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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.

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.


Before being referred to a gynecologist, patients with heavy menstrual bleeding should receive a comprehensive initial assessment (see Statement 1 for details), be offered a trial of pharmacological therapy (see Statement 3), and be offered ultrasound of the uterus if indicated (see Statement 5). Some patients may not want to try a pharmacological treatment, but these options should be offered to every patient. Taking these steps will decrease the wait time for the start of treatment and for specialist consultation and will provide the gynecologist with vital information to help identify the cause of the bleeding. Specialists should see referred patients within 3 months of referral.

For Patients

Before referring you to a gynecologist, your family doctor or nurse practitioner should do a full assessment and offer you a prescription to relieve your symptoms. If referred, you should receive an appointment within 3 months.


For Clinicians

Primary care providers: Always do a comprehensive initial assessment before considering referral to a gynecologist. The combination of results from the history, physical exam including pelvic exam, laboratory tests, and imaging (as indicated) should be shared with the gynecologist before they see the patient.

Gynecologists: Ensure you see the patient within 3 months of receiving the referral.


For Health Services

Ensure systems, processes, and resources are in place such that all patients have access to a gynecologist, if needed, within 3 months of referral by their primary care provider.

Process Indicator

Percentage of patients with heavy menstrual bleeding who were seen by a gynecologist within 3 months of referral

  • Denominator: number of patients with heavy menstrual bleeding who were referred to a gynecologist

  • Numerator: number of patients in the denominator who were seen by the gynecologist within 3 months of referral

  • Data source: local data collection


Percentage of patients with heavy menstrual bleeding who were seen by a gynecologist and who had a comprehensive initial assessment prior to referral (including detailed history, complete blood count, gynecological exam, and pregnancy test if indicated)

  • Denominator: number of patients with heavy menstrual bleeding who were seen by a gynecologist

  • Numerator: number of patients in the denominator who had a comprehensive initial assessment prior to referral including:

    • Detailed history

    • Complete blood count

    • Gynecological exam

    • Pregnancy test (if pregnancy is possible)

  • Data source: local data collection


Percentage of patients with heavy menstrual bleeding who were seen by a gynecologist and who were offered pharmacological treatment to address heavy menstrual bleeding prior to referral

  • Denominator: number of patients with heavy menstrual bleeding who were seen by a gynecologist

  • Numerator: number of patients in the denominator who were offered pharmacological treatment to address heavy menstrual bleeding prior to referral

  • Data source: local data collection

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