Heavy menstrual bleeding

Structure

a) Evidence of local arrangements that women with heavy menstrual bleeding and a normal uterus or small uterine fibroids who choose surgical intervention have a documented discussion about endometrial ablation as a preferred treatment to hysterectomy.

Data source: Local data collection.

b) Evidence that service providers have networks in place to refer women for endometrial ablation if this intervention is not provided locally.

Data source: Local data collection. The National heavy menstrual bleeding audit includes an organisational audit to establish provision of treatment options (see section 4 in the first annual report of the National heavy menstrual bleeding audit). These data may inform a baseline assessment.

Process

The proportion of women with heavy menstrual bleeding and a normal uterus or small uterine fibroids who choose surgical intervention have a documented discussion about endometrial ablation as a preferred treatment to hysterectomy.

Numerator – the number of women in the denominator who have a documented discussion about endometrial ablation as a preferred treatment to hysterectomy.

Denominator – the number of women with heavy menstrual bleeding and a normal uterus or small uterine fibroids who choose surgical intervention.

Data source: Local data collection. The National heavy menstrual bleeding audit includes an analysis of patterns of surgical treatment for women with heavy menstrual bleeding (see section 3 and appendix 3 in the first annual report of the National heavy menstrual bleeding audit). These data may inform a baseline assessment.

Outcome

a) Women's satisfaction with the decision‑making process when choosing surgical treatment for heavy menstrual bleeding.

Data source: Local data collection. The National heavy menstrual bleeding audit includes an analysis of women's self-reported experiences of the secondary care they received. The analysis includes the elements 'information received and satisfaction with information received', 'communication with doctors in secondary care' and 'overall rating of care received' (see section 7 in the third annual report of the National heavy menstrual bleeding audit). These data may inform a baseline assessment.

b) Rates of endometrial ablation and hysterectomy.

Data source: Local data collection. The National heavy menstrual bleeding audit includes an analysis of patterns of surgical treatment for women with heavy menstrual bleeding (see section 3 and appendix 3 in the first annual report of the National heavy menstrual bleeding audit). These data may inform a baseline assessment.

Documented discussion

The discussion should be between the woman and the relevant clinician. It should reflect the guidance in sections 1.6 and 1.8 of NICE clinical guideline 44 and include the different types of interventions and the potential short-, medium- and long-term effects these can have. This discussion should be documented in the woman's notes. Written information about the different treatment options should be given to the woman.

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.

Endometrial ablation

NICE clinical guideline 44 recommends that all women considering endometrial ablation should have access to a second-generation ablation technique (see recommendations 1.6.6 and 1.6.7).

Women who choose surgery

In women with heavy menstrual bleeding and a normal uterus or small uterine fibroids, drug treatment should be considered before surgical intervention (see quality statement 3). For some women drug treatment may be unsuitable because it is declined, contraindicated or fails to adequately control their symptoms.