Heavy menstrual bleeding (HMB) is a common condition that affects 20–30% of women during their reproductive lifetime and has a major impact on women’s quality of life. It is usually defined as, ‘excessive menstrual blood loss which interferes with a woman’s physical, emotional, social wellbeing and/or material quality of life’, which can occur alone or in combination with other symptoms [1].

A 44-year-old gravida 2, para 2 presents for evaluation of a four-month history of intermenstrual bleeding. Menses occur at regular, 28-day intervals, and last 4–5 days with recently heavy flow. For the past four months she has had painless intermenstrual bleeding at unpredictable times throughout her cycle. Intermenstrual bleeding ranges from spotting to moderate flow and lasts one to two days. Her last menstrual period was three weeks ago. She is up to date on cervical cancer screening and routine gynecologic care. Medical history is significant for hypothyroidism, two prior cesarean deliveries, and bilateral tubal ligation. She is on levothyroxine and denies any medications allergy. She is sexually active with one male partner and denies any history of sexually transmitted infections or recent exposures.

A 34-year-old gravida 2, para 2 woman presents to the gynecology clinic for increasingly heavy menstrual bleeding over the past year. Periods occur every 28–29 days and are predictable. Bleeding lasts for seven days with the heaviest bleeding occurring on days 2 and 3. On those days, she uses super tampons and maxi pads, changing them every 2 hours, and at night is using night-time pads. She has to leave long meetings at work to change protection and has menstrual accidents. She passes large clots and describes “gushing” type bleeding when on the toilet. She has tried non-steroidal anti-inflammatory drugs and tranexamic acid for bleeding with only slight improvement in heaviness; oral contraceptive pills have not worked in the past and she is not using them now. She has no relevant past medical or surgical history and denies any drug allergy.

A 33-year-old female, gravida 2, para 2, presents with irregular intermenstrual bleeding occurring each month since undergoing her second cesarean delivery 15 months ago. Since finishing breastfeeding, she has experienced light intermenstrual bleeding episodes following menses. She denies any change in bowel or bladder symptoms. She is sexually active with one partner using condoms and denies pain or bleeding with intercourse. She denies any history of sexually transmitted diseases or abnormal Pap test that required treatment. Her past medical and surgical histories are non-contributory. She is not taking any medications and denies medication allergy.

A 71-year-old gravida 2, para 2 woman presents with vaginal bleeding for one week. The bleeding has been light and dark red in color. She has not been on hormone replacement therapy. She denies pelvic pain, or changes in bowel or bladder function. Her medical and surgical history are non-contributory. There is no family history of breast, uterus, ovarian, or colon cancers. She is not taking medications and has no history of drug allergy.