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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.

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.


Endometrial ablation is an effective treatment option for patients with heavy menstrual bleeding and a normal uterine cavity. Patients who choose to have endometrial ablation require endometrial sampling to rule out cancer before the procedure; testing for cancer becomes difficult once the endometrial lining is destroyed. Patients who chose endometrial ablation require contraception for the rest of their childbearing years.

Non-resectoscopic endometrial ablation techniques—also known as second-generation techniques—use a variety of energy sources to non-selectively destroy the endometrial lining. These techniques are preferred as they require shorter surgical time and less specialized training and are easier to perform. They can be performed in an outpatient setting with local or conscious sedation, and result in fewer complications related to fluid overload and uterine perforation. All patients considering endometrial ablation should have access to non-resectoscopic endometrial ablation techniques.

For Patients

If you never want to get pregnant, your gynecologist may offer an endometrial ablation, which removes the lining of the uterus. This procedure makes pregnancy unsafe for you, so you will need to use contraception for the rest of your childbearing years.


For Clinicians

Offer endometrial ablation as one of the first-line treatment options for heavy menstrual bleeding. If your patient chooses this option, first perform endometrial sampling. Non-resectoscopic techniques done without general anesthetic are the methods of choice for endometrial ablation.


For Health Services

Ensure systems, processes, and resources are in place such that all patients have access to non-resectoscopic endometrial ablation techniques. Ensure clinicians are aware of gynecologists who accept referrals for endometrial ablation.

Process Indicator

Percentage of patients with heavy menstrual bleeding who had endometrial ablation, by type of ablation (any, resectoscopic, non-resectoscopic)

  • Denominator: number of patients with heavy menstrual bleeding

  • Numerator: number of patients with heavy menstrual bleeding who had endometrial ablation, by type of ablation:

    • Any

    • Resectoscopic

    • Non-resectoscopic

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

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


Percentage of patients with heavy menstrual bleeding who had endometrial ablation and who had endometrial sampling within 3 months before the procedure

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

  • Numerator: number of patients in the denominator who had endometrial sampling within 3 months before the procedure, including the day of the procedure

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

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