Heavy menstrual bleeding: assessment and management.

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.

DIAGNOSIS

History

Take a history that covers

• The nature of the bleeding
• Related symptoms e.g. persistent intermenstrual bleeding, pelvic pain/pressure that might suggest uterine cavity or histological abnormality, adenomyosis* or fibroids
• Impact on quality of life
• Co-morbidities or previous treatments for HMB

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.

Physical examination

• If the woman has a history of HMB with other related symptoms, offer a physical examination
• Carry out a physical examination before all investigations or fitting an LNG-IUS.

Laboratory tests

• Carry out full blood count
• Test for coagulation disorders for women who have had HMB since their periods started or have a personal or family history suggesting a coagulation disorder
• Do not routinely carry out serum ferritin test, female hormone testing, thyroid hormone testing.

Investigations

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.

• Saline infusion sonography and MRI should not be used as first-line diagnostic tools, and dilatation and curettage (D&C) should not be used alone as a diagnostic tool for HMB.

INFORMATION ABOUT TREATMENT OPTIONS

Provide women with information about HMB and its management, including all possible treatment options. Discussions should include:

• The benefits and risks of the options
• Suitable treatments if she is trying to conceive
• Whether she wants to retain her fertility and/or her uterus

LNG-IUS

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

Endometrial ablation

Advise women to avoid subsequent pregnancy and use effective contraception, if needed, after endometrial ablation.

Hysterectomy

Discuss the implications of surgery before a decision is made, to include

• Sexual feelings
• Impact on fertility
• Bladder function
• Need for further treatment
• Treatment complications
• Her expectations
• Alternative surgery
• Psychological impact

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.

LNG-IUS

• Consider an LNG-IUS as first treatment for HMB in women with no identified pathology, fibroids less that 3cm in diameter that are not causing distortion of the uterine cavity, or suspected or diagnosed adenomyosis

Pharmacological treatment

If the woman declines LNG-IUS, consider:

• Non-hormonal treatments – tranexamic acid or NSAIDs
• Hormonal – combined hormonal contraception or cyclical oral progestogens

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.

• For women with HMB and fibroids of 3cm or more, refer to specialist care for additional investigations and to discuss treatment. Offer tranexamic acid or NSAIDs if treatment is needed while investigations and definitive treatments are being organised.
• Ulipristal acetate (Esmya) is only indicated for premenopausal women; consider for intermittent treatment of moderate to severe symptoms of uterine fibroids if surgery or uterine artery embolisation is insuitable or have failed, or the woman has declined surgery or embolisation
  • Advise that ulipristal acetate is associated with serious liver injury, and the signs and symptoms to look out for
  • Measure liver function before starting treatment and monthly for the first 2 courses
  • If there is no underlying liver injury, consider ulipristal acetate 5mg (up to 4 courses)
  • If the woman shows signs and symptoms of liver failure, stop treatment and perform liver function tests urgently
• Depending on the size, location and number of fibroids, consider pharmacological treatments as above with the addition of LNG-IUS, uterine artery embolization, or surgical options (myomectomy or hysterectomy).
• Pre-treatment with gonadoptrophin-releasing hormone analogue should be considered before hysterectomy and myomectomy if fibroids are causing an enlarged or distorted uterus.
• Be aware that not all the pharmacological options listed in the guideline have an indication in these circumstances, and prescribers should follow relevant professional guidance, taking full responsibility for the decision, and informed consent should be obtained and documented.

Hysterectomy

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.

• D&C should not be offered as a treatment option for HMB.

*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

https://www.nice.org.uk/guidance/ng88