Recommendations

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.

1.1 Impact of heavy menstrual bleeding (HMB) on women

1.1.1 Recognise that heavy menstrual bleeding (HMB) has a major impact on a woman's quality of life, and ensure that any intervention aims to improve this rather than focusing on blood loss. [2007]

1.2 History, physical examination and laboratory tests

History

1.2.1 Take a history from the woman that covers:

  • 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). [2007, amended 2018]

1.2.2 Take into account the range and natural variability in menstrual cycles and blood loss when diagnosing HMB, and discuss this variation with the woman. If the woman feels that she does not fall within the normal ranges, discuss care options. [2007]

1.2.3 If the woman has a history of HMB without other related symptoms (see recommendation 1.2.1), consider pharmacological treatment without carrying out a physical examination (unless the treatment chosen is levonorgestrel-releasing intrauterine system [LNG IUS][1]). [2007, amended 2018]

Physical examination

1.2.4 If the woman has a history of HMB with other related symptoms (see recommendation 1.2.1) offer a physical examination. [2007, amended 2018]

1.2.5 Carry out a physical examination before all investigations or LNG-IUS[1] fittings. [2007]

Laboratory tests

1.2.6 Carry out a full blood count test for all women with HMB, in parallel with any HMB treatment offered. [2007]

1.2.7 Testing for coagulation disorders (for example, von Willebrand's disease) should be considered for women who:

  • have had HMB since their periods started and

  • have a personal or family history suggesting a coagulation disorder. [2007]

1.2.8 Do not routinely carry out a serum ferritin test for women with HMB. [2007]

1.2.9 Do not carry out female hormone testing for women with HMB. [2007]

1.2.10 Do not carry out thyroid hormone testing for women with HMB unless other signs and symptoms of thyroid disease are present. [2007]

1.3 Investigations for the cause of HMB

Before starting investigations

1.3.1 Consider starting pharmacological treatment for HMB without investigating the cause if the woman's history and/or examination suggests a low risk of fibroids, uterine cavity abnormality, histological abnormality or adenomyosis. [2018]

1.3.2 If cancer is suspected, see the NICE guideline on suspected cancer: recognition and referral. [2007]

Investigations

1.3.3 Take into account the woman's history and examination when deciding whether to offer hysteroscopy or ultrasound as the first-line investigation. [2018]

Women with suspected submucosal fibroids, polyps or endometrial pathology

1.3.4 Offer outpatient hysteroscopy to women with HMB if their history suggests submucosal fibroids, polyps or endometrial pathology because:

  • they have symptoms such as persistent intermenstrual bleeding or

  • they have risk factors for endometrial pathology (see recommendation 1.3.10). [2018]

1.3.5 Ensure that outpatient hysteroscopy services are organised and the procedure is performed according to best practice, including:

  • advising women to take oral analgesia before the procedure

  • vaginoscopy as the standard diagnostic technique, using miniature hysteroscopes (3.5 mm or smaller). [2018]

1.3.6 Ensure that hysteroscopy services are organised to enable progression to 'see-and-treat' hysteroscopy in a single setting if feasible. [2018]

1.3.7 Explain to women with HMB who are offered outpatient hysteroscopy what the procedure involves and discuss the possible alternatives. [2018]

1.3.8 If a woman declines outpatient hysteroscopy, offer hysteroscopy under general or regional anaesthesia. [2018]

1.3.9 For women who decline hysteroscopy, consider pelvic ultrasound, explaining the limitations of this technique for detecting uterine cavity causes of HMB. [2018]

1.3.10 Consider endometrial biopsy at the time of hysteroscopy for women who are at high risk of endometrial pathology, such as:

  • women with persistent intermenstrual or persistent irregular bleeding, and women with infrequent heavy bleeding who are obese or have polycystic ovary syndrome

  • women taking tamoxifen

  • women for whom treatment for HMB has been unsuccessful. [2007, amended 2018]

1.3.11 Obtain an endometrial sample only in the context of diagnostic hysteroscopy. Do not offer 'blind' endometrial biopsy to women with HMB. [2018]

Women with possible larger fibroids

1.3.12 Offer pelvic ultrasound to women with HMB if any of the following apply:

  • their uterus is palpable abdominally

  • history or examination suggests a pelvic mass

  • examination is inconclusive or difficult, for example in women who are obese. [2018]

Women with suspected adenomyosis

1.3.13 Offer transvaginal ultrasound (in preference to transabdominal ultrasound or MRI) to women with HMB who have:

  • significant dysmenorrhoea (period pain) or

  • a bulky, tender uterus on examination that suggests adenomyosis. [2018]

1.3.14 If a woman declines transvaginal ultrasound or it is not suitable for her, consider transabdominal ultrasound or MRI, explaining the limitations of these techniques. [2018]

1.3.15 Be aware that pain associated with HMB may be caused by endometriosis rather than adenomyosis (see NICE's guideline on endometriosis). [2018]

Other diagnostic tools

1.3.16 Do not use saline infusion sonography as a first-line diagnostic tool for HMB. [2007]

1.3.17 Do not use MRI as a first-line diagnostic tool for HMB. [2007]

1.3.18 Do not use dilatation and curettage alone as a diagnostic tool for HMB. [2007]

To find out why the committee made the 2018 recommendations on investigations for women with HMB and how they might affect practice, see rationale and impact.

1.4 Information for women about HMB and treatments

1.4.1 Provide women with information about HMB and its management. Follow the principles in the NICE guideline on patient experience in adult NHS services in relation to communication, information and shared decision-making. [2018]

1.4.2 Provide information about all possible treatment options for HMB and discuss these with the woman (see section 1.5). Discussions should 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. [2018]

Levonorgestrel-releasing intrauterine system (LNG-IUS)

1.4.3 Explain to women who are offered an LNG-IUS[1]:

  • about anticipated changes in bleeding pattern, particularly in the first few cycles and maybe lasting longer than 6 months

  • that it is advisable to wait for at least 6 cycles to see the benefits of the treatment. [2007]

Impact of treatments on fertility

1.4.4 Explain to women about the impact on fertility that any planned surgery or uterine artery embolisation may have, and if a potential treatment (hysterectomy or ablation) involves loss of fertility then opportunities for discussion should be made available. [2007]

1.4.5 Explain to women that uterine artery embolisation or myomectomy may potentially allow them to retain their fertility. [2007]

Endometrial ablation

1.4.6 Advise women to avoid subsequent pregnancy and use effective contraception, if needed, after endometrial ablation. [2007]

Hysterectomy

1.4.7 Have a full discussion with all women who are considering hysterectomy about the implications of surgery before a decision is made. The discussion should include:

  • sexual feelings

  • impact on fertility

  • bladder function

  • need for further treatment

  • treatment complications

  • her expectations

  • alternative surgery

  • psychological impact. [2007]

1.4.8 Inform women about the increased risk of serious complications (such as intraoperative haemorrhage or damage to other abdominal organs) associated with hysterectomy when uterine fibroids are present. [2007]

1.4.9 Inform women about the risk of possible loss of ovarian function and its consequences, even if their ovaries are retained during hysterectomy. [2007]

1.5 Management of HMB

1.5.1 When agreeing treatment options for HMB with women, take into account:

  • the woman's preferences

  • any comorbidities

  • the presence or absence of fibroids (including size, number and location), polyps, endometrial pathology or adenomyosis

  • other symptoms such as pressure and pain. [2018]

Treatments for women with no identified pathology, fibroids less than 3 cm in diameter, or suspected or diagnosed adenomyosis

1.5.2 Consider an LNG-IUS[1] as the first treatment for HMB in women with:

  • no identified pathology or

  • fibroids less than 3 cm in diameter, which are not causing distortion of the uterine cavity or

  • suspected or diagnosed adenomyosis. [2018]

1.5.3 If a woman with HMB declines an LNG-IUS or it is not suitable, consider the following pharmacological treatments:

  • non-hormonal:

    • tranexamic acid

    • NSAIDs (non-steroidal anti-inflammatory drugs)[2]

  • hormonal:

    • combined hormonal contraception[3]

    • cyclical oral progestogens. [2018]

1.5.4 Be aware that progestogen-only contraception may suppress menstruation, which could be beneficial to women with HMB. [2018]

1.5.5 If treatment is unsuccessful, the woman declines pharmacological treatment, or symptoms are severe, consider referral to specialist care for:

  • investigations to diagnose the cause of HMB, if needed (see section 1.3) taking into account any investigations the woman has already had and

  • alternative treatment choices, including:

    • pharmacological options not already tried (see recommendations 1.5.2 and 1.5.3)

    • surgical options:

      • second-generation endometrial ablation

      • hysterectomy. [2018]

1.5.6 For women with submucosal fibroids, consider hysteroscopic removal. [2018]

Treatments for women with fibroids of 3 cm or more in diameter

1.5.7 Consider referring women to specialist care to undertake additional investigations and discuss treatment options for fibroids of 3 cm or more in diameter. [2018]

1.5.8 If pharmacological treatment is needed while investigations and definitive treatment are being organised, offer tranexamic acid and/or NSAIDs[2]. [2007]

1.5.9 Advise women to continue using NSAIDs[2] and/or tranexamic acid for as long as they are found to be beneficial. [2007]

1.5.10 For women with fibroids of 3 cm or more in diameter, take into account the size, location and number of fibroids, and the severity of the symptoms and consider the following treatments:

  • pharmacological:

    • non-hormonal:

      • tranexamic acid

      • NSAIDs[2]

    • hormonal:

      • ulipristal acetate (see recommendations 1.5.11 and 1.5.12)

      • LNG-IUS[1]

      • combined hormonal contraception[3]

      • cyclical oral progestogens

  • uterine artery embolisation

  • surgical:

    • myomectomy

    • hysterectomy. [2018, amended Nov 2018]

1.5.11 If ulipristal acetate[4] is the preferred treatment option, be aware of measures to reduce the risk of rare but serious liver injury:

  • discuss the relative benefits and harms of ulipristal acetate with women, including recognising the signs and symptoms of liver injury, to enable an informed decision

  • monitor liver function for the first 2 treatment courses, and as clinically indicated, in line with current prescribing guidance. [Nov 2018]

1.5.12 When ulipristal[4] is used for intermittent treatment in women who are not eligible for surgery, for example where the risks of surgery outweigh the benefits or where the woman declines surgical treatment:

  • Offer ulipristal acetate 5 mg (up to 4 courses) to women with heavy menstrual bleeding and fibroids of 3 cm or more in diameter, and a haemoglobin level of 102 g per litre or below.

  • Consider ulipristal acetate 5 mg (up to 4 courses) for women with heavy menstrual bleeding and fibroids of 3 cm or more in diameter, and a haemoglobin level above 102 g per litre. [Nov 2018]

1.5.13 Be aware that the effectiveness of pharmacological treatments for HMB (excluding ulipristal acetate) may be limited in women with fibroids that are substantially greater than 3 cm in diameter. [2018, amended Nov 2018]

1.5.14 Prior to scheduling of uterine artery embolisation or myomectomy, the woman's uterus and fibroid(s) should be assessed by ultrasound. If further information about fibroid position, size, number and vascularity is needed, MRI should be considered. [2007]

1.5.15 Consider second-generation endometrial ablation as a treatment option for women with HMB and fibroids of 3 cm or more in diameter who meet the criteria specified in the manufacturers' instructions. [2018]

1.5.16 If treatment is unsuccessful:

  • consider further investigations to reassess the cause of HMB (see section 1.3), taking into account the results of previous investigations and

  • offer alternative treatment with a choice of the options described in recommendation 1.5.10. [2018]

1.5.17 Pretreatment with a gonadotrophin-releasing hormone analogue[5] or ulipristal acetate before hysterectomy and myomectomy should be considered if uterine fibroids are causing an enlarged or distorted uterus. [2007, amended 2018, amended Nov 2018]

Route and method of hysterectomy

1.5.18 When discussing the route of hysterectomy (laparoscopy, laparotomy or vaginal) with the woman, carry out an individual assessment and take her preferences into account. [2007, amended 2018]

1.5.19 Discuss the options of total hysterectomy (removal of the uterus and the cervix) and subtotal hysterectomy (removal of the uterus and retention of the cervix) with the woman. [2007, amended 2018]

Removal of ovaries (oophorectomy) with hysterectomy

1.5.20 Only remove ovaries with hysterectomy with the express wish and informed consent of the woman, after discussion of all associated risks and benefits. [2007, amended 2018]

Dilatation and curettage

1.5.21 Do not offer dilatation and curettage as a treatment option for HMB. [2007]

1.5.22 If dilatation is needed for non-hysteroscopic endometrial ablation:

  • confirm that there is no evidence of uterine perforation or false passage

  • use hysteroscopy before inserting the ablation device, to establish the condition of the uterus

  • ultrasound may be used to ensure correct uterine placement of the ablation device; if the device uses a balloon, keep this inflated during the ultrasound scan. [2007, amended 2018]

To find out why the committee made the 2018 recommendations on management of HMB and how they might affect practice, see rationale and impact.



[1] At the time of publication (March 2018), not all LNG-IUSs have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

[2] At the time of publication (March 2018), NSAIDs do not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

[3] At the time of publication (March 2018), not all combined hormonal contraceptives have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

[4] Ulipristal is indicated for 1 course (lasting up to 3 months) of pre-operative treatment for moderate to severe symptoms of uterine fibroids and for intermittent treatment (up to 4 courses) of moderate to severe symptoms of uterine fibroids in adult women of reproductive age who are not eligible for surgery. Use this recommendation in conjunction with the summary of product characteristics.

[5] At the time of publication (March 2018), not all gonadotrophin-releasing hormone analogues have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

  • National Institute for Health and Care Excellence (NICE)