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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.

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).


Patients presenting with acute heavy menstrual bleeding should be managed promptly to minimize morbidity and reduce the likelihood of requiring blood transfusions. Interventions to stop the bleeding include pharmacological therapies, intracavitary tamponade, dilation and curettage with hysteroscopy, resectoscopic endometrial ablation, uterine artery occlusion, and hysterectomy. Hysterectomies in the acute setting should be a last resort due to the risks associated with surgery in patients with acute anemia.

First-line therapy to correct severe anemia (a hemoglobin level of 90 g/L or lower) is intravenous iron. Red blood cell transfusion using the least number of units required is recommended when the patient has serious symptoms of anemia such as hypotension, chest pain, syncope, or tachycardia.

A follow-up appointment scheduled to correlate with the patient’s next period is important as it allows health care professionals to assess whether the problem is ongoing and to review the efficacy of any medications started in the hospital.

For Patients

If your bleeding is suddenly extremely heavy, your health care professional will try to stop it with medication or a procedure. You may also be given iron intravenously or a blood transfusion. You should have a follow-up appointment near your next period.


For Clinicians

When a patient presents with acute heavy menstrual bleeding, stabilize and manage them in a way that minimizes the need for blood transfusions. Ensure the patient has a follow-up outpatient appointment booked within 4 weeks, at or immediately following their next period, to assess whether the problem is ongoing and to review the efficacy of any medications started to treat the bleeding.


For Health Services

Ensure systems, processes, and resources are in place such that patients have access to all options to stop acute bleeding, receive rapid resuscitation, and start appropriate anemia treatment while in hospital. Ensure resources are available to enable timely follow-up appointments.

Process Indicator

Percentage of patients who have an outpatient follow-up visit with a health care professional within 4 weeks of leaving the hospital for an unplanned emergency department visit or hospital admission for heavy menstrual bleeding

  • Denominator: number of patients who had an unplanned emergency department visit or hospitalization for heavy menstrual bleeding

  • Numerator: number of patients in the denominator who had an outpatient follow-up visit with a health care professional within 4 weeks of leaving hospital

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

Note: Follow-up appointments should be scheduled to coincide with the patient’s next period, which is estimated to be within 4 weeks. OHIP, DAD, and NACRS at system level can measure follow-up with a physician but cannot capture follow-up appointments with other health care professionals.


Outcome Indicator

Percentage of patients who had an unplanned emergency department visit for heavy menstrual bleeding within 60 days (i.e., to allow time for one or more subsequent menstrual cycles) after an initial emergency department visit or hospital discharge for heavy menstrual bleeding

  • Denominator: number of patients who had unplanned emergency department visit or hospital discharge for heavy menstrual bleeding

  • Numerator: number of patients in the denominator who had an unplanned emergency department visit for heavy menstrual bleeding within 60 days after the initial visit or hospital discharge

  • Data sources: local data collection; for system level, Discharge Abstract Database, National Ambulatory Care Reporting System

Acute heavy menstrual bleeding

An episode of heavy menstrual bleeding, not related to pregnancy, that is of sufficient quantity to require immediate intervention to prevent further blood loss.

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