Quality statement 1: Diagnosis – initial assessment

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.