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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.

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.


If a patient chooses hysterectomy as treatment for heavy menstrual bleeding, they should be offered the least invasive method possible, to minimize complications and recovery time. Both vaginal and laparoscopic approaches are less invasive than open abdominal hysterectomy and are associated with reduced morbidity and length of stay in hospital. Prior to the surgery, management of anemia is recommended with oral or intravenous iron to optimize the patient’s hemoglobin level to greater than 120 g/L.

For Patients

If you choose a hysterectomy, you should be offered the type of surgery that is safest for you.


For Clinicians

If your patient elects to have a hysterectomy, always use the least invasive method possible. If your patient has a hemoglobin level of less than 120 g/L, use oral or intravenous iron to get their hemoglobin above 120 g/L before surgery.


For Health Services

Ensure systems, processes, and resources are in place such that patients have access to the least invasive options possible for hysterectomy, and that physicians have the training and equipment necessary to use newer and less invasive techniques, such as vaginal and laparoscopic approaches versus abdominal hysterectomies.

Process Indicator

Proportion of hysterectomies among patients with heavy menstrual bleeding that are performed as vaginal, laparoscopic, or abdominal

  • Denominator: number of patients with heavy menstrual bleeding who had a hysterectomy

  • Numerator: number of patients in the denominator who had a hysterectomy, by method:

    • Vaginal

    • Laparoscopic

    • Abdominal

  • Data sources: Discharge Abstract Database, Ontario Health Insurance Plan claims database


Percentage of patients with heavy menstrual bleeding who had a hysterectomy and who had a preoperative hemoglobin concentration higher than 120 g/L

  • Denominator: number of patients with heavy menstrual bleeding who had a hysterectomy

  • Numerator: number of patients in the denominator who had a preoperative hemoglobin level higher than 120 g/L

  • Data source: local data collection

Note: When auditing, ensure you use the patient’s hemoglobin level most recent to the surgery.

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