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Heavy menstrual bleeding

About

What is covered

This interactive flowchart covers heavy menstrual bleeding.
Heavy menstrual bleeding is defined as excessive menstrual blood loss which interferes with a woman's physical, social, emotional and/or material quality of life. It can occur alone or in combination with other symptoms.
Heavy menstrual bleeding is not associated with significant mortality and may be considered unimportant by some healthcare professionals. Many women with heavy menstrual bleeding consult healthcare professionals in primary care and the condition is a common reason for referral to a specialist.
In the early 1990s, it was estimated that at least 60% of women presenting with heavy menstrual bleeding went on to have a hysterectomy. This was often the only treatment offered. Hysterectomy is a major operation and is associated with significant complications in a minority of cases. Since the 1990s the number of hysterectomies has been decreasing rapidly. This guideline makes recommendations on a range of treatment options for heavy menstrual bleeding. It aims to help healthcare professionals provide the right treatments for individual women. Healthcare professionals should be aware that it is the woman herself who determines whether a treatment is successful for her.

Updates

Updates to this interactive flowchart

23 August 2016 Heavy menstrual bleeding guidance recommendations (NICE guideline CG44) added to pharmaceutical treatments.
4 June 2015 Hysteroscopic morcellation of uterine leiomyomas (fibroids) (NICE interventional procedures guidance 522) added to procedures for fibroids and adenomyosis.
25 September 2013 Heavy menstrual bleeding (NICE quality standard 47) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on heavy menstrual bleeding in an interactive flowchart

What is covered

This interactive flowchart covers heavy menstrual bleeding.
Heavy menstrual bleeding is defined as excessive menstrual blood loss which interferes with a woman's physical, social, emotional and/or material quality of life. It can occur alone or in combination with other symptoms.
Heavy menstrual bleeding is not associated with significant mortality and may be considered unimportant by some healthcare professionals. Many women with heavy menstrual bleeding consult healthcare professionals in primary care and the condition is a common reason for referral to a specialist.
In the early 1990s, it was estimated that at least 60% of women presenting with heavy menstrual bleeding went on to have a hysterectomy. This was often the only treatment offered. Hysterectomy is a major operation and is associated with significant complications in a minority of cases. Since the 1990s the number of hysterectomies has been decreasing rapidly. This guideline makes recommendations on a range of treatment options for heavy menstrual bleeding. It aims to help healthcare professionals provide the right treatments for individual women. Healthcare professionals should be aware that it is the woman herself who determines whether a treatment is successful for her.

Updates

Updates to this interactive flowchart

23 August 2016 Heavy menstrual bleeding guidance recommendations (NICE guideline CG44) added to pharmaceutical treatments.
4 June 2015 Hysteroscopic morcellation of uterine leiomyomas (fibroids) (NICE interventional procedures guidance 522) added to procedures for fibroids and adenomyosis.
25 September 2013 Heavy menstrual bleeding (NICE quality standard 47) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Heavy menstrual bleeding: assessment and management (2007 updated 2016) NICE guideline CG44
Hysteroscopic morcellation of uterine leiomyomas (fibroids) (2015) NICE interventional procedures guidance 522
Uterine artery embolisation for treating adenomyosis (2013) NICE interventional procedures guidance 473
Uterine artery embolisation for fibroids (2010) NICE interventional procedures guidance 367
Laparoscopic techniques for hysterectomy (2007) NICE interventional procedures guidance 239
Endometrial cryotherapy for menorrhagia (2006) NICE interventional procedures guidance 157
Photodynamic endometrial ablation (2004) NICE interventional procedures guidance 47
Laparoscopic laser myomectomy (2003) NICE interventional procedures guidance 23
Heavy menstrual bleeding (2013) NICE quality standard 47

Quality standards

Heavy menstrual bleeding quality standard

These quality statements are taken from the heavy menstrual bleeding quality standard. The quality standard defines clinical best practice for heavy menstrual bleeding and should be read in full.

Quality statements

Diagnosis – initial assessment

This quality statement is taken from the heavy menstrual bleeding quality standard. The quality standard defines clinical best practice for heavy menstrual bleeding and should be read in full.

Quality statement

Women presenting with symptoms of heavy menstrual bleeding have a detailed history and a full blood count taken.

Rationale

Ensuring the woman has a full and accurate diagnosis is important, because the cause of her heavy menstrual bleeding and any related pathology (such as a structural or histological abnormality) will influence her treatment options and help to determine whether further investigations and referral are needed. A detailed menstrual history will indicate the likelihood of underlying disease such as uterine fibroids, cancer or a coagulation disorder.
A full blood count will identify iron-deficiency anaemia, which can be an associated condition in women with heavy menstrual bleeding. This can be treated with drugs.

Quality measures

Structure
Evidence of local arrangements for women presenting with symptoms of heavy menstrual bleeding to have a detailed history and a full blood count taken.
Data source: Local data collection.
Process
Proportion of women presenting with symptoms of heavy menstrual bleeding who have a detailed history and a full blood count taken.
Numerator – the number of women in the denominator who have a detailed history and a full blood count taken.
Denominator – the number of women presenting with symptoms of heavy menstrual bleeding.
Data source: Local data collection and the Royal College of Obstetricians and Gynaecologists’ National heavy menstrual bleeding audit.
Outcome
a) Identification of pathology associated with heavy menstrual bleeding.
Data source: Local data collection.
b) Identification of anaemia related to heavy menstrual bleeding.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that systems are in place for women presenting with symptoms of heavy menstrual bleeding to have a detailed history and a full blood count taken.
Healthcare professionals ensure that women presenting with symptoms of heavy menstrual bleeding have a detailed history and a full blood count taken.
Commissioners ensure that they commission services with local systems for women presenting with symptoms of heavy menstrual bleeding to have a detailed history and a full blood count taken.

What the quality statement means for patients and carers

Women who seek help from their GP for heavy menstrual bleeding have a detailed medical history and blood samples taken.

Source guidance

Definitions of terms used in this quality statement

Detailed history
As a minimum, a detailed history should include questions about the following:
  • The nature of the bleeding in relation to the woman's cyclical ovarian activity.
  • The impact of heavy menstrual bleeding on the woman's physical, emotional, social and material quality of life.
  • Symptoms that may suggest a structural or histological abnormality, such as:
    • intermenstrual bleeding
    • postcoital bleeding
    • pelvic pain
pelvic pressure.
  • Family or personal history suggesting a coagulation disorder, particularly in women who have had heavy menstrual bleeding since menarche. Symptoms and signs suggestive of a coagulation disorder include easy bleeding or bruising, frequent nose bleeds, bleeding after tooth extraction and post-partum haemorrhage.
Full blood count
It may not be possible to take a full blood count during the presenting appointment, but this should be arranged as soon as possible. If treatment is needed for iron-deficiency anaemia, it should be provided in parallel with any treatment offered for heavy menstrual bleeding.

Equality and diversity considerations

Heavy menstrual bleeding is diagnosed partly on the basis of symptoms and its impact on quality of life, and some women may need support to be able to accurately describe it. The support should be tailored to the individual, especially for women with additional needs such as physical, sensory or learning disabilities, or women who do not speak English. Women presenting with heavy menstrual bleeding should have access to an interpreter or advocate if needed.

Diagnosis – physical examination

This quality statement is taken from the heavy menstrual bleeding quality standard. The quality standard defines clinical best practice for heavy menstrual bleeding and should be read in full.

Quality statement

Women with heavy menstrual bleeding in whom a structural or histological abnormality is suspected have a physical examination before referral for further investigations.

Rationale

Accurate diagnosis is important because the presence of a structural or histological abnormality, particularly uterine fibroids larger than 3 cm, influences the woman's treatment options. Evidence presented in the full clinical guideline on heavy menstrual bleeding suggests that up to 30% of women with heavy menstrual bleeding have associated uterine fibroids. The purpose of a physical examination (see definition) is to detect underlying pathology to inform treatment options or the need for referral for further investigations.

Quality measures

Structure
Evidence of local arrangements for women with heavy menstrual bleeding in whom a structural or histological abnormality is suspected to have a physical examination before referral for further investigations.
Data source: Local data collection. The National heavy menstrual bleeding audit collected data about which investigations, including a physical examination, are considered at the initial consultation in specialist services (see section 4 in the first annual report of the National heavy menstrual bleeding audit). These data may inform a baseline assessment.
Process
Proportion of women with heavy menstrual bleeding in whom a structural or histological abnormality is suspected who have a physical examination before referral for further investigations.
Numerator – the number of women in the denominator who have a physical examination before referral for further investigations.
Denominator – the number of women with heavy menstrual bleeding in whom a structural or histological abnormality is suspected.
Data source: Local data collection. The National heavy menstrual bleeding audit collected data about which investigations, including a physical examination, are considered at the initial consultation in specialist services (see section 4 in the first annual report of the National heavy menstrual bleeding audit). These data may inform a baseline assessment.
Outcome
Identification of pathology associated with heavy menstrual bleeding.
Data source: Local data collection. The National heavy menstrual bleeding audit collected data about conditions related to heavy menstrual bleeding (see section 5 in the second annual report of the National heavy menstrual bleeding audit). These data may inform a baseline assessment.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that systems are in place for women with heavy menstrual bleeding in whom a structural or histological abnormality is suspected to have a physical examination before referral for further investigations.
Healthcare professionals ensure that women with heavy menstrual bleeding in whom a structural or histological abnormality is suspected have a physical examination before referral for further investigations.
Commissioners ensure that they commission services with local systems for women with heavy menstrual bleeding in whom a structural or histological abnormality is suspected to have a physical examination before referral for further investigations.

What the quality statement means for patients and carers

Women with heavy menstrual bleeding that may be caused by another problem such as uterine fibroids (non-cancerous growths in the womb) are offered a physical examination before being referred for other examinations or tests.

Source guidance

  • NICE clinical guideline 44 recommendations 1.2.4 and 1.2.6.

Definitions of terms used in this quality statement

Suspected structural or histological abnormalities
Structural and histological abnormalities may be suspected as result of the woman's detailed history, which should be taken when the woman presents with symptoms of heavy menstrual bleeding (see quality statement 1).
Structural abnormality (uterine fibroids)
The full clinical guideline on heavy menstrual bleeding defines uterine fibroids as smooth-muscle tumours of the uterus, generally benign although occasionally (less than 1%) malignant. They vary greatly in size from millimetres to tens of centimetres, and are associated with heavy periods, pressure symptoms and occasionally pain. Small uterine fibroids are 3 cm or less in diameter and large uterine fibroids are more than 3 cm in diameter.
Histological abnormality
In particular, this means cancer or atypical hyperplasia.
Physical examination
The full clinical guideline on heavy menstrual bleeding defines physical examination in this context as observation, abdominal palpation, visualisation of the cervix and bimanual (internal) examination with the purpose of detecting underlying pathology to inform treatment and the need for investigations. A physical examination should also be carried out before fitting a levonorgestrel-releasing intrauterine system (NICE clinical guideline 44 recommendation 1.2.6).
A physical examination may be inappropriate for a woman who has never been sexually active. This may be of relevance to all women, but could be particularly important for younger women.
Further investigations
NICE clinical guideline 44 recommendation 1.2.15 states that ultrasound is the first-line diagnostic tool for identifying structural abnormalities. Recommendation 1.2.13 states that if appropriate a biopsy should be undertaken to exclude endometrial cancer or atypical hyperplasia.

Equality and diversity considerations

All women should be offered the option to be examined by a female doctor. This may be particularly important for women from certain cultural or religious groups.

Drug treatment

This quality statement is taken from the heavy menstrual bleeding quality standard. The quality standard defines clinical best practice for heavy menstrual bleeding and should be read in full.

Quality statement

Women with heavy menstrual bleeding without suspected structural or histological abnormalities are offered drug treatment at the initial assessment.

Rationale

In some women with heavy menstrual bleeding, hormonal or non-hormonal drug treatments can reduce the bleeding or stop it completely. These treatments can be started in primary care, and may reduce the number of inappropriate referrals to specialist services.

Quality measures

Structure
a) Evidence of local arrangements for women with heavy menstrual bleeding without suspected structural or histological abnormalities to be offered drug treatment at the initial assessment.
Data source: Local data collection. The National heavy menstrual bleeding audit collected data about patterns of primary care treatment among women before referral (see section 7 in the second annual report of the National heavy menstrual bleeding audit). These data may inform a baseline assessment.
b) Evidence that service providers have networks in place to refer women for the fitting of a levonorgestrel-releasing intrauterine system if this is not provided within the referring service.
Data source: Local data collection.
Process
Proportion of women with heavy menstrual bleeding without suspected structural or histological abnormalities who are offered drug treatment at the initial assessment.
Numerator – the number of women in the denominator who are offered drug treatment at the initial assessment.
Denominator – the number of women presenting with heavy menstrual bleeding without suspected structural or histological abnormalities.
Data source: Local data collection. The National heavy menstrual bleeding audit collected data about patterns of primary care treatment among women before referral (see section 7 in the second annual report of the National heavy menstrual bleeding audit). These data may inform a baseline assessment.
Outcome
a) Women's satisfaction with symptom control and quality of life related to their heavy menstrual bleeding.
Data source: Local data collection. The National heavy menstrual bleeding audit collected data about clinical symptoms among women referred for heavy menstrual bleeding to outpatient clinics and quality of life of women at the first outpatient visit and at the 1-year follow-up appointment (see sections 5 and 6 in the second annual report of the National heavy menstrual bleeding audit and section 6 in the third annual report of the National heavy menstrual bleeding audit). These data may inform a baseline assessment.
b) Rates of referral to specialist services.
Data source: Local data collection. The National heavy menstrual bleeding audit collected data about referral patterns (see section 4 in the first annual report of the National heavy menstrual bleeding audit). These data may inform a baseline assessment.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that systems are in place for women with heavy menstrual bleeding without suspected structural or histological abnormalities to be offered drug treatment at the initial assessment.
Healthcare professionals ensure that women with heavy menstrual bleeding without suspected structural or histological abnormalities are offered drug treatment at the initial assessment.
Commissioners ensure that they commission services with local arrangements for women with heavy menstrual bleeding without suspected structural or histological abnormalities to be offered drug treatment at the initial assessment.

What the quality statement means for patients and carers

Women with heavy menstrual bleeding are offered drug treatment straight away as long as there are no signs or symptoms of another problem such as uterine fibroids (non-cancerous growths in the womb).

Source guidance

  • NICE clinical guideline 44 recommendations 1.2.3, 1.5.1 and 1.5.3 (key priority for implementation).

Definitions of terms used in this quality statement

Suspected structural or histological abnormalities
Structural and histological abnormalities may be suspected as result of the woman's detailed history, which should be taken when the woman presents with symptoms of heavy menstrual bleeding (see quality statement 1).
Structural abnormality (uterine fibroids)
The full clinical guideline on heavy menstrual bleeding defines uterine fibroids as smooth-muscle tumours of the uterus, generally benign although occasionally (less than 1%) malignant. They vary greatly in size from millimetres to tens of centimetres, and are associated with heavy periods, pressure symptoms and occasionally pain. Small uterine fibroids are 3 cm or less in diameter and large uterine fibroids are more than 3 cm in diameter.
Histological abnormality
In particular, this means cancer or atypical hyperplasia.
Drug treatments
The drug treatment option chosen should take account of individual circumstances, including age, family planning needs and the relevant licensing considerations. Informed consent is needed when using medicines outside the licensed indications. Prescribers should also consider Long-acting reversible contraception (NICE clinical guideline 30).
NICE clinical guideline 44 recommendation 1.5.3 (key priority for implementation) recommends that treatments should be considered in the following order:
  • levonorgestrel-releasing intrauterine system, provided long-term use (at least 12 months) is anticipated
  • tranexamic acid, non-steroidal anti-inflammatory drugs (NSAIDs) or combined oral contraceptives
  • norethisterone (15 mg) daily from days 5 to 26 of the menstrual cycle, or injected long-acting progestogens.
NICE clinical guideline 44 recommendation 1.5.4 recommends that if hormonal treatments are not acceptable to the woman, then either tranexamic acid or NSAIDs can be used.
Initial assessment
The initial assessment starts when the woman presents with symptoms of heavy menstrual bleeding. It is usually undertaken in primary care and involves 1 or more appointments, in which the woman receives a diagnosis and her treatment options are discussed.
The term 'initial assessment' has been included in the quality statement based on expert consensus.

Equality and diversity considerations

The drug treatment option chosen should take account of individual circumstances, including age and the relevant licensing considerations.

Interim drug treatment

This quality statement is taken from the heavy menstrual bleeding quality standard. The quality standard defines clinical best practice for heavy menstrual bleeding and should be read in full.

Quality statement

Women with heavy menstrual bleeding who are undergoing further investigations or awaiting definitive treatment are offered tranexamic acid or non-steroidal anti-inflammatory drugs at the initial assessment.

Rationale

Definitive treatment can take months to organise for women who have a suspected or confirmed structural abnormality (such as uterine fibroids) or histological abnormality (cancer or atypical hyperplasia). These women will undergo further investigations (such as ultrasound) and, depending on the outcome of the further investigations, may need a referral to specialist services. Heavy menstrual bleeding can be a painful condition to live with and heavy menstrual blood loss lowers women's quality of life. Tranexamic acid or non-steroidal anti-inflammatory drugs (NSAIDs) can provide some symptom relief for women who are undergoing investigations or awaiting definitive treatment.

Quality measures

Structure
Evidence of local arrangements that women with heavy menstrual bleeding who are undergoing further investigations or awaiting definitive treatment are offered tranexamic acid or NSAIDs at the initial assessment.
Data source: Local data collection. The National heavy menstrual bleeding audit collected data about patterns of primary care treatment among women before referral (see section 7 in the second annual report of the National heavy menstrual bleeding audit). These data may inform a baseline assessment.
Process
Proportion of women with heavy menstrual bleeding who are undergoing further investigations or awaiting definitive treatment who are offered tranexamic acid or NSAIDs at the initial assessment.
Numerator – the number of women in the denominator who are offered tranexamic acid or NSAIDs at the initial assessment.
Denominator – the number of women with heavy menstrual bleeding who are undergoing further investigations and awaiting definitive treatment.
Data source: Local data collection. The National heavy menstrual bleeding audit collected data about patterns of primary care treatment among women before referral (see section 7 in the second annual report of the National heavy menstrual bleeding audit). These data may inform a baseline assessment.
Outcome
Women's satisfaction with symptom control and quality of life.
Data source: Local data collection. The National heavy menstrual bleeding audit collected related data about clinical symptoms among women referred for heavy menstrual bleeding to outpatient clinics and quality of life of women at the first outpatient visit and at the 1-year follow-up appointment (see sections 5 and 6 in the second annual report of the National heavy menstrual bleeding audit and section 6 in the third annual report of the National heavy menstrual bleeding audit). These data may inform a baseline assessment.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that women with heavy menstrual bleeding who are undergoing further investigations or awaiting definitive treatment are offered tranexamic acid or NSAIDs at the initial assessment.
Healthcare professionals ensure that women with heavy menstrual bleeding who are undergoing further investigations or awaiting definitive treatment are offered tranexamic acid or NSAIDs at the initial assessment.
Commissioners ensure that women with heavy menstrual bleeding who are undergoing further investigations or awaiting definitive treatment are offered tranexamic acid or NSAIDs at the initial assessment.

What the quality statement means for patients and carers

Women with heavy menstrual bleeding who are having further tests or waiting for treatment are offered temporary treatment with tranexamic acid (to help reduce bleeding) or a non-steroidal anti-inflammatory drug (or NSAID for short – a drug that helps reduce bleeding and pain) to ease their symptoms.

Source guidance

  • NICE clinical guideline 44 recommendation 1.5.6.

Definitions of terms used in this quality statement

Drug treatment
The drug treatment option chosen should take account of individual circumstances, including age and the relevant licensing considerations. Informed consent is needed when using medicines outside the licensed indications.
Initial assessment
The initial assessment starts when the woman presents with symptoms of heavy menstrual bleeding. It is usually undertaken in primary care and involves 1 or more appointments, in which the woman receives a diagnosis and her treatment options are discussed.
The term 'initial assessment' has been included in the quality statement based on expert consensus.
Further investigations
NICE clinical guideline 44 recommendation 1.2.15 states that ultrasound is the first-line diagnostic tool for identifying structural abnormalities. Recommendation 1.2.13 states that if appropriate a biopsy should be undertaken to exclude endometrial cancer or atypical hyperplasia.

Equality and diversity considerations

The drug treatment option chosen should take account of individual circumstances, including age and the relevant licensing considerations.

Access to endometrial ablation

This quality statement is taken from the heavy menstrual bleeding quality standard. The quality standard defines clinical best practice for heavy menstrual bleeding and should be read in full.

Quality statement

Women with heavy menstrual bleeding and a normal uterus or small uterine fibroids who choose surgical intervention have a documented discussion about endometrial ablation as a preferred treatment to hysterectomy.

Rationale

Some women with heavy menstrual bleeding and a normal uterus or small uterine fibroids may choose surgery if they do not wish to have drug treatment or if drug treatment is contraindicated or fails to adequately control their symptoms. Endometrial ablation is a less invasive surgical procedure than hysterectomy, is associated with fewer complications and can be performed as day surgery. It is important that all women have the opportunity to discuss the risks and benefits of both endometrial ablation and hysterectomy to enable them to make an informed decision about which intervention is most appropriate for them. Evidence suggests that women who live in poorer areas are more likely to undergo hysterectomy rather than endometrial ablation compared with women who live in more affluent areasRoyal College of Obstetricians and Gynaecologists (2011) National heavy menstrual bleeding audit. First annual report.

Quality measures

Structure
a) Evidence of local arrangements that women with heavy menstrual bleeding and a normal uterus or small uterine fibroids who choose surgical intervention have a documented discussion about endometrial ablation as a preferred treatment to hysterectomy.
Data source: Local data collection.
b) Evidence that service providers have networks in place to refer women for endometrial ablation if this intervention is not provided locally.
Data source: Local data collection. The National heavy menstrual bleeding audit includes an organisational audit to establish provision of treatment options (see section 4 in the first annual report of the National heavy menstrual bleeding audit). These data may inform a baseline assessment.
Process
The proportion of women with heavy menstrual bleeding and a normal uterus or small uterine fibroids who choose surgical intervention have a documented discussion about endometrial ablation as a preferred treatment to hysterectomy.
Numerator – the number of women in the denominator who have a documented discussion about endometrial ablation as a preferred treatment to hysterectomy.
Denominator – the number of women with heavy menstrual bleeding and a normal uterus or small uterine fibroids who choose surgical intervention.
Data source: Local data collection. The National heavy menstrual bleeding audit includes an analysis of patterns of surgical treatment for women with heavy menstrual bleeding (see section 3 and appendix 3 in the first annual report of the National heavy menstrual bleeding audit). These data may inform a baseline assessment.
Outcome
a) Women's satisfaction with the decision making process when choosing surgical treatment for heavy menstrual bleeding.
Data source: Local data collection. The National heavy menstrual bleeding audit includes an analysis of women's self-reported experiences of the secondary care they received. The analysis includes the elements 'information received and satisfaction with information received', 'communication with doctors in secondary care' and 'overall rating of care received' (see section 7 in the third annual report of the National heavy menstrual bleeding audit). These data may inform a baseline assessment.
b) Rates of endometrial ablation and hysterectomy.
Data source: Local data collection. The National heavy menstrual bleeding audit includes an analysis of patterns of surgical treatment for women with heavy menstrual bleeding (see section 3 and appendix 3 in the first annual report of the National heavy menstrual bleeding audit). These data may inform a baseline assessment.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that systems are in place for women with heavy menstrual bleeding and a normal uterus or uterine fibroids who choose surgical intervention to have a documented discussion about endometrial ablation as a preferred treatment to hysterectomy.
Healthcare professionals ensure that women with heavy menstrual bleeding and a normal uterus or small uterine fibroids who choose surgical intervention have a documented discussion about endometrial ablation as a preferred treatment to hysterectomy.
Commissioners ensure that they commission services with local agreements for women with heavy menstrual bleeding and a normal uterus or small uterine fibroids who choose surgical intervention to have a documented discussion about endometrial ablation as a preferred treatment to hysterectomy.

What the quality statement means for patients and carers

Women with heavy menstrual bleeding and a normal uterus or small uterine fibroids (non-cancerous growths in the womb) who choose surgery have a recorded discussion about endometrial ablation (removal of the lining of the womb) as an alternative to hysterectomy (removal of the womb).

Source guidance

  • NICE clinical guideline 44 recommendations 1.6.4 and 1.6.5 (key priority for implementation).

Definitions of terms used in this quality statement

Documented discussion
The discussion should be between the woman and the relevant clinician. It should reflect the guidance in sections 1.6 and 1.8 of NICE clinical guideline 44 and include the different types of interventions and the potential short-, medium- and long-term effects these can have. This discussion should be documented in the woman's notes. Written information about the different treatment options should be given to the woman.
Uterine fibroids
The full clinical guideline on heavy menstrual bleeding defines uterine fibroids as smooth-muscle tumours of the uterus, generally benign although occasionally (less than 1%) malignant. They vary greatly in size from millimetres to tens of centimetres, and are associated with heavy periods, pressure symptoms and occasionally pain. Small uterine fibroids are 3 cm or less in diameter and large uterine fibroids are more than 3 cm in diameter.
Endometrial ablation
NICE clinical guideline 44 recommends that all women considering endometrial ablation should have access to a second-generation ablation technique (see recommendations 1.6.6 and 1.6.7).
Women who choose surgery
In women with heavy menstrual bleeding and a normal uterus or small uterine fibroids, drug treatment should be considered before surgical intervention (see quality statement 3). For some women drug treatment may be unsuitable because it is declined, contraindicated or fails to adequately control their symptoms.

Equality and diversity considerations

Women from all socioeconomic backgrounds should have equal access to information about their treatment options. Evidence suggests that women who live in poorer areas are more likely to undergo hysterectomy rather than endometrial ablation compared with women who live in more affluent areas.

Access to interventions for uterine fibroids

This quality statement is taken from the heavy menstrual bleeding quality standard. The quality standard defines clinical best practice for heavy menstrual bleeding and should be read in full.

Quality statement

Women with heavy menstrual bleeding related to large uterine fibroids who choose surgical or radiological intervention have a documented discussion about uterine artery embolisation, myomectomy and hysterectomy.

Rationale

Historically hysterectomy was the only treatment available to women with heavy menstrual bleeding related to large uterine fibroids. However, alternative surgical and radiological treatments are now available and it is important that the benefits and risks of uterine artery embolisation, myomectomy and hysterectomy are all discussed with the woman. Evidence suggests that some women are not offered alternatives to hysterectomy and therefore do not have access to the full range of treatment optionsRoyal College of Obstetricians and Gynaecologists (2011) National heavy menstrual bleeding audit. First annual report.

Quality measures

Structure
a) Evidence of local arrangements for women with heavy menstrual bleeding related to large uterine fibroids who choose surgical or radiological intervention to have a documented discussion about uterine artery embolisation, myomectomy and hysterectomy.
Data source: Local data collection.
b) Evidence that service providers have arrangements to refer women for uterine artery embolisation and myomectomy if these interventions are not provided locally.
Data source: Local data collection. The National heavy menstrual bleeding audit includes an organisational audit to establish provision of treatment options (see section 4 in the first annual report of the National heavy menstrual bleeding audit). These data may inform a baseline assessment.
Process
The proportion of women with heavy menstrual bleeding related to large uterine fibroids who choose surgical or radiological intervention who have a documented discussion about uterine artery embolisation, myomectomy and hysterectomy.
Numerator – the number of women in the denominator who have a documented discussion about uterine artery embolisation, myomectomy and hysterectomy.
Denominator – the number of women with large uterine fibroids and heavy menstrual bleeding who choose surgical or radiological intervention.
Data source: Local data collection. The National heavy menstrual bleeding audit includes an analysis of patterns of surgical treatment for women with heavy menstrual bleeding (see section 3 and appendix 3 in the first annual report of the National heavy menstrual bleeding audit). These data may inform a baseline assessment.
Outcome
a) Women's satisfaction with the decision-making process around radiological and surgical treatment options for heavy menstrual bleeding related to large uterine fibroids.
Data source: Local data collection. The National heavy menstrual bleeding audit includes an analysis of women's self-reported experiences of the secondary care they received. The analysis includes the elements 'information received and satisfaction with information received', 'communication with doctors in secondary care' and 'overall rating of care received' (see section 7 in the third annual report of the National heavy menstrual bleeding audit). These data may inform a baseline assessment.
b) Rates of uterine artery embolisation, myomectomy and hysterectomy.
Data source: Local data collection. The National heavy menstrual bleeding audit includes an analysis of patterns of surgical treatment for women with heavy menstrual bleeding (see section 3 and appendix 3 in the first annual report of the National heavy menstrual bleeding audit). These data may inform a baseline assessment.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that systems are in place for women with heavy menstrual bleeding related to large uterine fibroids who choose surgical or radiological intervention to have a documented discussion about uterine artery embolisation, myomectomy and hysterectomy.
Healthcare professionals ensure that women with heavy menstrual bleeding related to large uterine fibroids who choose surgical or radiological intervention have a documented discussion about uterine artery embolisation, myomectomy and hysterectomy.
Commissioners ensure that they commission services that have local systems for women with heavy menstrual bleeding related to large uterine fibroids who choose surgical or radiological intervention to have a documented discussion about uterine artery embolisation, myomectomy and hysterectomy.

What the quality statement means for patients and carers

Women with heavy menstrual bleeding related to large uterine fibroids (non-cancerous growths in the womb) who choose surgery or radiological treatment have a recorded discussion about uterine artery embolisation (treatment to block the blood supply to uterine fibroids), myomectomy (removal of uterine fibroids) and hysterectomy.

Source guidance

Definitions of terms used in this quality statement

Documented discussion
The discussion should be between the woman and the relevant clinician. It should reflect the guidance in sections 1.7 and 1.8 of NICE clinical guideline 44 and include the different types of interventions and the potential short-, medium- and long-term effects these can have. This discussion should be documented in the woman's notes. Written information about the different treatment options should be given to the woman.
Uterine fibroids
The full clinical guideline on heavy menstrual bleeding defines uterine fibroids as smooth-muscle tumours of the uterus, generally benign although occasionally (less than 1%) malignant. They vary greatly in size from millimetres to tens of centimetres, and are associated with heavy periods, pressure symptoms and occasionally pain. Small uterine fibroids are 3 cm or less in diameter and large uterine fibroids are more than 3 cm in diameter.
Women who choose further intervention
This includes women for whom other treatments have failed, been declined or are contraindicated.

Equality and diversity considerations

Women from all socioeconomic backgrounds should have equal access to information about their treatment options. Evidence suggests that some women are not offered alternatives to hysterectomy and therefore do not have access to the full range of treatment options.

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Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Table 1 Potential unwanted outcomes experienced by some women

Levonorgestrel-releasing intrauterine system
Common: irregular bleeding that may last for over 6 months; hormone-related problems such as breast tenderness, acne or headaches, which, if present, are generally minor and transient
Less common: amenorrhoea
Rare: uterine perforation at the time of insertion
Tranexamic acid
Less common: indigestion; diarrhoea; headaches
Non-steroidal anti-inflammatory drugs
Common: indigestion; diarrhoea
Rare: worsening of asthma in sensitive individuals; peptic ulcers with possible bleeding and peritonitis
Combined oral contraceptives
Common: mood changes; headaches; nausea; fluid retention; breast tenderness
Very rare: deep vein thrombosis; stroke; heart attacks
Oral progestogen (norethisterone)
Common: weight gain; bloating; breast tenderness; headaches; acne (but all are usually minor and transient)
Rare: depression
Injected progestogen
Common: weight gain; irregular bleeding; amenorrhoea; premenstrual-like syndrome (including bloating, fluid retention, breast tenderness)
Less common: small loss of bone mineral density, largely recovered when treatment discontinued
Ulipristal acetate
Very common: endometrial thickening, amenorrhoea
Common: vertigo, nausea, abdominal pain, hot flushes, headache, fatigue, ovarian cyst, breast pain and tenderness, pelvic pain, musculoskeletal pain, acne, weight increase
Less common: dizziness, dry mouth, constipation, anxiety, urinary incontinence, alopecia, dry skin, hyperhidrosis, back pain, uterine haemorrhage, metrorrhagia, genital discharge, oedema, asthenia, increased blood lipids
Rare: epistaxis, dyspepsia, flatulence, ruptured ovarian cyst, breast swelling
Gonadotrophin-releasing hormone analogue
Common: menopausal-like symptoms (such as hot flushes, increased sweating, vaginal dryness)
Less common: osteoporosis, particularly trabecular bone with longer than 6-months' use
Endometrial ablation
Common: vaginal discharge; increased period pain or cramping (even if no further bleeding); need for additional surgery
Less common: infection
Rare: perforation (but very rare with second generation techniques)
Uterine artery embolisation
Common: persistent vaginal discharge; post-embolisation syndrome – pain, nausea, vomiting and fever (not involving hospitalisation)
Less common: need for additional surgery; premature ovarian failure particularly in women over 45 years old; haematoma
Rare: haemorrhage; non-target embolisation causing tissue necrosis; infection causing septicaemia
Myomectomy
Less common: adhesions (which may lead to pain and/or impaired fertility); need for additional surgery; recurrence of fibroids; perforation (hysteroscopic route); infection
Rare: haemorrhage
Hysterectomy
Common: infection
Less common: intraoperative haemorrhage; damage to other abdominal organs, such as the urinary tract or bowel; urinary dysfunction – frequent passing of urine and incontinence
Rare: thrombosis (deep vein thrombosis and clot on the lung)
Very rare: death
(Complications are more likely when hysterectomy is performed in the presence of fibroids.)
Oophorectomy at time of hysterectomy
Common: menopausal-like symptoms
Common: 1 in 100 chance; less common: 1 in 1,000 chance; rare: 1 in 10,000 chance; very rare: 1 in 100,000 chance
Be aware that the information about potential unwanted outcomes is from 2007, except that for ulipristal acetate, which was added in 2016.

Glossary

levonorgestrel-releasing intrauterine system
non-steroidal anti-inflammatory drugs
uterine artery embolisation

Paths in this pathway

Pathway created: February 2012 Last updated: June 2017

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