Quality statement 2: Diagnosis – physical examination

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.