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Evidence to Improve Care

Heavy Menstrual Bleeding

Care for Adults and Adolescents of Reproductive Age

Click below to see a list of brief quality statements and scroll down for more information.​​


Quality standards are sets of concise statements designed to help health care professionals easily and quickly know what care to provide, based on the best evidence. ​

See below for the quality statements and click for more detail.​


Quality Statement 1: Comprehensive Initial Assessment
Patients with symptoms of heavy menstrual bleeding have a detailed history taken, gynecological exam, complete blood count test, and pregnancy test (if pregnancy is possible) during their initial assessment.


Quality Statement 2: Shared Decision-Making
Patients with heavy menstrual bleeding are provided with information on all potential treatment options and are supported in making an informed decision on the most appropriate treatments for them, based on their values, preferences, and goals, including their desire for future fertility.


Quality Statement 3: Pharmacological Treatments
Patients with heavy menstrual bleeding are offered a choice of non-hormonal and hormonal pharmacological treatment options.


Quality Statement 4: Endometrial Biopsy
Patients with heavy menstrual bleeding who exhibit risk factors for endometrial cancer or endometrial hyperplasia are offered an endometrial biopsy.


Quality Statement 5: Ultrasound Imaging
Patients with heavy menstrual bleeding who have suspected structural abnormalities based on a pelvic exam, or who have tried pharmacological treatment but have not had significant improvement in their symptoms, are offered an ultrasound of their uterus.


Quality Statement 6: Referral to a Gynecologist
Patients with heavy menstrual bleeding have a comprehensive initial assessment and pharmacological treatments offered prior to referral to a gynecologist. Once the referral has been made, patients are seen by the gynecologist within 3 months.


Quality Statement 7: Endometrial Ablation
Patients with heavy menstrual bleeding who do not wish to preserve their fertility are offered endometrial ablation. In the absence of structural abnormalities, patients have access to non-resectoscopic endometrial ablation techniques.


Quality Statement 8: Acute Heavy Menstrual Bleeding
Patients presenting acutely with uncontrolled heavy menstrual bleeding receive interventions to stop the bleeding, therapies to rapidly correct severe anemia, and an outpatient follow-up appointment with a health care professional at or immediately following their next period (roughly 4 weeks).


Quality Statement 9: Dilation and Curettage
Patients with heavy menstrual bleeding do not receive dilation and curettage unless they present acutely with uncontrolled bleeding and medical therapy is ineffective or contraindicated.


Quality Statement 10: Offering Hysterectomy
Patients with heavy menstrual bleeding are offered hysterectomy only after a documented discussion about other treatment options, or after other treatments have failed.


Quality Statement 11: Least Invasive Hysterectomy
Patients with heavy menstrual bleeding who have chosen to have a hysterectomy have it performed by the least invasive method possible.


Quality Statement 12: Treatment for Fibroids Causing Heavy Menstrual Bleeding
Patients with heavy menstrual bleeding related to fibroids are offered uterine artery embolization, myomectomy, and hysterectomy as treatment options.


Quality Statement 13: Bleeding Disorders in Adolescents
Adolescents with heavy menstrual bleeding are screened for risk of inherited bleeding disorder, using a structured assessment tool.


Quality Statement 14: Treatment of Anemia and Iron Deficiency
Patients with heavy menstrual bleeding who have been diagnosed with anemia or iron deficiency are treated with oral and/or intravenous iron.

Summary

This quality standard addresses care for people of reproductive age who have heavy menstrual bleeding, regardless of the underlying cause. The quality standard includes both acute and chronic heavy menstrual bleeding, and applies to all care settings. It does not apply to people with non-menstrual bleeding or with heavy menstrual bleeding occurring within 3 months of a pregnancy, miscarriage, or abortion.


This quality standard includes 14 quality statements addressing areas that were identified by Health Quality Ontario’s Heavy Menstrual Bleeding Quality Standard Advisory Committee as having high potential for improvement in the way that care for heavy menstrual bleeding is currently provided in Ontario. This quality standard focuses on adults and adolescents of reproductive age presenting with either acute or chronic heavy menstrual bleeding in any care setting, regardless of the underlying cause of the bleeding. However, it does not cover the management of cancer or endometriosis once diagnosed. This quality standard does not apply to people who are pregnant or postmenopausal, or who have had a delivery, miscarriage, or abortion in the past 3 months.

In this quality standard, we consider heavy menstrual bleeding to mean excessive menstrual blood loss that interferes with people’s physical, social, emotional, or material quality of life. It can occur alone or in combination with other symptoms.

Heavy menstrual bleeding affects up to 30% of women of reproductive age. It can be debilitating and persistent, and can ultimately have a negative impact on a person’s quality of life.Fatigue due to iron deficiency anemia and worry about the bleeding may lead people to miss work or withdraw from social activities they previously enjoyed. Rare complications associated with heavy menstrual bleeding include hypovolemic shock,2 acute ischemic stroke, retinopathy, and venous sinus thrombosis.

The quality of care for heavy menstrual bleeding varies across Ontario. For example, the age-adjusted rate of hysterectomies for people with heavy menstrual bleeding varies more than 10-fold across the 14 local health integration networks (LHINs) (2013/2014 data from the Discharge Abstract Database and the National Ambulatory Care Reporting System). This suggests that patients have inequitable access to the variety of medical and surgical treatment options for heavy menstrual bleeding. In contrast, there is only a small variation across the LHINs in the age-adjusted rates of hysterectomies for cancer and for prolapse.

Based on evidence and expert consensus, the 14 quality statements that make up this standard provide guidance on high-quality care, with accompanying indicators to help health care professionals and organizations measure the quality of the care they provide.

Helping patients actively share in decision-making about their treatment choices is also a focus of this quality standard. There is no single "best treatment" for all cases of heavy menstrual bleeding. The most appropriate treatment for an individual patient will depend on personal factors such as the cause of the heavy menstrual bleeding, its impact on their quality of life, their other health conditions, their desire for future fertility, and the cost of treatment.

This quality standard is underpinned by the principles of respect and equity. People with heavy menstrual bleeding should receive services that are respectful of their rights and dignity and that promote self-determination.

People with heavy menstrual bleeding should receive services that are respectful of their gender identity, sexual orientation, socioeconomic status, housing, age, background (including self-identified cultural, ethnic, and religious background), and disability.

A high-quality health system is one that provides good access, experience, and outcomes for all Ontarians no matter where they live, what they have, or who they are.

A limited number of overarching objectives are set for this quality standard; these objectives have been mapped to performance indicators to measure the success of this quality standard as a whole.

  • Percentage of patients with heavy menstrual bleeding who reported being satisfied with symptom control

  • Percentage of patients with heavy menstrual bleeding who reported that their health care professional always or often involves them in decisions about their care and treatment

  • Percentage of patients with heavy menstrual bleeding who had unplanned emergency department visits for heavy menstrual bleeding

  • Rate of hysterectomies among patients with heavy menstrual bleeding, by LHIN (to show regional variation in the use of this treatment option)

In addition, each quality statement within this quality standard is accompanied by one or more indicators to measure the successful implementation of the statement.

Heavy menstrual bleeding affects up to 30% of women of reproductive age. It can be debilitating and persistent, and can ultimately have a negative impact on a person’s quality of life. Fatigue due to iron deficiency anemia and worry about the bleeding may lead people to miss work or withdraw from social activities they previously enjoyed.

The quality of care for heavy menstrual bleeding varies across Ontario. Data suggests that the age-adjusted rate of hysterectomies for people with heavy menstrual bleeding varies more than 10-fold across the 14 local health integration networks (LHINs)1. This may be due to variance in practice caused by inequitable access to the variety of medical and surgical treatment options, or differences in surgeon training, experience and familiarity with newer procedures and medical options used to treat bleeding. That is why Health Quality Ontario has created a quality standard for heavy menstrual bleeding to inform clinicians, organizations and patients what high-quality health care for people living with this condition should look like.

Figure 1

graph



12013/2014 data from the Discharge Abstract Database and the National Ambulatory Care Reporting System.

Heavy Menstrual Bleeding Quality Standard – Provider’s quote

“Right now, I feel all the knowledge and information on how to provide care for patients with Heavy Menstrual Bleeding (HMB) remains in silos. For example, in the emergency department, an active bleed may be approached one way and gynecologists will approach heavy menstrual bleeding with other options. But providers need to connect better. And that is why the HMB quality standard will be helpful. It will create a ‘continuum’ and bring providers together, helping us understand what everyone’s role is in the care process. It will encourage providers to use a common approach when providing patient care, and will help set expectations of care when referring patients to our colleagues and specialists. In addition, I hope the standard will help women understand what can be done for them.”

Dr. Mary Johnston, Heavy Menstrual Bleeding Advisory Panel Member

“I was advised at different occasions to have an ultrasound (despite not having had a recent physical examination) to identify the cause of the heavy bleeding. Many discussions I had with providers were around the ultrasound results. To get rid of the symptoms I was offered medication, but I did not want to take them and wanted to know why I needed medication, when we did not know the cause of the heavy bleeding. The statement on shared-decision making is very important. Providers want to treat symptoms and patients want to understand what is going on, be given options and be involved in deciding what diagnostic procedures and treatment they should receive. I hope this set of quality standards will encourage a dynamic where physicians work with patients on treatment options and standardize practices across the board.”

Magdalena Turlejski, Heavy Menstrual Bleeding Quality Standard Advisory Committee, panel member

This quality standard was completed in September 2017.

For more information, contact QualityStandards@HQOntario.ca.

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