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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.

4

Endometrial Biopsy

Patients with heavy menstrual bleeding who exhibit risk factors for endometrial cancer or endometrial hyperplasia are offered an endometrial biopsy.


Endometrial biopsy is a minimally invasive procedure that provides information about abnormalities of the endometrial cells. If a patient with heavy menstrual bleeding exhibits risk factors for endometrial cancer or hyperplasia, they require an endometrial biopsy to confirm or rule out these conditions. Clinicians should assess the contributing risk factors for endometrial cancer when deciding to recommend an endometrial biopsy.

For Patients

You may need an endometrial biopsy, a procedure to take a tissue sample from your uterus to look for abnormal cells or an overgrowth of the lining.


For Clinicians

Ensure your patient has an endometrial biopsy if they have risk factors for endometrial cancer or hyperplasia.


For Health Services

Ensure systems, processes, and resources are in place such that patients are able to receive an endometrial biopsy if they exhibit risk factors for endometrial cancer. This includes access to skilled professionals capable of performing a biopsy, the equipment required to do so, and the laboratories required to test the samples once obtained.

Process Indicator

Percentage of patients with heavy menstrual bleeding who had an endometrial biopsy

  • Denominator: number of patients with heavy menstrual bleeding

  • Numerator: number of patients in the denominator who had endometrial biopsies (exclude biopsies done within a month of endometrial ablation, to exclude non-diagnostic biopsies)

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

Note: The purpose of this indicator is to measure the overall rate of endometrial biopsies and variation across the province. It is not intended to show whether endometrial biopsies are being done appropriately.


Proportion of women with heavy menstrual bleeding with risk factors for endometrial cancer or hyperplasia who did not have an endometrial biopsy

  • Denominator: number of patients with heavy menstrual bleeding who have risk factors for endometrial cancer or hyperplasia

    • Risk factors: age older than 40 years, bleeding that does not improve with pharmacological treatment, chronic anovulation, persistent intermenstrual bleeding, obesity, prolonged exposure to unopposed estrogens or tamoxifen, diabetes, nulliparity, early menarche, family history of endometrial cancer

  • Numerator: number of patients in the denominator who did not have an endometrial biopsy

  • Data source: local data collection

Risk factors for endometrial cancer:

The history should address the following:

  • Bleeding that does not improve with pharmacological treatment

  • Persistent intermenstrual bleeding

  • Age

    • Older than 40 years

  • Nature of the bleeding

    • Bleeding that does not improve with pharmacological treatment‒Persistent intermenstrual bleeding

  • Other risk factors for endometrial cancer

    • Chronic anovulation

    • Obesity

    • Prolonged exposure to unopposed estrogens or tamoxifen

    • Diabetes

    • Nulliparity

    • Early menarche

    • Family history of endometrial cancer

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