Heavy Menstrual Bleeding (HMB) in a 40-Year-Old - Clinical Approach

Step 1 - Clarify Terminology & Definition

Step 2 - History (Targeted)

• Cycle length, duration of bleeding, number of pads/tampons soaked
• Passage of clots, flooding, need to double up protection
• Onset - sudden vs. gradual, change from baseline

• Dysmenorrhoea (suggests adenomyosis, fibroids, endometriosis)
• Dyspareunia, pelvic pressure, urinary frequency (fibroids)
• Intermenstrual or postcoital bleeding (polyp, cervical pathology, malignancy)
• Symptoms of anaemia: fatigue, dyspnoea, palpitations

• Unexplained weight loss
• Postcoital bleeding
• Irregular / unpredictable bleeding (vs. heavy but regular)
• Family history of colorectal or endometrial cancer

• Obesity, PCOS, diabetes, nulliparity, unopposed oestrogen exposure, tamoxifen use, family history of Lynch syndrome

• History of postpartum haemorrhage, surgical bleeding, easy bruising, epistaxis, dental bleeding, family history of bleeding disorders (von Willebrand disease)

Step 3 - Physical Examination

• General: Pallor, signs of anaemia, weight/BMI (obesity = endometrial cancer risk)
• Thyroid: Goitre or signs of hypothyroidism
• Skin: Easy bruising, petechiae (coagulopathy)
• Signs of hyperandrogenism: Acne, hirsutism (PCOS)
• Abdominal exam: Uterine/fibroid mass
• Speculum exam: Cervical appearance, polyps, ectropion, trauma
• Bimanual exam: Uterine size, mobility, tenderness, adnexal masses (enlarged, bulky, tender uterus = adenomyosis; irregular, non-tender = fibroids)

Step 4 - Investigations

Mandatory (First Line)

Hormone Panel (Where Indicated)

Coagulation Studies (If Clinical Suspicion)

• PT, APTT, platelet count
• von Willebrand factor antigen + activity - screen if HMB since menarche, or family/personal bleeding history
• Goldman-Cecil: CBC, platelet count, and coagulation studies including vWD screening are part of the workup

Endometrial Biopsy - Mandatory at Age 40

• Any woman ≥45 with AUB - but at 40 with HMB, biopsy is strongly indicated if:
  • Obesity, PCOS, anovulatory cycles, unopposed oestrogen exposure
  • Persistent or treatment-refractory HMB
  • Endometrial thickness >7 mm on USS (in premenopausal)
  • Intermenstrual bleeding

• Pipelle biopsy (office procedure, first choice)
• Hysteroscopy + biopsy - gold standard when combined (better sensitivity and specificity for endometrial pathology) - Bailey & Love's

At age 40, always rule out endometrial hyperplasia and carcinoma before initiating treatment. - Goldman-Cecil Medicine

Hysteroscopy (Outpatient or Theatre)

• Directly visualises the endometrial cavity
• Allows diagnosis AND removal of polyps and submucosal fibroids in the same sitting
• Combined with biopsy improves sensitivity/specificity - Bailey & Love's

Step 5 - Treatment

1. Underlying cause (PALM-COEIN category)
2. Severity of bleeding and anaemia
3. Desire for future fertility
4. Patient preference

Medical Treatment (First Line for Most)

• OCP every 6 hours x 5-7 days (off-label) - bleeding should stop within 24 hours
• IV conjugated oestrogens 25 mg every 4 hours (up to 3 doses) + simultaneous progestin
• High-dose oral progestins (MPA 20-40mg/day or norethisterone acetate 10-15mg/day)

• GnRH agonists (pre-operative shrinkage)
• Newer agents: Relugolix 40mg daily, Elagolix 300mg BD (GnRH antagonists - reduce fibroid-related bleeding)
• Tranexamic acid + NSAIDs for symptom control

Surgical / Procedural Treatment (Second Line)

Hysterectomy should be reserved for patients who do not respond to or cannot tolerate medical therapy. Alternatives including endometrial ablation and UAE should be considered first. - Berek & Novak's Gynecology

Treat the Anaemia

• Oral ferrous sulphate 200mg BD-TDS if iron deficient
• IV iron if oral not tolerated or severe deficiency
• Blood transfusion if Hb <7g/dL or haemodynamically compromised

Summary Algorithm for a 40-Year-Old with HMB

1. History + Exam
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2. Exclude pregnancy (urine hCG)
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3. Labs: FBC, ferritin, TFT, coagulation screen if indicated
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4. Pelvic USS (TVS)
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5. Endometrial biopsy (Pipelle or hysteroscopy + biopsy) — MANDATORY at this age
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6. Identify PALM-COEIN cause
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7. Medical therapy first (LNG-IUS preferred / tranexamic acid / OCP / progestin)
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8. If failed → Surgical (ablation, hysteroscopic procedure, UAE, myomectomy)
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9. Hysterectomy as last resort (or if malignancy confirmed)

Key Points at Age 40

• Always biopsy the endometrium - she is approaching perimenopause, the risk of endometrial hyperplasia and carcinoma rises significantly after 40
• Fibroids peak between 40-50 and are the single most common structural cause at this age
• Perimenopause brings anovulatory cycles with unopposed oestrogen, a key driver of heavy irregular bleeding
• LNG-IUS (Mirena) is NICE-recommended first-line hormonal treatment for HMB without a structural cause
• Do not perform hysterectomy without prior endometrial sampling
• Explore desire for future fertility before any surgical intervention

• Goldman-Cecil Medicine, pp. 2555-2556
• Sabiston Textbook of Surgery, 28th Ed
• Berek & Novak's Gynecology, p. 1411
• Bailey & Love's Short Practice of Surgery, 28th Ed, pp. 1605-1606
• Rosen's Emergency Medicine
• NICE Guideline NG88 - Heavy Menstrual Bleeding (last reviewed July 2026)
• FOGSI-ICOG Management of AUB Guidelines 2024