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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.

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.


Imaging of the uterus by ultrasound is indicated if the clinician suspects that a patient with heavy menstrual bleeding has structural abnormalities within the pelvis that require further investigation.

If imaging is needed, a lower abdominal ultrasound is typically followed by transvaginal ultrasound to visualize the uterine cavity. Transabdominal pelvic evaluation alone may be more appropriate in patients who are not sexually active. If further investigations are needed, the clinician may consider saline-infused hysterography, hysteroscopy, or magnetic resonance imaging.

For Patients

You may need an ultrasound of your uterus to look at its size or shape. An ultrasound uses sound waves to take pictures.


For Clinicians

Ultrasound is the first-line imaging technique for patients with heavy menstrual bleeding. Do a pelvic exam before considering ultrasound. Your patient is a candidate for ultrasound if, based on the pelvic exam, you suspect structural abnormalities that need further investigation. If you’ve done a pelvic exam and do not suspect a structural abnormality, but your patient is not improving with pharmacological treatment, it is acceptable to order an ultrasound.


For Health Services

Ensure systems, processes, and resources are in place such that all patients, have access to ultrasound of the uterus when needed.

Process Indicator

Percentage of patients with heavy menstrual bleeding who have ultrasound imaging of the uterus and did not have a pelvic or gynecological exam in the preceding year

  • Denominator: number of patients with heavy menstrual bleeding who had ultrasound imaging of the uterus

  • Numerator: number of patients in the denominator who did not have a pelvic or gynecological exam in the 12 months before ultrasound imaging

  • Data source: local data collection

Note: This indicator measures the inappropriate use of ultrasound for heavy menstrual bleeding.

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