Heavy menstrual bleeding

Structure

a) Evidence of local arrangements for women with heavy menstrual bleeding without suspected structural or histological abnormalities to be offered drug treatment at the initial assessment.

Data source: Local data collection. The National heavy menstrual bleeding audit collected data about patterns of primary care treatment among women before referral (see section 7 in the second annual report of the National heavy menstrual bleeding audit). These data may inform a baseline assessment.

b) Evidence that service providers have networks in place to refer women for the fitting of a levonorgestrel-releasing intrauterine system if this is not provided within the referring service.

Data source: Local data collection.

Process

Proportion of women with heavy menstrual bleeding without suspected structural or histological abnormalities who are offered drug treatment at the initial assessment.

Numerator – the number of women in the denominator who are offered drug treatment at the initial assessment.

Denominator – the number of women presenting with heavy menstrual bleeding without suspected structural or histological abnormalities.

Data source: Local data collection. The National heavy menstrual bleeding audit collected data about patterns of primary care treatment among women before referral (see section 7 in the second annual report of the National heavy menstrual bleeding audit). These data may inform a baseline assessment.

Outcome

a) Women's satisfaction with symptom control and quality of life related to their heavy menstrual bleeding.

Data source: Local data collection. The National heavy menstrual bleeding audit collected data about clinical symptoms among women referred for heavy menstrual bleeding to outpatient clinics and quality of life of women at the first outpatient visit and at the 1-year follow-up appointment (see sections 5 and 6 in the second annual report of the National heavy menstrual bleeding audit and section 6 in the third annual report of the National heavy menstrual bleeding audit). These data may inform a baseline assessment.

b) Rates of referral to specialist services.

Data source: Local data collection. The National heavy menstrual bleeding audit collected data about referral patterns (see section 4 in the first annual report of the National heavy menstrual bleeding audit). These data may inform a baseline assessment.

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.

Histological abnormality

In particular, this means cancer or atypical hyperplasia.

Drug treatments

The drug treatment option chosen should take account of individual circumstances, including age, family planning needs and the relevant licensing considerations. Informed consent is needed when using medicines outside the licensed indications. Prescribers should also consider Long-acting reversible contraception (NICE clinical guideline 30).

NICE clinical guideline 44 recommendation 1.5.3 (key priority for implementation) recommends that treatments should be considered in the following order:

NICE clinical guideline 44 recommendation 1.5.4 recommends that if hormonal treatments are not acceptable to the woman, then either tranexamic acid or NSAIDs can be used.

Initial assessment

The initial assessment starts when the woman presents with symptoms of heavy menstrual bleeding. It is usually undertaken in primary care and involves 1 or more appointments, in which the woman receives a diagnosis and her treatment options are discussed.

The term 'initial assessment' has been included in the quality statement based on expert consensus.