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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.

3

Pharmacological Treatments

Patients with heavy menstrual bleeding are offered a choice of non-hormonal and hormonal pharmacological treatment options.


A variety of pharmacological treatment options are available for people with heavy menstrual bleeding. These can be grouped into hormonal and non-hormonal treatments, with each category having special considerations for patients. Patients should be aware of the potential out-of-pocket costs of these options, since many drugs for heavy menstrual bleeding are not publicly funded or covered under private insurance plans.

For Patients

Your health care professional should discuss with you options for hormonal and non-hormonal medication.


For Clinicians

Ensure you provide patients with information on all available pharmacological options. Make patients aware of the potential out-of-pocket costs, since many of these treatments are not publicly funded or covered under private insurance plans. Inform patients that if they do not see results in 3 to 6 months they should come back for a follow-up appointment to reassess their treatment plan.


For Health Services

Ensure systems, processes, and resources are in place such that patients have access to their pharmacological treatment of choice.

Process Indicator

Percentage of patients with heavy menstrual bleeding whose medical records indicate they were offered a choice of pharmacological treatments (hormonal and non-hormonal options)

  • Denominator: number of patients with heavy menstrual bleeding

  • Numerator: number of patients with heavy menstrual bleeding whose medical records indicate they were offered a choice of pharmacological treatments (hormonal and non-hormonal options)

  • Data source: local data collection

Non-hormonal pharmacological options

The following non-hormonal options can be used to treat heavy menstrual bleeding:

  • Tranexamic acid

  • Non-steroidal anti-inflammatory drugs (NSAIDs)

Note: NSAIDs also help relieve symptoms of dysmenorrhea.


Hormonal pharmacological options

The following hormonal options can be used to treat heavy menstrual bleeding:

  • Levonorgestrel-releasing intrauterine system

  • Combined hormonal contraceptives

  • High-dose continuous progestins

Patients with fibroids associated with heavy menstrual bleeding can try any of the above medications as well as the following two additional options that may be effective in shrinking fibroids and reducing associated bleeding symptoms

  • Gonadotropin-releasing hormone analogues

  • Selective progesterone-receptor modulators

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