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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.

Health Quality Ontario thanks the following individuals for their generous, voluntary contributions of time and expertise to help create this quality standard:

Adrian Brown (co-chair)
Associate Professor,
Department of Obstetrics and Gynaecology,
University of Toronto,
Chief of Obstetrics and Gynaecology and Medical
Program Director,
Maternal Newborn Program,
North York General Hospital

Catherine Caron (co-chair)
Family Practice Physician and Assistant Professor,
Women’s Health Clinic at the Bruyère Family Medicine Centre,
University of Ottawa

Jeannie Callum
Director of Transfusion Medicine,
Clinical Pathology,
Sunnybrook Health Sciences Centre

Elizabeth David
Vascular Interventional Radiologist,
Sunnybrook Health Sciences Centre

Sheila Dunn
Research Director and Associate Professor,
Department of Family & Community Medicine,
Women’s College Hospital,
University of Toronto

Mary Johnston
Emergency Physician,
Assistant Professor,
Queensway Carlton Hospital and Children’s Hospital of Eastern Ontario,
University of Ottawa

Frances Kilbertus
Associate Professor,
Family Medicine,
Northern Ontario School of Medicine

Lisa McCarthy
Pharmacy Scientist,
Women’s College Hospital and Leslie Dan Faculty of Pharmacy,
University of Toronto

Christine Miller
Nurse Practitioner,
Lakehead Nurse Practitioner-Led Clinic

Ally Murji
Obstetrician and Gynecologist,
Assistant Professor,
Mount Sinai Hospital,
University of Toronto

Diana Poulsen
Lived Experience Advisor,
Professor of Art History,
Fanshawe College,
and Systems Integrator, S&E Manufacturing

Rebecca Rich
Resident Physician,
Obstetrics and Gynaecology,
Clinical Epidemiology,
University of Toronto

Jacqueline Rivier
Program Coordinator,
Bruyère Continuing Care

Magdalena Turlejski
Lived Experience Advisor,
Healthcare Improvement Program,
Accreditation Canada

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