BEST PRACTICE
GUIDELINES - Heavy
Menstrual Bleeding (HMB)
SUMMARY OF RECOMMENDATIONS BASED ON
NICE CLINICAL GUIDELINE JANUARY 2007
INTRODUCTION
Heavy menstrual bleeding (HMB) has an adverse effect on the
quality of life of many women. It is not a problem
associated with significant mortality. The effectiveness of
the various treatments as well as their risks and benefits
are discussed in relation to their use in the treatment of
HMB. The implications of each treatment in relation to
fertility are also discussed.
This guideline aims to avoid this
by including evidence-based and comprehensible discussions
so that women can understand why doctors advise for or
against a particular treatment.
SUMMARY OF RECOMMENDATIONS AND CARE PATHWAY
For clinical purposes, HMB
should be defined as excessive menstrual blood loss
which interferes with the woman’s physical, emotional,
social and material quality of life, and which can occur
alone or in combination with other symptoms. Any
interventions should aim to improve quality of life
measures. [D]
Initially, a history should
be taken from the woman. This should cover the nature of
the bleeding, related symptoms that might suggest
structural or histological abnormality, impact on
quality of life and other factors that may determine
treatment options (such as presence of co-morbidity). [D(GPP)]
If the history suggests HMB
without structural or histological abnormality,
pharmaceutical treatment can be started without carrying
out a physical examination or other investigations at
initial consultation in primary care, unless the
treatment chosen is levonorgestrel-releasing
intrauterine system (LNG-IUS). [D(GPP)]
If the history suggests HMB
with structural or histological abnormality, with
symptoms such as intermenstrual or post-coital bleeding,
pelvic pain and/or pressure symptoms, a physical
examination and/or other investigations (such as
ultrasound) should be performed. [D(GPP)]
Measuring menstrual blood
loss either directly (alkaline haematin) or indirectly
(‘pictorial blood loss assessment chart’) is not
routinely recommended for HMB. Whether menstrual blood
loss is a problem should be determined not by measuring
blood loss but by the woman herself. [D (GPP)]
INVESTIGATIONS
A full blood count test should be
carried out on all women with HMB. This should be done
in parallel with any HMB treatment offered. [C]
Testing for coagulation disorders
(for example, von Willebrand disease) should be
considered in women who have had HMB since menarche and
have personal or family history suggesting a coagulation
disorder. [C]
Female hormone testing should not
be carried out on women with HMB. [C]. Thyroid testing
should only be carried out when other signs and symptoms
of thyroid disease are present. [C]
If appropriate, a biopsy should be
taken to exclude endometrial cancer or atypical
hyperplasia. Indications for a biopsy include, for
example, persistent intermenstrual bleeding, and in
women aged 45 and over treatment failure or ineffective
treatment. [D(GPP)]
Imaging should be undertaken in the
following circumstances:
• The uterus is palpable
abdominally
• Vaginal examination reveals a pelvic mass of
uncertain origin
• Pharmaceutical treatment fails. [d(gpp)]
Ultrasound is the first-line
diagnostic tool for identifying structural
abnormalities. [A]
Hysteroscopy should be used
as a diagnostic tool only when ultrasound results are
inconclusive, for example, to determine the exact
location of a fibroid or the exact nature of the
abnormality. [A]
If imaging shows the presence
of uterine fibroids then appropriate treatment should be
planned based on size, number and location of the
fibroids. [D(GPP)]
Saline infusion sonography
should not be used as a first-line diagnostic tool. [A]
Magnetic resonance imaging (MRI)
should not be used as a first-line diagnostic tool. [B]
Dilatation and curettage
alone should not be used as a diagnostic tool. [B]
Where dilatation is required
for non-hysteroscopic ablative procedures, hysteroscopy
should be used immediately prior to the procedure to
ensure correct placement of the device. [D(GPP)]
Pharmaceutical treatments for HMB
Pharmaceutical treatment
should be considered where no structural or histological
abnormality is present, or for fibroids less than 3 cm
in diameter which are causing no distortion of the
uterine cavity. [D(GPP)] If history and investigations
indicate that pharmaceutical treatment is appropriate
and either hormonal or non-hormonal treatments are
acceptable, treatments should be considered in the
following order:
levonorgestrel-releasing
intrauterine system (LNG-IUS) provided long-term (at least
12 months) use is anticipated [A].
Women offered an LNG-IUS
should be advised of anticipated changes in the bleeding
pattern, particularly in the first few cycles and maybe
lasting longer than 6 months.
2. Tranexamic acid [A] or
nonsteroidal anti-inflammatory drugs (NSAIDs) [A] or
combined oral contraceptives (COCs) [B].
When HMB coexists with
dysmenorrhea, NSAIDs should be preferred to tranexamic
acid. [D(GPP)]. Use of NSAIDs and/or tranexamic acid
should be stopped if it does not improve symptoms within
three menstrual cycles. [D(GPP)]
3. Norethisterone (15 mg) daily
from days 5 to 26 of the menstrual cycle, or injected
long-acting progestogens. [A]
When a first pharmaceutical
treatment has proved ineffective, a second
pharmaceutical treatment can be considered rather than
immediate referral to surgery. [D] Use of a
gonadotrophin-releasing hormone analogue could be
considered prior to surgery or when all other treatment
options for uterine fibroids, including surgery or
uterine artery embolisation (UAE), are contraindicated.
If this treatment is to be used for more than 6 months
or if adverse effects are experienced then hormone
replacement therapy (HRT) ‘add-back’ therapy is
recommended.**[B] Danazol should not be routinely used
for the treatment of HMB. [A]
Oral progestogens given during the
luteal phase only should not be used for the treatment of
HMB. [A]
Etamsylate should not be used for the treatment of HMB. [A]
Non-hysterectomy surgery for HMB
Endometrial ablation
Endometrial ablation should
be considered where bleeding is having a severe impact
on a woman’s quality of life, and she does not want to
conceive in the future. [C]
Endometrial ablation may be
offered as an initial treatment for HMB after full
discussion with the woman of the risks and benefits and
of other treatment options. [A]
Women must be advised to
avoid subsequent pregnancy and on the need to use
effective contraception, if required, after endometrial
ablation. [D(GPP)]
Endometrial ablation should
be considered in women who have a normal uterus and also
those with small uterine fibroids (less than 3 cm in
diameter). [A]
In women with HMB alone, with
uterus no bigger than a 10 week pregnancy, endometrial
ablation should be considered preferable to
hysterectomy. [A]
All women considering
endometrial ablation should have access to a
second-generation ablation technique. [D(GPP)]
Second-generation ablation
techniques should be used where no structural or
histological abnormality is present. [A]
First-generation ablation
techniques (for example, rollerball endometrial ablation
(REA) and transcervical resection of the endometrium (TCRE))
are appropriate if hysteroscopic myomectomy is to be
included in the procedure. [D(GPP)]
Dilatation and curettage should not
be used as a therapeutic treatment. [C]
Further interventions for uterine fibroids associated with
HMB
Uterine Artery Embolozation (UAE),
myomectomy or hysterectomy should be considered in cases
of HMB where large fibroids (greater than 3 cm in
diameter) are present and bleeding is having a severe
impact on a woman’s quality of life. [C].
Prior to scheduling of UAE or
myomectomy, the uterus and fibroid(s) should be assessed
by ultrasound. If further information about fibroid
position, size, number and vascularity is required, MRI
should be considered. [D(GPP)]
Pre-treatment before
hysterectomy and myomectomy with a gonadotrophin-releasing
hormone analogue for 3 to 4 months should be considered
where uterine fibroids are causing an enlarged or
distorted uterus. [A].
Hysterectomy should not be
used as a first-line treatment solely for HMB.
Hysterectomy should be considered only when:
• Other treatment options have failed, are
contraindicated or are declined by the woman
• There is a wish for amenorrhea
• The woman (who has been fully informed) requests it
• The woman no longer wishes to retain her uterus and
fertility. [C]
Women offered hysterectomy
should be informed about the increased risk of serious
complications (such as intraoperative hemorrhage or
damage to other abdominal organs) associated with
hysterectomy when uterine fibroids are present. [C]
Women should be informed
about the risk of possible loss of ovarian function and
its consequences, even if their ovaries are retained
during hysterectomy. [D(GPP)]
Removal of ovaries at the time of
hysterectomy
Removal of healthy ovaries at
the time of hysterectomy should not be undertaken. [D(GPP)]
Removal of ovaries should
only be undertaken with the express wish and consent of
the woman. [D(GPP)]
If removal of ovaries is
being considered, the impact of this on the woman’s
wellbeing and, for example, the possible need for
hormone replacement therapy (HRT) should be discussed. [D(GPP)]
Women considering bilateral
oopherectomy should be informed about the impact of this
treatment on the risk of ovarian and breast cancer. [D(GPP)]
Potential
unwanted outcomes of interventions for HMB
