Reproductive Health

[NG88] Heavy menstrual bleeding: assessment and management

NICE CKS: Dysmennorrhoea: Management - Primary Dysmennorhoea

First line: self-care

Offer an NSAID unless contraindicated. Ibuprofen first line if suitable, naproxen may be considered

Paracetamol can be used if NSAIDs are contraindicated or not tolerated, or in addition to an NSAID if the response is insufficient

If the woman does not wish to conceive, consider prescribing a 3–6 month trial of a hormonal contraceptive as an alternative treatment if appropriate - see NICE CKS for more information.

Consider recommending the following non-drug measures (in addition to drug treatments) to help reduce pain:

• Local application of heat (for example, a hot water bottle or heat patch)
• Transcutaneous electrical nerve stimulation (TENS) — set to a high frequency

Provide patient information on dysmenorrhoea. For example:

• The NHS website (www.nhs.uk) has patient information on Period pain.
• The Women’s Health Concern (WHC) website (www.womens-health-concern.org) has a leaflet on Period pain.

If symptoms are severe and do not respond to initial treatment within 3–6 months, or if there is doubt about the diagnosis, refer to a gynaecologist.

Red flags can be found in the NICE CKS: Dysmenorrhoea: Management - Secondary Dysmenorrhoea

From age 12 years onwards

From NICE CKS- Management of premenstrual syndrome.

Management of PMS should be tailored to the severity and type of symptoms, the person's treatment preferences, and any desire to become pregnant. There are no formal criteria available for defining mild, moderate, or severe PMS; severity is usually based on clinical judgement after considering the woman's perception of symptom severity, the impact of symptoms on the woman's quality of life, and the presence or absence of distress or impairment of socioeconomic function.

See NICE CKS: Management | Premenstrual syndrome for management information

NICE CKS: PMS

NHS Website: PMS

Premenstrual Syndrome, Management (Green-top Guideline No. 48) | RCOG

A very small number of women get a severe form of Premenstrual Syndrome, known as Premenstrual Dysphoric Disorder (PMDD). PMDD is defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Symptoms should be present at most menstrual cycles and improve at the onset of menses. Symptoms can range from emotional to physical and behavioural, significantly affecting life during the luteal phase of the cycle.

While many people women may experience symptoms of PMS, in women with PMDD these symptoms are much worse and can have a serious impact on their life. Experiencing PMDD can make it difficult to work, socialise and have healthy relationships and can lead to depression and suicidal feelings.

People with PMDD could benefit from a tailored contraception regimen including a continuous regimen, more information can be read in the FSRH Clinical Guideline: Combined Hormonal Contraception (January 2019, Amended October 2023) - Faculty of Sexual and Reproductive Healthcare

For more information on treatment options for Severe PMS see the NICE Scenario: Management of premenstrual syndrome

Premenstrual Syndrome, Management (Green-top Guideline No. 48) | RCOG

MIND: Understanding PMDD

Mind: Self-care for PMDD may be helpful, particularly whilst keeping a symptom diary & awaiting a diagnosis

Treatment for PMDD - Mind