Quality standard
Quality statement 2: Diagnosis – physical examination
- Quality statement
- Rationale
- Quality measures
- What the quality statement means for service providers, healthcare professionals and commissioners
- What the quality statement means for patients and carers
- Source guidance
- Definitions of terms used in this quality statement
- Equality and diversity considerations
Quality statement 2: Diagnosis – physical examination
Quality statement
Women with heavy menstrual bleeding in whom a structural or histological abnormality is suspected have a physical examination before referral for further investigations.
Rationale
Accurate diagnosis is important because the presence of a structural or histological abnormality, particularly uterine fibroids larger than 3 cm, influences the woman's treatment options. Evidence presented in the full clinical guideline on heavy menstrual bleeding suggests that up to 30% of women with heavy menstrual bleeding have associated uterine fibroids. The purpose of a physical examination (see definition) 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 in whom a structural or histological abnormality is suspected 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 in whom a structural or histological abnormality is suspected 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 in whom a structural or histological abnormality is suspected.
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 in whom a structural or histological abnormality is suspected to have a physical examination before referral for further investigations.
Healthcare professionals ensure that women with heavy menstrual bleeding in whom a structural or histological abnormality is suspected have a physical examination before referral for further investigations.
Commissioners ensure that they commission services with local systems for women with heavy menstrual bleeding in whom a structural or histological abnormality is suspected 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.
Definitions of terms used in this quality statement
Suspected structural or histological abnormalities
Structural and histological abnormalities may be suspected as result of the woman's detailed history, which should be taken when the woman presents with symptoms of heavy menstrual bleeding (see quality statement 1).
Structural abnormality (uterine fibroids)
The full clinical guideline on heavy menstrual bleeding defines uterine fibroids as smooth-muscle tumours of the uterus, generally benign although occasionally (less than 1%) malignant. They vary greatly in size from millimetres to tens of centimetres, and are associated with heavy periods, pressure symptoms and occasionally pain. Small uterine fibroids are 3 cm or less in diameter and large uterine fibroids are more than 3 cm in diameter.
Physical examination
The full clinical 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 (NICE clinical guideline 44 recommendation 1.2.6).
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
NICE clinical guideline 44 recommendation 1.2.15 states that ultrasound is the first-line diagnostic tool for identifying structural abnormalities. Recommendation 1.2.13 states that if appropriate a biopsy should be undertaken to exclude endometrial cancer or atypical hyperplasia.