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Heavy menstrual bleeding

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What is covered

This NICE Pathway 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.
The focus of this guidance is on women of reproductive age (after puberty and before the menopause) with heavy menstrual bleeding, including women with suspected or confirmed fibroids, and women with suspected or confirmed adenomyosis.
The guidance aims to help healthcare professionals advise each woman with heavy menstrual bleeding about the treatments that are right for her, with a clear focus on the woman's choice. It should be borne in mind that it is the woman herself who decides whether a treatment has been successful.

Updates

Updates to this NICE Pathway

16 October 2020 Heavy menstrual bleeding (NICE quality standard 47) updated.
31 March 2020 Recommendations on ulipristal acetate removed from fibroids 3 cm or more in response to MHRA advice. These may be reinstated at a later date depending on the outcome of the safety review now in progress.
23 July 2019 Ultrasound-guided high-intensity transcutaneous focused ultrasound for symptomatic uterine fibroids (NICE interventional procedures guidance 657) added to procedures for fibroids and adenomyosis.
13 March 2018 Updated on publication of heavy menstrual bleeding: assessment and management (NICE guideline NG88). Heavy menstrual bleeding (NICE quality standard 47) updated to bring it in line with the new guideline.
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 assessing and managing heavy menstrual bleeding in an interactive flowchart

What is covered

This NICE Pathway 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.
The focus of this guidance is on women of reproductive age (after puberty and before the menopause) with heavy menstrual bleeding, including women with suspected or confirmed fibroids, and women with suspected or confirmed adenomyosis.
The guidance aims to help healthcare professionals advise each woman with heavy menstrual bleeding about the treatments that are right for her, with a clear focus on the woman's choice. It should be borne in mind that it is the woman herself who decides whether a treatment has been successful.

Updates

Updates to this NICE Pathway

16 October 2020 Heavy menstrual bleeding (NICE quality standard 47) updated.
31 March 2020 Recommendations on ulipristal acetate removed from fibroids 3 cm or more in response to MHRA advice. These may be reinstated at a later date depending on the outcome of the safety review now in progress.
23 July 2019 Ultrasound-guided high-intensity transcutaneous focused ultrasound for symptomatic uterine fibroids (NICE interventional procedures guidance 657) added to procedures for fibroids and adenomyosis.
13 March 2018 Updated on publication of heavy menstrual bleeding: assessment and management (NICE guideline NG88). Heavy menstrual bleeding (NICE quality standard 47) updated to bring it in line with the new guideline.
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 (2018, updated 2020) NICE guideline NG88
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, updated 2020) NICE quality standard 47

Quality standards

Heavy menstrual bleeding

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

Menstrual history

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

People presenting with symptoms related to heavy menstrual bleeding have a focused history taken that includes the impact on their quality of life.

Rationale

Heavy menstrual bleeding can be distressing and have a major impact on the person’s wellbeing and many aspects of their life, including work and education. Documenting a focused menstrual history is important to identify the severity and range of the person’s symptoms, and the impact on their quality of life. A focused history can ensure that people have appropriate diagnostic tests, further investigations for any underlying pathologies, and prompt and effective treatment. It can also help to avoid unnecessary referrals to secondary care.

Quality measures

Structure
a) Evidence that healthcare professionals are aware of and recognise symptoms related to heavy menstrual bleeding that might suggest uterine cavity abnormality, histological abnormality, adenomyosis or fibroids.
Data source: Local data collection, for example training records.
b) Evidence of local clinical protocols for a focused history that includes the impact on quality of life based on symptoms related to heavy menstrual bleeding.
Data source: Local data collection, for example local clinical protocols.
Process
Proportion of people presenting with symptoms related to heavy menstrual bleeding who have a focused history taken that includes the impact on their quality of life.
Numerator – the number in the denominator who have a focused history taken that includes the impact on their quality of life.
Denominator – the number of people who present with symptoms of heavy menstrual bleeding.
Data source: Local data collection, for example NHS England's heavy periods self-assessment tool.
Outcome
People who report they were satisfied that the impact of their heavy menstrual bleeding on quality of life was recognised.
Data source: Local data collection, for example audit of patient records.

What the quality statement means for different audiences

Service providers (such as general practices and sexual health clinics) ensure that staff are aware of symptoms related to heavy menstrual bleeding so that they can document a focused history. The history should include severity of bleeding, related symptoms, comorbidities and the impact of heavy menstrual bleeding on quality of life.
Healthcare professionals (such as GPs and nurses) document a focused history in line with the Royal College of General Practitioners' menstrual wellbeing toolkit and NHS England's heavy periods self-assessment tool when a person presents with symptoms related to heavy menstrual bleeding. The history should include severity of bleeding, related symptoms (for example irregular periods), comorbidities and the impact of heavy menstrual bleeding on quality of life.
Commissioners (such as clinical commissioning groups and NHS England) ensure that they have service specifications in place that include clinical protocols for focused histories to be taken that address severity of bleeding, related symptoms, comorbidities and the impact on quality of life when a person presents with symptoms related to heavy menstrual bleeding.
People with heavy periods are asked about the severity of bleeding, any other symptoms or conditions that they have and how their periods affect their life, in line with NHS England's heavy periods self-assessment tool. This includes the impact on work, education and daily life. The information is recorded in their notes by their healthcare professional.

Source guidance

Definitions of terms used in this quality statement

Symptoms related to heavy menstrual bleeding
These include persistent intermenstrual bleeding, and pelvic pain or pressure that might suggest uterine cavity abnormality, histological abnormality, adenomyosis or fibroids. [NICE’s guideline on heavy menstrual bleeding, recommendation 1.2.1]
Focused history
A focused history should include questions about the following:
  • the nature of the bleeding
  • related symptoms such as pain and irregular periods
  • impact on quality of life, for example bleeding through to clothing or bedding, needing to use 2 types of sanitary product together (such as tampons and pads) or disruption to daily life (such as being unable to go out)
  • other factors that may affect treatment options such as comorbidities or previous treatment for heavy menstrual bleeding.

Outpatient hysteroscopy

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

People with heavy menstrual bleeding and suspected submucosal fibroids, polyps or endometrial pathology are offered outpatient hysteroscopy.

Rationale

Outpatient hysteroscopy is recommended in preference to pelvic ultrasound for investigating suspected submucosal fibroids, polyps or endometrial pathology. When carried out in accordance with the Royal College of Obstetricians and Gynaecologists’ green-top guideline no.59 on hysteroscopy, best practice in outpatient, it is an efficient and safe technique with a low risk of complications, pain and distress for most people. Before carrying out hysteroscopy, the healthcare professional should discuss the procedure with the person and advise on the possible alternatives. This will ensure people have a positive experience and trust in their clinician.

Quality measures

Structure
a) Evidence of local arrangements to ensure that outpatient hysteroscopy services are organised according to the Royal College of Obstetricians and Gynaecologists’ green-top guideline no.59 on hysteroscopy, best practice in outpatient, for example facilities are adequately sized, equipped and staffed.
Data source: Local data collection, for example service protocols.
b) Evidence that healthcare professionals are trained to perform outpatient hysteroscopy procedures according to the Royal College of Obstetricians and Gynaecologists’ green-top guideline no.59 on hysteroscopy, best practice in outpatient, using techniques and equipment that minimise discomfort and pain.
Data source: Local data collection, for example benchmarked, patient-reported outcome measures including pain scores.
Process
Proportion of people with heavy menstrual bleeding and suspected submucosal fibroids, polyps or endometrial pathology who were offered outpatient hysteroscopy.
Numerator – the number in the denominator who were offered outpatient hysteroscopy.
Denominator – the number of people with heavy menstrual bleeding and suspected submucosal fibroids, polyps or endometrial pathology.
Data source: Local data collection, for example audit of patient records.
Outcome
Proportion of people with heavy menstrual bleeding and suspected submucosal fibroids, polyps or endometrial pathology who report satisfaction with outpatient hysteroscopy.
Numerator – the number in the denominator who report satisfaction with outpatient hysteroscopy.
Denominator – the number of people with heavy menstrual bleeding and suspected submucosal fibroids, polyps or endometrial pathology having outpatient hysteroscopy.
Data source: Local data collection, for example audit of patient records. The British Society of Gynaecological Endoscopy's outpatient hysteroscopy patient survey includes national data on patient satisfaction.

What the quality statement means for different audiences

Service providers (such as hospitals, primary care and community-based clinics) ensure that locally agreed referral pathways are in place to allow direct-access booking into one-stop diagnostic outpatient hysteroscopy services for people with heavy menstrual bleeding and suspected submucosal fibroids, polyps or endometrial pathology. Service providers ensure that the outpatient hysteroscopy procedure follows best practice guidelines. They organise regular audits that include patient reported outcomes benchmarked against local and national standards.
Healthcare professionals (such as gynaecologists, GPs and nurses) are trained to perform outpatient hysteroscopy procedures according to best practice guidelines, with techniques and equipment that minimise discomfort and pain. They advise people to take oral analgesia before the procedure and perform vaginoscopy as the standard diagnostic technique, using miniature hysteroscopes (3.5 mm or smaller). A member of staff acts as the person’s advocate during the procedure to provide reassurance, explanation and support.
Commissioners (such as clinical commissioning groups and NHS England) ensure they commission outpatient hysteroscopy services for people with heavy menstrual bleeding and suspected submucosal fibroids, polyps or endometrial pathology that have clinical protocols in place to ensure adherence to best practice guidelines. Outpatient services may be delivered in community settings if they meet best practice guidelines.
People with heavy periods that may be related to other problems are offered a procedure called hysteroscopy, carried out in an outpatient hysteroscopy service. People having this procedure have a discussion with their healthcare professional about what this involves and possible alternatives, and are supported to make an informed choice about their care. A member of staff acts as the person’s advocate during the procedure to provide reassurance, explanation and support.

Source guidance

Definition of terms used in this quality statement

Outpatient hysteroscopy
A procedure to examine the inside of the uterus. This is done by passing a thin telescope-like device, called a hysteroscope, that is fitted with a small camera through the neck of the womb (cervix). This procedure is done without general or regional anaesthesia. Vaginoscopy is the recommended technique and a miniature hysteroscope (3.5 mm or smaller) should be used. [Adapted from the Royal College of Obstetricians and Gynaecologists’ outpatient hysteroscopy patient information leaflet]

Discussing treatment options

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

People with heavy menstrual bleeding have a discussion with their healthcare professional about all their treatment options.

Rationale

Discussing the full range of treatment options for heavy menstrual bleeding, including the benefits and risks of each option, enables the person to make an informed decision. It is important that the healthcare professional follows the principles in NICE’s guideline on patient experience in adult NHS services on communication, information and shared decision making to maximise adherence to treatment and patient satisfaction.

Quality measures

Structure
Evidence of local arrangements to ensure that people with heavy menstrual bleeding have a documented discussion with their healthcare professional about all their treatment options.
Data source: Local data collection, for example service protocols.
Process
Proportion of people with heavy menstrual bleeding who have a documented discussion with their healthcare professional about all their treatment options.
Numerator – the number in the denominator who have a documented discussion with their healthcare professional about all their treatment options.
Denominator – the number of people with heavy menstrual bleeding.
Data source: Local data collection, for example audit of patient records.
Outcome
Proportion of people with heavy menstrual bleeding who report satisfaction with the decision making process when choosing treatment.
Numerator – the number in the denominator who report satisfaction with the decision making process when choosing treatment.
Denominator – the number of people with heavy menstrual bleeding.
Data source: Local data collection, for example audit of patient records.

What the quality statement means for different audiences

Service providers (such as hospitals, GP practices and community-based clinics) ensure that systems are in place for healthcare professionals to have documented discussions about the full range of available treatment options with people who have heavy menstrual bleeding.
Healthcare professionals (such as gynaecologists, GPs and nurses) carry out a documented discussion about the full range of available treatment options for heavy menstrual bleeding with the person and follow the principles in NICE’s guideline on patient experience in adult NHS services on communication, information and shared decision making. The healthcare professional also takes into account the person’s fertility preferences, any comorbidities, the presence or absence of fibroids (including size, number and location), polyps, endometrial pathology or adenomyosis, and other symptoms such as pressure and pain.
Commissioners (such as clinical commissioning groups and NHS England) ensure that they commission services to provide people with the full range of treatment options available for heavy menstrual bleeding.
People with heavy periods have a discussion with a healthcare professional about the full range of treatments available that could help and what they involve. They are supported by their healthcare professional to choose the right treatment for them.

Source guidance

Heavy menstrual bleeding: assessment and management. NICE guideline NG88 (2018, updated 2020), recommendations 1.4.1, 1.4.2, 1.4.7, 1.5.1 and 1.5.5

Definition of terms used in this quality statement

Discussion about treatment options
Discussions should cover:
  • the benefits and risks of the various options
  • suitable treatments if the person is trying to conceive
  • whether the person wants to retain their fertility and/or uterus.
A full discussion is essential when people are considering hysterectomy and should include the implications of surgery. Surgical options including hysterectomy can be offered if treatment is unsuccessful, the person declines pharmacological treatment or symptoms are severe. [Adapted from NICE’s guideline on heavy menstrual bleeding, recommendations 1.4.2, 1.4.7 and 1.5.5, NHS England’s evidence-based interventions programme and the NICE endorsed shared decision making aid for heavy menstrual bleeding]

Effective interventions library

Effective interventions library

Successful effective interventions library details

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

Before starting investigations

The committee agreed that investigation is not necessary before starting treatment when history and examination do not suggest structural abnormalities or endometrial pathology.

Hysteroscopy or ultrasound

The choice of first-line investigation should depend on the woman's history and examination findings. The committee made recommendations for using hysteroscopy or ultrasound that were based on the available evidence for diagnostic accuracy.

How the recommendations might affect practice

Hysteroscopy
Hysteroscopy, in preference to pelvic ultrasound, is recommended for women with HMB who are suspected of having submucosal fibroids, polyps or endometrial pathology based on their history and examination. This change in practice will have a resource impact on service organisation and training.
Ultrasound is available through direct booking in primary care, whereas hysteroscopy is not. Changes to services will be needed to allow direct access booking into one-stop hysteroscopy services and ideally to increase delivery in community-based clinics. Specialists could offer more services in the community, or GPs and nurses could be trained to perform hysteroscopy in primary care. However, there should be ongoing savings because the number of unnecessary investigations is reduced and women are offered effective treatment as a result of more accurate diagnosis.
To ensure that outpatient hysteroscopy is acceptable to women, it is essential that the procedure is done according to best practice guidelines, including techniques and equipment to minimise discomfort and pain in women; adequately sized, equipped, and staffed facilities; staff with necessary training, skills and expertise; and the need for audit and benchmarking of outcomes.
Ultrasound
Transvaginal and transabdominal ultrasound are already widely available in secondary care and sometimes in primary care.
The committee noted that clinicians might need additional training and experience in interpreting transvaginal ultrasound scans to identify signs of adenomyosis.

Suspected submucosal fibroids, polyps or endometrial pathology

Outpatient hysteroscopy is recommended for women with HMB if uterine cavity abnormalities or endometrial pathology are suspected because:
  • the evidence showed that it is more accurate (higher sensitivity and specificity) in identifying them than pelvic ultrasound
  • it is safe and has a low risk of complications
  • it is acceptable to women if done according to best practice guidelines
  • women can have submucosal fibroids and polyps removed during the procedure, and targeted biopsy if needed
  • it is cost-effective as part of a diagnosis and treatment strategy.
For women who decline outpatient hysteroscopy, the committee agreed that hysteroscopy under general or regional anaesthetic should be offered, because the benefits of accurate identification outweigh the risks of anaesthesia.
Pelvic ultrasound can be considered for women who decline hysteroscopy, provided that they understand and accept that it is less accurate in detecting uterine cavity abnormalities and endometrial pathology.
Endometrial biopsy should only be taken in the context of hysteroscopy and only from women who a have a high risk of endometrial pathology, to avoid unnecessary and painful biopsies. 'Blind' endometrial biopsy is not recommended because it may not identify treatable lesions.

How the recommendations might affect practice

Hysteroscopy, in preference to pelvic ultrasound, is recommended for women with HMB who are suspected of having submucosal fibroids, polyps or endometrial pathology based on their history and examination. This change in practice will have a resource impact on service organisation and training.
Ultrasound is available through direct booking in primary care, whereas hysteroscopy is not. Changes to services will be needed to allow direct access booking into one-stop hysteroscopy services and ideally to increase delivery in community-based clinics. Specialists could offer more services in the community, or GPs and nurses could be trained to perform hysteroscopy in primary care. However, there should be ongoing savings because the number of unnecessary investigations is reduced and women are offered effective treatment as a result of more accurate diagnosis.
To ensure that outpatient hysteroscopy is acceptable to women, it is essential that the procedure is done according to best practice guidelines, including techniques and equipment to minimise discomfort and pain in women; adequately sized, equipped, and staffed facilities; staff with necessary training, skills and expertise; and the need for audit and benchmarking of outcomes.

Possible larger fibroids

Hysteroscopy is not able to detect abnormalities outside the uterine cavity, such as subserous or intramural fibroids, or adenomyosis. If an examination suggests a large fibroid or several fibroids, pelvic ultrasound (transvaginal or transabdominal) is recommended instead of hysteroscopy and is likely to be particularly cost effective in this context.
The committee agreed that if abdominal or vaginal examination is difficult to perform or inconclusive (for example, because the woman is obese), pelvic ultrasound would be helpful to identify any abnormalities that might have otherwise been suggested by examination.

How the recommendations might affect practice

Transvaginal and transabdominal ultrasound are already widely available in secondary care and sometimes in primary care.
The committee noted that clinicians might need additional training and experience in interpreting transvaginal ultrasound scans to identify signs of adenomyosis.

Suspected adenomyosis

The evidence showed that transvaginal ultrasound is more accurate than transabdominal ultrasound or MRI for detecting adenomyosis. Although transvaginal ultrasound is more intrusive than the other investigations, the committee's experience suggests that many women find it acceptable. It is also widely available in secondary care, and sometimes in primary care.
Transvaginal ultrasound may not be acceptable to or suitable for some women, such as women who have not been sexually active or women with female genital mutilation. The committee agreed that transabdominal ultrasound or MRI can be considered for these women, provided that they understand and accept that they are less accurate for detecting adenomyosis.

How the recommendations might affect practice

Transvaginal and transabdominal ultrasound are already widely available in secondary care and sometimes in primary care.
The committee noted that clinicians might need additional training and experience in interpreting transvaginal ultrasound scans to identify signs of adenomyosis.

Agreeing treatment options

The committee emphasised the importance of talking to the woman about her needs and preferences when deciding on treatments for heavy menstrual bleeding. This includes any plans for pregnancy and whether she wants to retain her uterus or fertility. The committee also highlighted that the cause of heavy menstrual bleeding and other symptoms should be taken into account. This is to ensure that the most appropriate management strategy is offered to the woman.
For full details of the evidence and the committee's discussion see evidence review B: management of heavy menstrual bleeding.

No identified pathology, fibroids less than 3 cm in diameter, or suspected or diagnosed adenomyosis

In current practice LNG-IUS is a first-line treatment for heavy menstrual bleeding in these women. Evidence supported this, showing that it is as effective as, or more effective than, other treatments in improving health-related quality of life and satisfaction with treatment. It also offered the best balance of benefits and costs. However, the committee agreed that more research is needed to determine the benefit to women of investigations before treatment with LNG-IUS as a management strategy.
The available evidence did not show clinically important differences in effectiveness and acceptability among the other pharmacological treatments, so there are several options that may be considered if a woman declines LNG-IUS or it is not suitable.
For women with severe symptoms and those for whom initial treatment is unsuccessful, the committee agreed that referral to specialist care may be considered, because some women may benefit from further investigations (in particular those who started treatment without investigations) or from specialist management.
There was a lack of evidence about second-line treatment, so a choice of pharmacological and surgical options can be considered.
The committee agreed that women who decline pharmacological treatment and ask for surgery as a first treatment may be referred to specialist care for consideration of further investigations and surgical treatment. The evidence showed that reduction in blood loss and satisfaction with treatment was greater for hysterectomy and second-generation endometrial ablation techniques than for first-generation endometrial ablation.
No evidence was found about hysteroscopic removal of submucosal fibroids, but the committee agreed that it is an effective treatment that is acceptable to many women. It can be done at the same time as diagnostic hysteroscopy if facilities are available.

How the recommendations might affect practice

The committee noted that the recommendations should reinforce current best practice and help to reduce variation in clinical practice for the treatment of HMB.
In current practice, hysterectomy is a second-line treatment strategy for heavy menstrual bleeding, for which women need to have tried first-line treatment strategies, and for these to be unsuccessful, before being offered a hysterectomy. Offering hysterectomy as a first-line treatment option may result in an increase in hysterectomies. However, only a small group of women are expected to choose the procedure as first-line treatment.
For full details of the evidence and the committee's discussion see evidence review B: management of heavy menstrual bleeding.

Fibroids of 3 cm or more in diameter

The committee emphasised the importance of taking into account the size, number and location of fibroids, and severity of symptoms, when treating fibroids of 3 cm or more in diameter. This is because women with fibroids that are substantially greater than 3 cm in diameter may benefit from more invasive treatment, such as uterine artery embolisation or surgery. Therefore, referral to specialist care to discuss all treatment options with the woman should be considered.
There was limited evidence that did not favour any one treatment over others for women with fibroids of 3 cm or more in diameter. However, the evidence for pharmacological treatment options was mainly for fibroids not substantially greater than 3 cm in diameter, whereas the evidence for interventional or surgical treatments was mainly for fibroids substantially greater than 3 cm in diameter. The committee agreed that pharmacological treatment is not always the best option for fibroids that are substantially greater than 3 cm in diameter because of their physical effect on the uterine cavity. In addition, some women may prefer not to have pharmacological treatment. Therefore uterine artery embolisation and surgery are included as first-line treatment options.
Evidence on ulipristal acetate was not reviewed as part of this guideline update, but the committee agreed that it is an option for these women.
The committee agreed that second-generation endometrial ablation may be suitable for some women with fibroids that are substantially greater than 3 cm in diameter in the absence of associated pressure-related fibroid symptoms. They were unable to define criteria for eligibility, because these differ for the different techniques (in terms of the size, shape, uniformity and integrity of the uterine cavity) and are specified by the manufacturers.
There was a lack of evidence about specific second-line treatments, so the committee agreed that alternative pharmacological and surgical options should be considered if initial treatment is unsuccessful, after reviewing whether further investigation is needed.

How the recommendations might affect practice

The committee noted that the recommendations should reinforce current best practice and help to reduce variation in clinical practice for the treatment of HMB.
In current practice, hysterectomy is a second-line treatment strategy for heavy menstrual bleeding, for which women need to have tried first-line treatment strategies, and for these to be unsuccessful, before being offered a hysterectomy. Offering hysterectomy as a first-line treatment option may result in an increase in hysterectomies. However, only a small group of women are expected to choose the procedure as first-line treatment.
For full details of the evidence and the committee's discussion see evidence review B: management of heavy menstrual bleeding.

Glossary

levonorgestrel-releasing intrauterine system
non-steroidal anti-inflammatory drugs

Paths in this pathway

Pathway created: February 2012 Last updated: October 2020

© NICE 2020. All rights reserved. Subject to Notice of rights.

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