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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.

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.


Taking a detailed history and performing a physical exam will help to establish the cause of the heavy menstrual bleeding, direct further investigations, and guide management options. The comprehensive initial assessment can be performed over several visits. It is not recommended that patients routinely be asked to measure their blood loss. Heavy menstrual bleeding should be considered a problem if the patient believes it interferes with their life and normal functioning.

The following laboratory tests should not routinely be part of the initial assessment:

  • Thyroid testing — This should be done only when the history or physical examination suggests thyroid disease

  • Hormone testing and ferritin testing — Iron supplementation for anemia can be started without ordering a serum ferritin. Ferritin should not be ordered during an initial assessment unless iron deficiency without anemia is suspected; see Statement 14 for indications for ordering a serum ferritin test

  • Testing for coagulation disorders — This should only be considered in patients who have a history of heavy menstrual bleeding since menarche, a history of abnormal bleeding from other sites, or a family history of abnormal bleeding, and who screen positive using a structured bleeding assessment tool

For Patients

At your initial assessment, your family doctor or nurse practitioner should ask you about your bleeding and how it affects your life, do a pelvic exam, and ask you to get blood and urine tests.


For Clinicians

Ensure you perform a detailed history, gynecological exam, complete blood count, and pregnancy test (if pregnancy is possible) during the initial assessment. Heavy menstrual bleeding should be considered a problem if your patient feels their bleeding is too heavy and interferes with their life and normal functioning.


For Health Services

Ensure systems, processes, and resources are in place to assist clinicians with the comprehensive initial assessment of patients with heavy menstrual bleeding.

Process Indicator

Percentage of patients with heavy menstrual bleeding who had a comprehensive initial assessment for heavy menstrual bleeding, including a detailed history, complete blood count, gynecological exam, and pregnancy test (if pregnancy is possible)

  • Denominator: number of patients with heavy menstrual bleeding

  • Numerator: number of patients with heavy menstrual bleeding who have the required comprehensive initial assessment within 3 months of their first visit, including:

    • Detailed history

    • Complete blood count

    • Gynecological exam

    • Pregnancy test (if pregnancy is possible)

  • Data source: local data collection

Note: The indicator can be calculated as an overall percentage and by each listed component.

Detailed history

The history should address the following:

  • Details about the bleeding

  • Symptoms of anemia and iron deficiency (e.g., restless leg syndrome, hair loss, fatigue)

  • Sexual and reproductive history

  • Desire for future fertility

  • Impact on quality of life, including social and sexual functioning

  • Symptoms suggestive of systemic causes of bleeding such as hypothyroidism or coagulation disorders

  • Associated symptoms such as vaginal discharge or odour, pelvic pain or pressure

  • Co-morbid conditions such as hormonally dependent tumours, thromboembolic disease, or cardiovascular problems that could influence treatment options

  • A list of medications including over-the-counter and natural or herbal remedies

  • Personal history of, or risk factors for, endometrial or colon cancer (see Statement 4 for risk factors for endometrial cancer)

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