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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.
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 interactive flowchart

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.
20 February 2018 European Medicines Agency safety alert about ulipristal acetate added.
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 assessing and managing 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.
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 interactive flowchart

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.
20 February 2018 European Medicines Agency safety alert about ulipristal acetate added.
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.
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 2018) 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 uterine cavity abnormality, histological abnormality, adenomyosis or fibroids) 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 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

Heavy menstrual bleeding: assessment and management (2018) NICE guideline NG88, recommendations 1.2.1 and 1.2.6

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
  • related symptoms, such as persistent intermenstrual bleeding, pelvic pain and/or pressure symptoms, that might suggest uterine cavity abnormality, histological abnormality, adenomyosis or fibroids
  • impact on her quality of life
  • other factors that may affect treatment options (such as comorbidities or previous treatment for HMB)
  • family or personal history suggesting a coagulation disorder, particularly in women who have had HMB since their periods started (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 who have a suspected uterine cavity abnormality, histological abnormality, adenomyosis or fibroids have a physical examination before referral for further investigations.

Rationale

Accurate diagnosis is important because the presence of a uterine cavity abnormality, histological abnormality, adenomyosis or fibroids influences the woman’s treatment options. Up to 30% of women with heavy menstrual bleeding may have associated uterine fibroids. The purpose of a physical examination 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 who have a suspected uterine cavity abnormality, histological abnormality, adenomyosis or fibroids 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 and a suspected uterine cavity abnormality, histological abnormality, adenomyosis or fibroids 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 and a suspected uterine cavity abnormality, histological abnormality, adenomyosis or fibroids.
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 who have a suspected uterine cavity abnormality, histological abnormality, adenomyosis or fibroids to have a physical examination before referral for further investigations.
Healthcare professionals ensure that women with heavy menstrual bleeding who have a suspected uterine cavity abnormality, histological abnormality, adenomyosis or fibroids have a physical examination before referral for further investigations.
Commissioners ensure that they commission services with local systems for women with heavy menstrual bleeding who have a suspected uterine cavity abnormality, histological abnormality, adenomyosis or fibroids 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

Heavy menstrual bleeding: assessment and management (2018) NICE guideline NG88, recommendations 1.2.4 and 1.2.5

Definitions of terms used in this quality statement

Physical examination
The NICE 2007 full 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.
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
The woman's history and examination should be taken into account when deciding whether to offer hysteroscopy or ultrasound as the first-line investigation.

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 statement has been removed. For more details see update information.

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 uterine cavity abnormality, histological abnormality, adenomyosis or fibroids. These women will undergo further investigations 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 affects women’s quality of life. Tranexamic acid and/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 and/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 and/or NSAIDs at the initial assessment.
Numerator – the number of women in the denominator who are offered tranexamic acid and/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 and/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 and/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 and/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) and/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

Heavy menstrual bleeding: assessment and management (2018) NICE guideline NG88, recommendation 1.5.8

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’s guideline on heavy menstrual bleeding, recommendation 1.3.3, states that the woman's history and examination should be taken into account when deciding whether to offer hysteroscopy or ultrasound as the first-line investigation.

Equality and diversity considerations

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

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

Women with heavy menstrual bleeding have a documented discussion about all recommended treatment options.

Rationale

It is important that all women have the opportunity to discuss the treatment options available to them. Understanding the risks and benefits of various options gives them choice and enables them to make an informed decision about which treatment is most appropriate for them.

Quality measures

Structure
a) Evidence of local arrangements that women with heavy menstrual bleeding have a documented discussion about all recommended treatment options.
Data source: Local data collection.
b) Evidence that service providers have networks in place to refer women if their choice of 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 who have a documented discussion about all recommended treatment options.
Numerator – the number of women in the denominator who have a documented discussion about all recommended treatment options.
Denominator – the number of women with heavy menstrual bleeding.
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
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.

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 to have a documented discussion about all recommended treatment options.
Healthcare professionals ensure that women with heavy menstrual bleeding have a documented discussion about all recommended treatment options.
Commissioners ensure that they commission services with local agreements for women with heavy menstrual bleeding to have a documented discussion about all recommended treatment options.

What the quality statement means for patients and carers

Women with heavy menstrual bleeding¬ discuss all recommended treatment options with their doctor.

Source guidance

Heavy menstrual bleeding: assessment and management (2018) NICE guideline NG88, recommendation 1.4.2

Definitions of terms used in this quality statement

Documented discussion
The discussion should be between the woman and the relevant doctor. It should reflect the advice in section 1.5 of NICE’s guideline on heavy menstrual bleeding and cover:
  • the benefits and risks of the various options
  • suitable treatments if she is trying to conceive
  • whether she wants to retain her fertility and/or her uterus.
This discussion should be documented in the woman’s notes. Written information about the different treatment options should be given to the woman.
Recommended treatment options
Treatments as outlined in section 1.5 of NICE’s guideline on heavy menstrual bleeding.

Equality and diversity considerations

Women from all socioeconomic backgrounds should have equal access to information about their treatment options.

Access to interventions for uterine fibroids

This statement has been removed. For more details see update information.

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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

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. However, before publication ulipristal acetate was removed from the recommendations because the European Medicines Agency (EMA) is reviewing its use for uterine fibroids and have introduced temporary safety measures. This is due to concerns about serious liver injury. See the EMA website for more information.
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: March 2018

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