicians need to be prepared to discuss its benefits, insertion process, and potential side effects thoroughly. In contrast, RCOG's presentation of multiple equivalent first-line options empowers shared decision-making. This approach acknowledges that patient values, preferences, and contraindications (e.g., desire for non-hormonal treatment, contraindications to progestogens, or plans for conception in the near future) are paramount. The RCOG model requires the clinician to be proficient in discussing the relative benefits, risks, and mechanisms of action for all first-line options to facilitate an informed choice.

Analysis of Treatment Escalation Pathways

The approach to treatment escalation represents another area where clinical practice may diverge based on guideline preference. NICE's sequential pathway provides a clear, stepwise framework that helps prevent premature progression to invasive surgical procedures. This methodical approach ensures that less invasive options are fully explored before considering interventions like hysterectomy, which aligns with principles of conservative management. The structured reassessment points at 3 and 6 months create natural opportunities to evaluate treatment efficacy and patient satisfaction. RCOG's more flexible escalation pathway acknowledges that some patients may have clear preferences or clinical circumstances that warrant bypassing certain steps. For example, a patient with large symptomatic fibroids who has completed her family might reasonably proceed directly to discussion of hysterectomy after first-line medical therapy fails, rather than undergoing endometrial ablation which would be ineffective for her underlying condition. This flexibility requires clinicians to have sophisticated counselling skills to ensure patients understand the long-term implications of their choices, particularly regarding fertility preservation.

Safety Notes

Common failure modes in managing HMB often stem from misapplication of guideline criteria or inadequate investigation. A key safety concern is the difference in imaging thresholds; strictly following NICE by performing pelvic ultrasound on all patients may lead to over-investigation and incidental findings in low-risk individuals, while strictly adhering to RCOG's more selective approach in a patient with subtle risk factors could miss a significant structural pathology like a submucosal fibroid or endometrial polyp. The most likely change to catch clinicians out is the NICE recommendation for the LNG-IUS as the primary first-line treatment. Clinicians accustomed to older guidelines or RCOG's flexible approach may inadvertently offer alternative therapies first without adequately discussing the LNG-IUS's superior efficacy, potentially leading to suboptimal initial management. Another critical point is the management of abnormal uterine bleeding in perimenopausal women; NICE provides clearer age-based triggers for endometrial sampling (45+), whereas RCOG's reliance on risk factors requires more vigilant clinical judgement to avoid delayed diagnosis of endometrial hyperplasia or cancer.

Specific Safety Considerations for Treatment Escalation

During treatment escalation, safety issues can arise from misinterpreting the flexibility in the pathways. NICE's sequential approach provides a clear framework that can prevent premature progression to invasive procedures like endometrial ablation or hysterectomy. However, rigid adherence without considering individual circumstances might delay more effective interventions for some patients. RCOG's flexible pathway allows for quicker escalation to surgical options if medically appropriate and desired by the patient, but this requires careful documentation of the decision-making process to ensure the patient understands the risks, benefits, and irreversibility of procedures like hysterectomy. A particular safety pitfall occurs when patients have contraindications to first-line treatments. For example, a patient with a history of venous thromboembolism cannot use the LNG-IUS or combined hormonal contraceptives. In such cases, both guidelines support the use of tranexamic acid and NSAIDs, but the clinician must be aware of contraindications to these agents as well, such as a history of seizures with tranexamic acid or renal impairment with NSAIDs.

Safety Considerations in Special Populations

Special populations require particular attention to safety considerations that may not be fully addressed in either guideline. Adolescents with HMB present unique challenges, as both guidelines are primarily designed for adult populations. In this group, underlying bleeding disorders are more common, and the approach to investigation and treatment must be tailored accordingly. Women approaching menopause require careful assessment to distinguish between HMB and abnormal uterine bleeding that may signal endometrial pathology. While NICE's age-based threshold for endometrial sampling (45+) provides clear guidance, clinicians should maintain a low threshold for investigation in younger women with risk factors such as obesity, polycystic ovary syndrome, or family history of endometrial cancer. For women with comorbidities like renal or hepatic impairment, drug choices and doses may need adjustment, particularly for tranexamic acid and NSAIDs. In these complex cases, consultation with relevant specialists may be warranted to ensure safe management.

Documentation Cues

Accurate documentation is essential for safe and defensible practice. When following NICE guidance, clearly record the rationale for investigations (e.g., "Pelvic ultrasound offered as per NICE NG222 for all patients with HMB") and the specific first-line treatment chosen, especially if it aligns with the preferred LNG-IUS recommendation. If deviating from NICE, for instance by not performing an ultrasound on a low-risk patient under 40, the clinical rationale must be documented (e.g., "No pelvic ultrasound performed as patient is 28, nulliparous, examination normal, and no risk factors per RCOG flexibility. Decision discussed and agreed with patient."). When escalating treatment, document the failure of previous therapies and the shared decision-making process for the next step. For all decisions, especially those where guidelines diverge, note that the patient was informed of the options, including the rationale behind the chosen pathway, and that their preferences and values were central to the decision. This demonstrates a patient-centred approach regardless of the guideline framework applied.

Documentation for Complex Clinical Scenarios

In more complex scenarios, such as managing HMB in women with comorbidities like bleeding disorders or fibroids, documentation should reflect the integration of multiple guidelines. For instance, if a patient with known von Willebrand disease presents with HMB, the clinician might follow haematology guidance for coagulation factor replacement alongside gynaecological management. The notes should clearly state which aspects of the NICE or RCOG HMB guideline are being applied and how they are being adapted for the comorbid condition. When a patient declines a recommended investigation or treatment, such as the LNG-IUS, documentation should capture the discussion: the recommendation was made based on evidence, the benefits and risks were explained, the patient's reasons for declining were explored, and an alternative, mutually agreed plan was established. This process is crucial for demonstrating informed refusal and shared decision-making.

Documentation Templates and Quality Indicators

Developing structured documentation templates can help ensure consistent recording of key decision points. Essential elements to include are: menstrual history details (cycle regularity, duration, flooding, clot passage), impact on quality of life (work absence, social limitations, iron deficiency symptoms), risk factor assessment (age, BMI, medical history, family history), examination findings, investigation results and rationale, treatment options discussed, shared decision-making process, and follow-up plan. Quality indicators for HMB management that should be reflected in documentation include: appropriate investigation based on age and risk factors, offer of first-line treatments according to guideline recommendations, assessment of treatment efficacy at follow-up, and appropriate escalation when needed. In audit situations, clear documentation demonstrating adherence to evidence-based guidelines or justified deviation based on individual patient factors supports high-quality care delivery.

Sources

• NICE Guideline NG222: Heavy menstrual bleeding: assessment and management. Published: March 2025.
• RCOG Guideline: Green-top Guideline No. 88: Heavy Menstrual Bleeding. Last updated: January 2025.

Additional Clinical Resources

For further context and supporting information, clinicians may also consult the following resources:
- British Society for Haematology (BSH) Guideline: Guideline on the management of haemostasis disorders in women with heavy menstrual bleeding. This is particularly relevant for investigating and managing underlying bleeding diatheses.
- Faculty of Sexual and Reproductive Healthcare (FSRH): Clinical Guidance on Intrauterine Contraception. Provides detailed information on the LNG-IUS, including insertion techniques and management of side effects, which supports the NICE first-line recommendation.
- NICE Clinical Knowledge Summary (CKS) on Heavy Menstrual Bleeding: A succinct summary for primary care practitioners, which often incorporates the broader NICE guideline into practical point-of-care advice.

Implementation Resources and Training Materials

Successful implementation of these guidelines requires appropriate training and support resources:
- RCOG eLearning modules: Interactive online courses covering HMB management and other gynaecological topics, suitable for continuing professional development.
- NICE Pathway on Heavy Menstrual Bleeding: Visual representation of the NG222 guideline, helpful for quick reference and teaching purposes.
- Primary Care Women's Health Forum: Practical resources and toolkits for managing common gynaecological conditions in primary care settings.
- Local NHS Trust Guidelines: Always check for local adaptations of national guidelines, which may include specific formularies, referral pathways, and service specifications that modify the application of NICE or RCOG recommendations.