NICE has published Referral Advice - guide to approriate referral from general to specialist services, which deals with 11 common complaints.

Last month we covered atopic eczema in children; in this issue we reproduce the advice on menorrhagia.

The referral advice is set out in consensus statements based on the best available evidence. It is designed to help clinicians determine how urgently particular patients need to be referred.

For a summary of the consensus statements click here.


Menorrhagia is excessive (heavy), cyclical menstrual bleeding over several cycles. In practice, it is defined by the womanÍs subjective assessment of blood loss. In research, it is usually defined as an objectively measured blood loss of 80ml or more per period.

Menorrhagia can occur at any age between menarche and menopause, and each year it prompts one in 20 women amongst those aged between 30 and 49 years to consult their GP.

If severe, menorrhagia can seriously disrupt day-to-day activity. It is the commonest cause of iron deficiency anaemia in women of reproductive age in the UK.

In many women, the underlying cause of menorrhagia is not known. In others, the excessive bleeding could be secondary to a gynaecological, hormonal or haematological disorder.

Primary care

If medication is indicated, effective drugs include nonsteroidal anti-inflammatory drugs (NSAIDs), antifibrinolytics, the combined oral contraceptive pill and the levonorgestrel intra-uterine system. High dose norethisterone (5mg three times a day for 3 weeks out of 4) is effective but low dose luteal norethisterone (5-10mg daily) is not. Advice on the initial management of menorrhagia can Se obtained from the Royal College of Obstetricians and Gynaecologists guidelines

Assessment prior to referral should usually include bimanual examination of the uterus and speculum examination of the cervix (with cytology if appropriate) and a full blood count to check for anaemia.

The results of the most recent cervical cytology and blood tests should be included with any referral letter.

Specialist services

These are in a position to:

  • confirm, establish or exclude a diagnosis. This may involve endometrial biopsy, hysteroscopy and/or pelvic ultrasound
  • advise on, and where necessary oversee, management including drug therapy
  • discuss treatment options with the patient and where appropriate undertake surgery including endometrial ablative techniques or hysterectomy.

Referral Advice

Many women with menorrhagia can be managed successfully in primary care. However, referral to a specialist service is advised if:


there is a suspicion of underlying cancer. For detailed advice on cancer referral see the Department of Health Referral Guidelines for Suspected Cancer (

they also have persistent intermenstrual or post-coital bleeding

despite 3 months of drug treatment, the heavy bleeding persists and is interfering with quality of life. Failure is best based upon the womanÍs own assessment

they wish to explore the possibility of surgical intervention rather than persist with drug treatment

they have severe anaemia that has failed to respond to treatment

The starring system developed by NICE to identify referral priorities

Arrangements should be made so that the patient:

is seen immediately1
is seen urgently2
is seen soon2
has a routine appointment2
is seen within an appropriate time depending on his or her clinical circumstances (discretionary)

1 within a day

2 health authorities, trusts and primary care organisations should work to local definitions of maximum waiting times in each of these categories. The multidisciplinary advisory groups considered a maximum waiting time of 2 weeks to be appropriate for the urgent category.

Reproduced with kind permission from: Referral Advice - A Guide to Appropriate Referral from General to Specialist Services. London: NICE, December 2001.

The complete document can be downloaded from the NICE website

Guidelines in Practice, February 2002, Volume 5(2)
© 2002 MGP Ltd
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