Heavy menstrual bleeding: assessment and management. NICE NG88, March 2018
This guideline covers assessing and managing heavy menstrual bleeding (menorrhagia). It aims to help healthcare professionals investigate the cause of heavy periods that are affecting a woman’s quality of life and to offer the right treatments, taking into account the woman’s priorities and preferences, and to ensure that any intervention aims to improve the woman’s quality of life, rather than focusing on blood loss.
Heavy menstrual bleeding (HMB) is defined as excessive menstrual blood loss which interferes with a woman’s physical, social, emotional and/or material quality of life. It can occur alone or in combination with other symptoms.
HMB is one of the most common reasons for gynaecological consultations in both primary and secondary care: about 1 in 20 women aged between 30 and 49 years consult their GP each year about heavy periods or menstrual problems, and menstrual disorders account for 12% of all gynaecology referrals.
Since publication of the original guideline in 2007, diagnostic strategies have improved and become more widely available, and some treatments – such as insertion of a levornorgestrel-releasing intrauterine system (LNG-IUS) have gained in popularity, while others – e.g. microwave endometrial ablation – are no longer available in the UK.
This guideline aims to help healthcare professionals advise women about the treatment options that are right for her, with a clear focus on the woman’s choice: it will be the woman herself who decides whether a treatment has been successful.
Take a history that covers
Take account of natural variability in menstrual cycles and blood loss but if the woman feels she does not fall within normal ranges, discuss care options.
If the woman has HMB without other related symptoms, consider pharmacological treatment without physical examination, unless the option chosen in LNG-IUS.
Before starting investigations consider starting pharmacological treatment without investigation the cause if the woman’s history and/or examination suggest a low risk of fibroids or other abnormalities. If cancer is suspected, refer following the NICE guideline on suspected cancer https://www.nice.org.uk/guidance/ng12
Hysteroscopy or ultrasound are the first line investigations, selected according to the woman’s history and examination. Endometrial biopsy should only be offered in the context of diagnostic hysteroctopy, not blind.
INFORMATION ABOUT TREATMENT OPTIONS
Provide women with information about HMB and its management, including all possible treatment options. Discussions should include:
Explain to women the anticipated changes in bleeding pattern in the first few cycles, and potentially for longer than 6 months; also that it is advisable to wait for at least 6 cycles to see the benefits of treatment
Advise women to avoid subsequent pregnancy and use effective contraception, if needed, after endometrial ablation.
Discuss the implications of surgery before a decision is made, to include
MANAGEMENT OF HMB
Take into account the woman’s preferences, any comorbidities, the presence or absence of fibroids, endometrial pathology or adenomyosis, and other symptoms such as pressure and pain.
If the woman declines LNG-IUS, consider:
Be aware that progestogen-only contraception may suppress menstruation, which could be beneficial to women with HMB
If treatment is unsuccessful, the woman declines pharmacological treatment, or symptoms are severe, consider referral to specialist care.
Discuss with the woman the route of hysterectomy (laparascopy, laparotomy or vaginal, total hysterectomy (removal of the uterus and cervix) or subtotal (removal of the uterus and retention of the cervix). The ovaries should only be removed (oophorectomy) with the express wish and informed consent of the woman after discussion of all risks and benefits.
*Adenomyosis is a condition where part of the endometrium becomes embedded in the wall of the uterus, causing small pockets of bleeding within the muscle during menstrual periods, causing painful and heavy periods. If affects approximately 1 in 10 women and is most common in women aged 40-50. It is diagnosed by transvaginal ultrasound, or by MRI scan. Treatment options depend on the woman’s age, proximity to the menopause, whether or not she wishes to become pregnant, previous treatments and views on surgery. An alternative to hysterectomy is uterine artery embolisation, which cuts off the blood supply to the adenomyosis. It is less invasive than surgery and may preserve fertility. It is likely to improve symptoms in the short term, but symptoms may recur.
NICE NG88. Heavy menstrual bleeding: assessment and management, March 2018
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