Return to CG44 Overview

Heavy menstrual bleeding [CG44]

Measuring the use of this guidance

Recommendation: 1.2.1

Initially, a history should be taken from the woman. This should cover the nature of the bleeding, related symptoms that might suggest structural or histological abnormality (see recommendation 1.2.4), impact on quality of life and other factors that may determine treatment options (such as presence of comorbidity).

What was measured: Proportion of women who were asked about their quality of life before referral for heavy menstrual bleeding.
Data collection end: May 2013
23%
Area covered: Local
Source: Joseph B.M. (2014) Primary care referrals for heavy menstrual bleeding. Gynecological Surgery; 329-330


Recommendation: 1.2.4

If the history suggests HMB with structural or histological abnormality, with symptoms such as intermenstrual or postcoital bleeding, pelvic pain and/or pressure symptoms, a physical examination and/or other investigations (such as ultrasound) should be performed

What was measured: Women referred to secondary care who had an examination recorded from their primary care contact
9.5%
Number that met the criteria: 4 / 42
Area covered: Local
Source: Wahba J, O’Reilly R & Miskry T (2012) Adherence to published guidelines for the management of menorrhagia in primary and secondary care. British Journal of Obstetrics and Gynaecology. Vol 119 (June) RCOG Congress Abstracts Page 208


Recommendation: 1.2.5

Measuring menstrual blood loss either directly (alkaline haematin) or indirectly ('Pictorial blood loss assessment chart') is not routinely recommended for HMB. Whether menstrual blood loss is a problem should be determined not by measuring blood loss but by the woman herself.

What was measured: Units that rarely or never consider the use of objective measures of blood loss at first outpatient appointment
82.3%
Number that met the criteria: / 220
Area covered: National
Source: Cox SM et al (2013) The delivery of heavy menstrual bleeding services in England and Wales after publication of national guidelines: a survey of hospitals. BMC Health Services Research Vol 13 pp491

What was measured: Percentage of hospitals that reported objective method of measuring blood loss was 'always' or 'mostly' considered.
Data collection end: December 2013
19.4%
Number that met the criteria: 35 / 180
Area covered: National
Source: The Royal College of Obstetricians and Gynaecologists. National Heavy Menstrual Bleeding Audit.


Recommendation: 1.2.8

A full blood count test should be carried out on all women with HMB. This should be done in parallel with any HMB treatment offered

What was measured: Women who had a full blood count recorded in primary care
50%
Area covered: Local
Source: Wahba J, O’Reilly R & Miskry T (2012) Adherence to published guidelines for the management of menorrhagia in primary and secondary care. British Journal of Obstetrics and Gynaecology. Vol 119 (June) RCOG Congress Abstracts Page 208

What was measured: Units that always or mostly consider ordering a full blood count at the first outpatient appointment
61.2%
Number that met the criteria: / 214
Area covered: National
Source: Cox SM et al (2013) The delivery of heavy menstrual bleeding services in England and Wales after publication of national guidelines: a survey of hospitals. BMC Health Services Research Vol 13 pp491

What was measured: Percentage of hospitals that 'always' or mostly' considered taking a full blood count.
Data collection end: December 2013
53.1%
Number that met the criteria: 95 / 179
Area covered: National
Source: The Royal College of Obstetricians and Gynaecologists. National Heavy Menstrual Bleeding Audit.

What was measured: Percentage of hospitals that reported that patients would ‘always’ or ‘mostly’ have had full blood count in primary care before being referred to hospital.
Data collection end: December 2013
52.2%
Area covered: National
Source: The Royal College of Obstetricians and Gynaecologists. National Heavy Menstrual Bleeding Audit.

What was measured: Proportion of women who had a full blood count carried out before referral for heavy menstrual bleeding.
Data collection end: May 2013
24%
Area covered: Local
Source: Joseph B.M. (2014) Primary care referrals for heavy menstrual bleeding. Gynecological Surgery; 329-330


Recommendation: 1.2.13

If appropriate, a biopsy should be taken to exclude endometrial cancer or atypical hyperplasia. Indications for a biopsy include, for example, persistent intermenstrual bleeding, and in women aged 45 and over treatment failure or ineffective treatment

What was measured: Units that always or mostly consider the use of pathology, e.g. endometrial biopsy, at first outpatient appointment
50.7%
Number that met the criteria: / 219
Area covered: National
Source: Cox SM et al (2013) The delivery of heavy menstrual bleeding services in England and Wales after publication of national guidelines: a survey of hospitals. BMC Health Services Research Vol 13 pp491


Recommendation: 1.2.15

Ultrasound is the first-line diagnostic tool for identifying structural abnormalities.

What was measured: Units that always or mostly consider the use of an ultrasound at the first outpatient appointment
70.6%
Number that met the criteria: / 221
Area covered: National
Source: Cox SM et al (2013) The delivery of heavy menstrual bleeding services in England and Wales after publication of national guidelines: a survey of hospitals. BMC Health Services Research Vol 13 pp491


Recommendation: 1.3.1

A woman with HMB referred to specialist care should be given information before her outpatient appointment. The Institute's information for patients ('Understanding NICE guidance') is available.

What was measured: Percentage of hospital who provided an information leaflet to women attending an outpatient appointment.
Data collection end: December 2013
84.4%
Area covered: National
Source: The Royal College of Obstetricians and Gynaecologists. National Heavy Menstrual Bleeding Audit.

What was measured: Percentage of hospital who referred patients to a website for information.
Data collection end: December 2013
10.6%
Area covered: National
Source: The Royal College of Obstetricians and Gynaecologists. National Heavy Menstrual Bleeding Audit.

What was measured: Percentage of hospital who provided written information.
Data collection end: December 2013
87.8%
Area covered: National
Source: The Royal College of Obstetricians and Gynaecologists. National Heavy Menstrual Bleeding Audit.


Recommendation: 1.5.2

The healthcare professional should determine whether hormonal contraception is acceptable to the woman before recommending treatment (for example, she may wish to conceive).

What was measured: Women who were asked if they wish to conceive in primary care
21.4%
Number that met the criteria: 9 / 42
Area covered: Local
Source: Wahba J, O’Reilly R & Miskry T (2012) Adherence to published guidelines for the management of menorrhagia in primary and secondary care. British Journal of Obstetrics and Gynaecology. Vol 119 (June) RCOG Congress Abstracts Page 208

What was measured: Women who were asked if they wish to conceive in secondary care
64.3%
Number that met the criteria: 27 / 42
Area covered: Local
Source: Wahba J, O’Reilly R & Miskry T (2012) Adherence to published guidelines for the management of menorrhagia in primary and secondary care. British Journal of Obstetrics and Gynaecology. Vol 119 (June) RCOG Congress Abstracts Page 208


Recommendation: 1.6.6

All women considering endometrial ablation should have access to a second-generation ablation technique.

What was measured: Percentage of hospitals who offered one or more second-generation ablation techniques.
Data collection end: December 2013
96.7%
Area covered: National
Source: The Royal College of Obstetricians and Gynaecologists. National Heavy Menstrual Bleeding Audit.


Recommendation: 1.6.7

Second-generation ablation techniques should be used where no structural or histological abnormality is present. The second-generation techniques recommended for consideration are as follows. Providers should ensure that when purchasing any of these that they buy the least expensive available option.[5],[6],[7],[8] • Impedance-controlled bipolar radiofrequency ablation (formerly NICE interventional procedure guidance 104) • Fluid-filled thermal balloon endometrial ablation (TBEA) (formerly NICE interventional procedure guidance 6) • Microwave endometrial ablation (MEA) (formerly NICE interventional procedure guidance 7) • Free fluid thermal endometrial ablation (formerly NICE interventional procedure guidance 51).

What was measured: Percentage of hospitals who offered one or more second-generation ablation techniques.
Data collection end: December 2013
96.7%
Area covered: National
Source: The Royal College of Obstetricians and Gynaecologists. National Heavy Menstrual Bleeding Audit.



 Return to CG44 Overview