Skip to main content

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.

Search below for a guide for patients; the guide for clinicians; an information brief demonstrating why the quality standard is needed; quality improvement tools and resources; and performance indicators to help clinicians and organizations track their progress against the standard.

Quality Standard

Know what quality care looks like, based on evidence and expert consensus

The clinical guide cover for heavy menstrual bleeding

Patient Reference Guide

Patients: know what to ask for in your care

Patient reference guide cover for heavy menstrual bleeding

Recommendations for Adoption

System-wide and regional requirements to help health care professionals and organizations meet the standards

Recommendations for Adoption

Getting Started Guide

Quality improvement tools and resources for health care professionals, including an action plan template. For best results, please view the Guide on your desktop using Adobe Reader.

Tools to support patient care


See why we need a quality standard for heavy menstrual bleeding in Ontario

Information Brief

Find out why a particular quality standard has been created and the data behind it

Colleagues in a meeting

Indicator Guide

See the technical specifications for the indicators within the clinical guide

measurement ruler

We have prepared a summary of the public feedback we received for this quality standard. If you would like a copy of this report, please email us at

Let’s make our health system healthier

Join Our Patient, Family and Public Advisors Program

Patients, families and the public are central to improving health quality.

Man smiling

Sign up for our newsletter

Are you passionate about quality health care for all Ontarians? Stay in-the-know about our newest programs, reports and news.

Health Quality Connect - Health Quality Ontario's newsletter - on an iPad and a cell phone