1. Exclude pregnancy
   • Urine or serum beta-hCG, if pregnancy is possible.
2. Assess blood loss and anemia
   • Complete blood count (CBC) with hemoglobin and platelet count.
   • Ferritin/iron studies if anemia is present, symptoms suggest iron deficiency, or bleeding has been prolonged/heavy.
3. Clinical and pelvic assessment
   • Full menstrual, medication, contraceptive, obstetric, and bleeding history.
   • Speculum and bimanual pelvic examination.
   • Ensure cervical screening (Pap/HPV) is up to date.
   • Cervical/vaginal infection testing if there is discharge, pelvic pain, postcoital bleeding, or STI risk.
4. Targeted hormonal tests, only when clinically indicated
   • TSH if symptoms/signs of thyroid dysfunction, or no obvious cause.
   • Prolactin if galactorrhea, headaches/visual symptoms, or suspected anovulation.
   • Consider assessment for PCOS/anovulation if obesity, acne, excess facial hair, irregular/infrequent cycles, or infertility.
   • Routine FSH/LH/estradiol testing is usually not useful unless premature ovarian insufficiency or perimenopause is specifically suspected.
5. Endometrial cavity assessment
   • Given frequent irregular bleeding at age 40, discuss outpatient hysteroscopy, especially if bleeding persists despite initial treatment. It can identify polyps or submucosal fibroids that a routine ultrasound can miss.
   • Endometrial biopsy, preferably directed during hysteroscopy, is indicated if there are risk factors for endometrial hyperplasia/cancer: obesity, PCOS/chronic anovulation, diabetes, tamoxifen use, Lynch syndrome/family history, persistent intermenstrual or irregular bleeding, or failed medical treatment. NICE recommends hysteroscopy for suspected uterine-cavity or endometrial pathology and biopsy during hysteroscopy for higher-risk patients. NICE HMB guidance
6. Bleeding disorder tests only if suggested by history
   • PT/INR, aPTT, and possibly von Willebrand testing if heavy bleeding has been present since menarche, or there is easy bruising, frequent nosebleeds, excess surgical/dental bleeding, or family history.

Options that reduce bleeding

1. Levonorgestrel-releasing intrauterine system (LNG-IUS)
   • Often the most effective long-term medical option when the uterine cavity is normal and contraception is acceptable.
   • It substantially lightens periods and may eventually stop them.
   • Irregular spotting is common in the first 3 to 6 months.
   • Do not insert until pregnancy is excluded and a clinician has assessed whether hysteroscopy/endometrial sampling is needed first.
2. Tranexamic acid
   • A non-hormonal tablet taken only on heavy-bleeding days.
   • Helpful if pregnancy is desired or hormonal contraception is not wanted.
   • It should be prescribed cautiously or avoided with a personal history of blood clots, certain thrombophilias, significant kidney impairment, or active clotting disease. A gynecologist should review its suitability, particularly if combined hormonal contraception is also being considered.
3. NSAIDs
   • Examples include ibuprofen, naproxen, or mefenamic acid, generally taken during menstruation.
   • They can reduce menstrual loss and period pain.
   • Avoid or use only under clinician advice with gastric ulcer/bleeding, kidney disease, anticoagulant use, NSAID-sensitive asthma, or certain cardiovascular risks.
4. Combined hormonal contraception
   • Combined oral contraceptive pill, patch, or vaginal ring can make bleeding more regular and lighter.
   • May be used cyclically or continuously to reduce/avoid withdrawal bleeding.
   • It is not suitable for everyone, including people who smoke and are age 35 or older, have migraine with aura, prior venous thrombosis/stroke, uncontrolled hypertension, or certain liver/breast conditions.
5. Progestogen-only treatment
   • Cyclical oral progestogens may help control irregular/anovulatory bleeding.
   • Continuous progestogen methods, such as a progestogen-only pill, depot injection, implant, or LNG-IUS, are options when estrogen is unsuitable.
   • The exact regimen should be selected by the gynecologist because frequent cycles can reflect anovulatory bleeding and because progestogen also protects the endometrium.
6. Treat anemia
   • If CBC/ferritin show iron deficiency, oral iron replacement is usually needed in addition to controlling the bleeding. Severe symptomatic anemia may require urgent treatment.

If medications fail or a cavity lesion is found

• Hysteroscopic removal of a polyp or submucosal fibroid.
• Endometrial ablation for women who have completed childbearing. Pregnancy afterward is unsafe, so reliable contraception is still needed.
• Hysterectomy is definitive treatment when symptoms remain severe despite other measures, or when pathology warrants it.