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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.

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.


Dilation and curettage has historically been used as a treatment and/or diagnostic tool for both acute and chronic heavy menstrual bleeding. Unfortunately, the benefits of this procedure are temporary.1 When dilation and curettage is performed, simultaneous hysteroscopy should also be performed to decrease the incidence of missed lesions (e.g., polyps) that may contribute to or be the cause of the acute heavy menstrual bleeding.2 See Statement 8 for additional guidance on treating acute heavy menstrual bleeding.

For Patients

You should only receive dilation and curettage (D&C) if you have very severe bleeding and if medications did not slow it. D&C removes abnormal tissue from the lining of your uterus. If you have a D&C, hysteroscopy (a procedure to look at the inside of your uterus) should be done at the same time.


For Clinicians

Use dilation and curettage only for patients presenting with acute heavy menstrual bleeding where medications are not working to suppress the bleeding. In these cases, use simultaneous hysteroscopy to visualize lesions that may be causing the bleeding.


For Health Services

Ensure systems, processes, and resources are in place such that patients do not receive dilation and curettage for investigation or treatment of heavy menstrual bleeding unless absolutely necessary to treat acute heavy menstrual bleeding unresponsive to medical intervention.

Process Indicator

Percentage of patients with heavy menstrual bleeding who underwent elective (i.e., inappropriate) dilation and curettage

  • Denominator: number of patients with heavy menstrual bleeding

  • Numerator: number of patients with heavy menstrual bleeding who underwent dilation and curettage (exclude non-elective dilation and curettage)

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


Percentage of patients with acute heavy menstrual bleeding who underwent dilation and curettage and who also had a hysteroscopy

  • Denominator: number of patients with acute heavy menstrual bleeding who had dilation and curettage

  • Numerator: number of patients in the denominator who had a hysteroscopy during the same procedure

  • Data sources: local data collection

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