Heavy Menstrual Bleeding (HMB) is a type of Abnormal Uterine Bleeding (AUB), and according to the International Federation of Gynecology and Obstetrics (FIGO) classification of AUB [1,2], HMB can also be classified as acute or chronic, and this article will focus on the progress in the management of chronic HMB, which is defined as HMB occurring at least three times in the last 6 months. Errors in the perception of HMB. HMB is more common clinically, but there is still a lack of information on the exact number and prevalence of affected women. There are several reasons for this, one being that the prevalence of HMB depends on the perception of “normal” menstruation, which varies culturally, socially, and by age [1], and the lack of standardized etiology and screening methods due to confusing and inconsistent names, which hinders the screening and statistics of HMB [2]. The definition of HMB currently considered more appropriate and accepted by the majority of clinicians includes the objective quantitative criteria of the International Federation of Gynecology and Obstetrics (FIGO) and the subjective criteria of the National Institute for Health and Clinical Excellence (NICE) guidelines for HMB in the U.K. FIGO adopted the definition of menstrual blood loss (MBL) ≥80 mL as HMB [3], and the average MBL of normal women is 50-60 ml, the advantage of this definition is that the amount of bleeding can be objectively determined by special examination methods and is accurate, but the disadvantage is that it is cumbersome, difficult for patients to assess in clinical practice with a specific number of ml, and difficult to operate in clinical work. According to this objective criterion, studies have shown that 9% and 14% of women suffer from HMB [4,5]. The British NICE guidelines define HMB as a woman’s excessive menstrual blood loss that affects her quality of life (QOL) in terms of physical health, emotional life, social activities, and material life, and excessive menstruation can occur alone or in combination with other symptoms [6]. This diagnostic criterion is simpler and is based on the impact on QOL, which is more in line with the ultimate goal of medical diagnosis and treatment, which is to improve QOL and reduce the patient’s pain and discomfort. According to this criterion, approximately one-third of women are affected by HMB at some point in their lives [7], and other studies have reported that between 20% and 52% of women have HMB based on self-assessment of blood loss during menstruation [4]. However, it is disturbing that the level of knowledge and awareness of HMB among women and society is low to date [1]. There are various reasons for this, one being related to women’s traditional cultural beliefs about menstrual volume, and the other to women’s lack of understanding of the dangers of HMB. Menstrual taboos are still deeply rooted in many cultures [8], and patients are reluctant to talk much about or inform their parents about excessive menstruation. Many women, especially Chinese women, are more concerned about menstrual flow in relation to low menstrual flow or amenorrhea. With low menstrual flow, they worry if it affects future pregnancy, if it is a sign of going through menopause and aging, and thus repeatedly visit the clinic seeking to increase menstrual flow for psychological comfort. But for HMB, female patients or their families adopt a habitual, accepting, tolerant and even pleasant attitude, thinking that HMB is “detoxification”, “drainage”, “more toxins “This is a “normal” phenomenon, and patients or their family members tend to adapt and cope with the lifestyle changes, and therefore do not often or do not want to seek medical attention [9]. In a study of 6179 women aged 18-55 years in 15 countries, more than half (59%) of women with above-average MBL considered this to be normal, 41% considered that there was no good treatment for the condition, and only 35% of women with HMB discussed the problem with their primary care physician [1]. It is suggested that HMB is a global problem, not only in China. Except for acute HMB, patients presenting with inability to walk or work generally do not go to the hospital. The few that do go to the hospital may be dismissed or not treated because of the physicians’ own errors and stereotypes, or because of confusing diagnostic criteria for HMB. The lack of awareness of HMB among clinicians also contributes to the reluctance of HMB patients, and women with HMB may have very limited treatment options when seeking treatment, resulting in poor outcomes. This may be related to the overwhelming number of factors that physicians and patients and families consider when administering medications, including contraindications to treatment due to age, comorbidities, or family history, side effects of medications (especially when it comes to hormones), lack of available medications and treatments at the visiting hospital, physicians’ consideration of the need for symptom relief and willingness to maintain fertility, and patient acceptability of the treatments offered by physicians, including the need for hormonal versus non-hormonal treatment options, and physicians’ misconceptions about HMB, such as the absence of anemia, the absence of medications available, and the perception that no treatment is needed, and thus failing to provide help and instead simply suggesting lifestyle changes to accommodate HMB, ultimately leading to the illusion that HMB patients are reluctant to seek care or feel little help even if they do. HMB has adverse effects on women’s health In fact, HMB has far-reaching effects on women’s quality of life [10].HMB can lead to dirty or inconvenient periods, pain, discomfort, and PMS symptoms, which can seriously interfere with quality of life and cause absenteeism, missed school, and reduced productivity.HMB can affect women’s social life and interpersonal relationships, affecting women’s work and daily activities Most women with HMB also suffer from iron deficiency and even anemia, and the incidence of anemia is more than twice as high in women than in men. a study of 421 Chinese women showed that hematocrit levels were associated with MBL. with MBL less than 20 ml, there was no anemia, with MBL at 60C80 ml, anemia was 17%, and with MBL greater than 100 ml anemia was up to 26.1% [11]. HMB Limited data also suggest that HMB is associated with higher direct and indirect costs, mainly due to the cost of procedures performed for HMB, which account for 20% of outpatient gynaecological referrals in the UK. More than half of gynecological procedures are performed because of HMB, and 50% of these hysterectomies are performed with “normal” uterine pathology, i.e. no significant uterine pathology is found [12]. The cause of HMB may be pathological or organic changes in the uterus itself, such as polyps, adenomyosis, fibroids, endometrial malignancy or atypical hyperplasia (PALM in FIGO staging); or it may be caused by other sites or other causes, such as systemic coagulation disorders (including aplastic anemia (including aplastic anemia, various types of leukemia, abnormalities of various coagulation factors, abnormalities of systemic coagulation mechanisms such as thrombocytopenia, etc.), ovulation disorders (including sporadic ovulation, anovulation and luteal insufficiency), local abnormalities of the endometrium (abnormalities of endometrial local coagulation and fibrinolytic function), medical causes (such as IUD placement, levonorgestrel-containing IUD system, subcutaneous implantation of pill-containing contraceptive devices, etc.), and systemic or local causes. device, etc., as well as systemic or local medications and treatments), and some etiologies that are still difficult to classify (e.g., uterine arteriovenous malformations, etc.) (belonging to the FIGO classification of COEIN) [13]. Some etiologies may be self-limiting and can stop bleeding on their own, while many etiologies causing severe HMB may be fatal, such as hematologic diseases, and require aggressive treatment. The etiology of HMB is confounding and difficult to identify. many of the underlying causes of HMB are often asymptomatic and can coexist within a single body, HMB may occur in both ovulatory and anovulatory cycles, it may occur at any time of the cycle, and in female patients with HMB associated with hormonal imbalance, there are usually no identifiable organic pathological changes. Therefore, specifying the exact cause of HMB is difficult and is related to the physician’s knowledge background, experience, and the condition of the hospital’s examination facilities, but this should not affect the initial symptomatic treatment of the patient. Aggressive and correct treatment of HMB is needed HMB, as a disease that seriously affects the quality of life of women, has attracted the attention of professionals in various countries, and guidelines for the treatment of HMB in various countries have been developed. Clinicians generally find that guidelines are useful to guide clinical practice, but they do not always follow them because following them can be laborious, overly specialized, and expensive to implement, and they are often developed on an all-population basis, not for individual circumstances, specific hospitals, and specific conditions, and the methods and measures recommended in them are sometimes not on hand by physicians. are sometimes not on hand, and there are inconsistencies and inconsistencies in treatment recommendations from different guidelines, etc [6]. In addition, the diagnosis of HMB is hampered by several clinical factors. The presence of confusing and inconsistently applied clinical names and definitions, such as abnormal uterine bleeding, hemorrhage, functional uterine bleeding, and “crash”, and thus inconsistent findings; the lack of standardized tests and classification of potential causes; the possibility of obtaining the correct diagnostic tests (including laboratory tests, ultrasonography, and endometrial biopsy) Limited access to correct diagnostic tests (including laboratory tests, ultrasonography and endometrial biopsy) and limited availability of skilled personnel to perform them; reliance on patient narrative, diagnosis without examination or ultrasound findings (“endometrial” thickness) can lead to frequent over- or underestimation of menstrual blood. In response to these circumstances, in order to simplify the cumbersome process from a practical point of view, with the goal of addressing heavy bleeding and improving QOL, an international panel of experts from 12 countries around the world dedicated to evaluating and studying HMB was established, and after analyzing, synthesizing, and simplifying the large amount of available data, guidelines, and evidence-based evidence, proposed the HMB Best Clinical Practice Learning (HELP) based on evidence-based medicine program to promote the diagnosis and treatment norms of HMB worldwide. To simplify and recognize HMB, the HELP group recommended three key questions that strongly suggest HMB from multiple questioning questions [14,15], the presence of any one of which is diagnostic of HMB: (i) Do you have to schedule your social activities according to your menstrual period and/or are you concerned about having accidents due to bleeding? (ii) Do you need to change your sanitary protection at night and/or have you experienced menstrual blood penetrating tampons or tampons within 2 hours? ③ Have you had large blood clots during your period and/or have you experienced iron deficiency or anemia during your period? To establish the presence of HMB and to find and diagnose the common causes as soon as possible, the HELP panel recommends three key measures for finding the cause of abnormal bleeding, guiding further investigations and guiding treatment management choices: ① Obtain a medical history: ② Physical examination: unless there is a good reason to avoid it, such as in young girls, or if you are menstruating, a pelvic examination should be done transvaginally or rectally to observe the cervix, with attention to General condition, abdominal palpation to exclude pressure pain and rebound pain. ③ Blood work and ultrasound (if possible), and other imaging and endometrial evaluation and biopsy are needed only if indicated. Other necessary tests will be considered through history taking. If there is a possibility of pregnancy, a urine or serum pregnancy test should be performed. Screening for coagulopathy is only performed in women with a history of HMB since the first menstrual period or with a personal or family history of AUB. Thyroid function tests are only necessary in the presence of clinical findings suggestive of thyroid disease [16,17]. In women with post-coital bleeding, persistent intermenstrual bleeding, abdominal distention, abdominal pain, age >40 years, failed pharmacological therapy, evidence of structural etiology, history of poor lifestyle (diabetes, obesity, use of sex hormones, smoking, history of genetic disorders, etc.), the risk of endometrial malignancy needs to be excluded [6,16,18,19] before further imaging and pathology. After a definite diagnosis of HMB, treatment can be started, with pharmacological treatment being preferred. Pharmacological treatment is further divided into hormonal (including levonorgestrel IUD system, injectable progestin, long-cycle oral progestin over 20 days, compounded oral contraceptives, GnRHa, etc.) and non-hormonal (antifibrinolytic drugs, non-steroidal anti-inflammatory drugs) treatments. When choosing a treatment method, the effectiveness, safety, side effects and accessibility of the treatment should be considered. After the failure of drug therapy, the reasons should be analyzed, and when the first drug therapy is ineffective, a second drug therapy can be considered instead of immediate conversion to surgical treatment. If necessary, surgical treatment is then used, including diagnostic curettage sent for pathological examination, endometrial resection or hysterectomy, etc. In conclusion, clinicians need to fully understand the adverse effects of HMB on women’s quality of life, promote and educate women about HMB, and use effective, safe, and easy treatments for patients who present to improve the quality of life of women with HMB.