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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.

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.


Patients presenting with heavy menstrual bleeding are at an increased risk of developing anemia and iron deficiency due to the excessive blood loss they experience each month. Anemia and iron deficiency need to be treated to improve the patient’s mental and physical functioning and prevent the need for transfusion. In addition, dietary counselling may be considered.

All patients who have anemia (hemoglobin concentration below 120 g/L in a non-pregnant menstruating patient), a low mean cell volume, a low red blood cell count, and a clear history of bleeding should be treated with iron but do not need a ferritin test. However, if patients with anemia do not respond to oral iron, their ferritin should be tested. Patients who are not anemic but exhibit symptoms of iron deficiency, such as restless legs, fatigue, or hair loss, should also have a ferritin test. Ferritin levels below 15 mcg/L are diagnostic of iron deficiency and levels of 15 to 50 mcg/L are strongly suggestive of iron deficiency.

For Patients

If you have low iron or anemia (low red blood cell count), you should be advised to take iron pills. You may need iron in liquid form through a needle (intravenously).


For Clinicians

If your patient has iron deficiency anemia from heavy menstrual bleeding, treat them with iron: first oral, then intravenous. Use transfusion only if the patient is suffering from serious side effects such as hypotension, chest pain, syncope, or tachycardia.


For Health Services

Ensure systems, processes, and resources are in place such that patients with heavy menstrual bleeding have equal access to all options to correct their iron deficiency anemia. Ensure clinicians have access to the appropriate laboratory tests for their patients and to protocols to avoid unnecessary transfusions in this population.

Process Indicator

Percentage of patients with heavy menstrual bleeding diagnosed with anemia or iron deficiency who were treated with iron, by delivery method (oral or intravenous)

  • Denominator: number of patients with heavy menstrual bleeding diagnosed with anemia or iron deficiency

  • Numerator: number of patients in denominator treated with iron, by delivery method:

    • Oral

    • Intravenous

  • Data source: local data collection

Note: Each type of iron treatment should be calculated separately as well as the overall rate.


Percentage of patients with heavy menstrual bleeding diagnosed with anemia who had a blood transfusion

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

  • Numerator: number of patients in the denominator who had a blood transfusion

  • Data sources: local data collection; for system level, Ontario Health Insurance Plan claims database, Discharge Abstract Database

Interventions to manage anemia and iron deficiency

Anemia and iron deficiency should be treated with oral or intravenous iron, in the following order:

  1. Oral iron for a minimum of 3 months to correct hemoglobin level and treat symptoms of iron deficiency (fatigue, cognitive impairment, exercise intolerance, restless legs)

  2. Intravenous iron for patients with severe anemia (hemoglobin concentration of less than 90 g/L), severe symptoms of anemia, patients unresponsive or intolerant to oral iron, or patients in need of rapid correction prior to an operative procedure

  3. Transfusion only if the patient is suffering from serious side effects such as hypotension, chest pain, syncope, or tachycardia.Transfusion is associated with adverse events including a 1-in-13 risk of alloimmunization that can complicate future pregnancies

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