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Heavy Menstrual Bleeding: Assessment and Management (NICE 88 - Mar 2018) …
Heavy Menstrual Bleeding: Assessment and Management
(NICE 88 - Mar 2018)
History
Nature of bleeding
Persistent intermenstrual bleeding
Pelvic pain
Pressure symptoms
Impact on quality of life
Other factors that may affect treatment options
Counselling
Discuss and consider
Benefits and risks of various options
Suitable treatments if trying to conceive
Whether retaining fertility and/or uterus is important
Patient preferences
Comorbidities
Presence or absence of fibroids (
size, number, location
), polyps, endometrial pathology, adenomyosis
LNG-IUS
Explain anticipated changes in bleeding pattern, particularly in first few cycles and maybe lasting >6 months
Advisable to wait for at least 6 cycles to see any benefits
Impact on fertility
Explain about impact on fertility that any planned surgery or uterine artery embolisation may have, and if a potential treatment (hysterectomy or ablation) involves loss of fertility
Uterine artery embolisation or myomectomy may potentially allow retention of fertility
Endometrial ablation
Advise women to avoid subsequent pregnancy and use effective contraception
Hysterectomy
Discuss implications of surgery: Including route and method, and removal of ovaries
Sexual feelings/psychological impact
Bladder function
Need for further treatment
Treatment complications
Patient expectations
Alternative options
Increased risk of serious complications when uterine fibroids are present
Possible loss of ovarian function and consequences, even if ovaries are retained during hysterectomy
Examination
Offer if there is HMB with other related symptoms
Perform before all investigations or LNG-IUS fittings
Investigations
Bloods
Coagulation disorders
: Consider in women who have had HMB since periods started or have a personal/family history suggesting a coagulation disorder
DO NOT TEST
: Ferritin, female hormone testing, thyroid hormone testing (unless signs and symptoms of thyroid disease)
FBC
Consider starting pharmacological treatment for HMB without investigating the cause if history +/- examination suggests low risk of fibroids, uterine cavity abnormality, histological abnormality or adenomyosis
Ultrasound
Suspected larger fibroids
: Palpable uterus abdominally, history/examination suggestive of a pelvic mass
Obese women
Women who decline hysteroscopy; explain limitations in detecting uterine cavity abnormalities and endometrial pathology
Suspected adenomyosis (20-35% prevalence)
: Significant dysmenorrhoea or a bulky tender uterus
If unable to do TVS, offer TAS or MRI, explaining limitations
Hysteroscopy
Suspected submucosal fibroids (15% of women), polyps, or endometrial pathology based on history (persistent intermenstrual bleeding) or risk factors for endometrial pathology
Best practice
: Advise oral analgesia pre-procedure, and use vaginoscopy as the standard technique
Can be performed as an outpatient or under general anaesthesia
If declining hysteroscopy, consider pelvic
Consider endometrial biopsy
Persistent intermenstrual or irregular bleeding
Infrequent heavy bleeding in obese women; PCOS
Women taking tamoxifen
Women for whom treatment for HMB has been unsuccessful
Management
HMB without other related symptoms
Consider pharmacological treatment without a physical examination (unless this is LNG IUS)
Women with no identified pathology, fibroids <3cm not causing cavity distorsion, or suspected/diagnosed adenomyosis
First-line: LNG-IUS
Non-hormonal: Tranexamic acid, NSAIDs
Hormonal: Combined hormonal contraception, cyclical oral progestogens
Surgical options: Second generation endometrial ablation, hysterectomy
Submucosal fibroids: Hysteroscopic removal
If treatment unsuccessful or symptoms severe, consider referral for investigations and alternative treatment choices not already tried.
Women with fibroids =/> 3cm
Refer to specialist care for additional investigations
Offer tranexamic acid and NSAIDs whilst awaiting investigations
Pharmacological: Non-hormonal (tranexamic acid, NSAIDs), hormonal (LNG-IUS, combined hormonal contraception, cyclical oral progestogens)
Uterine artery embolisation
Surgical: Myomectomy, hysterectomy, endometrial ablation
Prior to scheduling UAE or myomectomy, assess fibroids by ultrasound or MRI.
Pharmacological treatment may not be effective due to the physical effect on the uterine cavity.
If treatment is unsuccessful, consider referral for investigations and alternative treatment choices not already tried.
Pre-treatment with a GnRH analogue before hysterectomy and myomectomy should be considered if uterine fibroids are causing an enlarged or distorted uterus.
Epidemiology
Definition
: Excessive menstrual blood loss which interferes with a woman's physical, social, emotional, and/or material quality of life.
1 in 20 women aged 30-49 per year
Menstrual disorders comprise 12% of all referrals to gynaecology