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March 2007: Adopt an evidence-based approach to menorrhagia

How is menorrhagia defined?

When should patients be examined and/or treated?

What treatment options are available to GPs?

How is menorrhagia defined?

When should patients be examined and/or treated?

What treatment options are available to GPs?

Heavy menstrual bleeding has an adverse effect on the quality of life of many women. In the majority of cases no underlying cause is identified, but endometriosis, uterine fibroids and coagulation disorders are all known to be associated with heavy menstrual bleeding.1

Heavy menstrual bleeding is not associated with significant mortality,1 but many women seek help from their GP because of the morbidity it causes. It is also a common reason for referral to secondary care: an estimated 1.5 million women consult their GP each year with heavy menstrual bleeding in England and Wales, and menstrual disorders account for about 20 per cent of all referrals to specialist gynaecology services.2

In the early 1990s it was estimated that at least 60 per cent of women presenting with heavy menstrual bleeding in secondary care would have a hysterectomy for the problem, often as a first-line treatment.1 However, things have changed and the number of hysterectomies now being performed for heavy menstrual bleeding is decreasing rapidly. This decline is partly explained by the number of medical and surgical alternatives that have become available.

NICE has recently published a guideline on the management of heavy menstrual bleeding.3 The aim of this guidance is to ensure that information about evidence-based investigations and treatments is available both to doctors and to women presenting with heavy menstrual bleeding throughout the NHS.

The guideline

The algorithm4 in figure 2, attached, represents a highly condensed view of the patient's journey through the health service and not all patients will fit this model. Nevertheless, it does highlight the main decision points on the journey.

Definition of heavy menstrual bleeding

The definition of heavy menstrual bleeding used in the guideline (and reproduced below) differs from that found in standard medical textbooks:
‘For clinical purposes, heavy menstrual bleeding 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.'

This definition highlights the fact that heavy menstrual bleeding, as experienced by the woman and treated by healthcare professionals, is far more than just a measure of a particular volume of menstrual blood loss. It reflects the ethos of the guideline, which attempts to address the clinical ‘reality' of managing the impact of heavy menstrual bleeding.

Diagnosis

Based on the above definition, the diagnosis of heavy menstrual bleeding may appear straightforward. However, the main issue with heavy menstrual bleeding is differentiating it from other, potentially more serious conditions, and identifying any possible underlying cause.

History taking

The first health professional the patient will see is usually the GP. The guideline outlines the need for a good overall history to be taken from the woman. This will provide information as to whether there is likely to be any pathology associated with the presence of heavy menstrual bleeding.

Questioning should aim to establish: The nature of the bleeding:

• How heavy

• Regular or irregular

Presence of bleeding between periods or after intercourse

Signs of possible pathology:

Pressure symptoms

Dysmenorrhoea

Abdominal pain between periods

Other features that may determine treatment:

• A woman's ideas and concerns regarding heavy menstrual bleeding and its treatment.
(Symptoms in bold may suggest underlying pathology.)

If the history suggests that menstrual bleeding is not having a significant impact on the woman's quality of life, then reassurance may be sufficient and no treatment is required. However, the woman's concerns should never be dismissed as minor, and she must be given the option of treatment and/or to return if the menstrual blood loss remains a problem.

Physical examination

If the history suggests that heavy menstrual bleeding is present, medical treatment can be started immediately without the need for a physical examination, unless:

• The suggested treatment is a levonorgestrel-releasing intrauterine system

• Signs or symptoms of structural or histological abnormalities are present.

If the examination is normal, medical treatment can be commenced without the need for further investigation (unless the symptom is intermenstrual bleeding), but if the results suggest pathology then further investigation is required.

Reasons for not routinely recommending an examination for all women are:

• It rarely changes decisions about treatment in cases where no other signs or symptoms are already present

• It can be unpleasant for the woman

• It takes time that could be better used undertaking a more in-depth consultation about management options or providing reassurance.

Laboratory tests – full blood count

A full blood count should be undertaken on all women with heavy menstrual bleeding to assess the presence of anaemia. However, no other tests (for example thyroid function tests or tests for coagulation disorders) are routinely required, as evidence suggests that these are either not linked with heavy menstrual bleeding or other signs and symptoms will be present.

Biopsy

Routine endometrial biopsy is not recommended in women with heavy menstrual bleeding alone as analysis has shown that fewer than 1 in 10,000 women who present with heavy menstrual bleeding are likely to have endometrial cancer, and the likelihood is even less in those under 45 years of age. Undertaking a routine biopsy, therefore, is not necessary, causes undue worry for the woman and cost to the NHS.

Ultrasound

A woman presenting with heavy menstrual bleeding should be sent for an ultrasound investigation if:

• The uterus is palpable abdominally

• Vaginal examination reveals a pelvic mass of uncertain origin

• Medical treatment fails.

The guideline examines a number of imaging techniques but recommends the use of ultrasound as a first-line investigation.

The need for ultrasound examinations to be undertaken by someone trained in gynaecological imaging is highlighted in the guideline.

Non-heavy menstrual bleeding signs and symptoms

It should be remembered that if, at any time, pathology is suspected or the problem is not heavy menstrual bleeding alone, then a woman moves outside the guideline and should be referred for appropriate care.

Treatment

The treatment of heavy menstrual bleeding ranges from oral drugs to major irreversible surgery. It is therefore essential that the woman and healthcare professional are aware of all possible options and select the one that best meets the woman's needs.

Medical treatment

The guideline outlines the order in which medical treatments should be considered. This will depend on a number of factors, not least of which is whether the woman wishes to conceive: if she does, then obviously a treatment that is contraceptive would not be appropriate. Treatments should be considered in the following order:

1. Levonorgestrel-releasing intrauterine system (for at least 12 months)

2. Tranexamic acid or NSAIDs (for at least three months) or combined oral contraceptives (COCs)

3. Norethisterone (15 mg) daily from days five to 26 of the menstrual cycle, or injected long-acting progestogens.

Tranexamic acid and NSAIDs are the only preparations listed in the guideline that are suitable for women wishing to conceive. The decision on the order was based on comparison of the long-term effectiveness and cost-effectiveness of the treatments.

If a woman has to wait for a treatment (such as fitting of a levonorgestrel-releasing intrauterine system) then she should not be left without treatment. The guidance recommends that either NSAIDs or tranexamic acid be used whilea woman is waiting. In addition, if a medical treatment fails then it is recommended that a second is tried before referral, if the woman wishes it.

Patient education

The guideline recommends that written information is given to a woman with heavy menstrual bleeding before referral to a specialist. This should include information on potential unwanted outcomes of interventions (see table 1, attached). NICE has produced a patient version of the guideline.5 GPs may wish to download copies and make them available in their surgeries.

Referral criteria

The criteria for referral of a woman with heavy menstrual bleeding to secondary care are based on three factors:

• Does the heavy menstrual bleeding have a pathological cause, such as fibroids?

• What impact is the heavy menstrual bleeding having on the woman?

• What, if any, treatment option does the woman want?

The referral criteria are summarised in figure 2, attached.

In the majority of cases, referral for specialist care will be based on the presence of pathology or failed medical treatment. However, in some circumstances (where heavy menstrual bleeding is having a particularly severe impact) the GP may feel, in consultation with the woman, that immediate referral for endometrial ablation is necessary where no pathology has been identified and medical treatment has not first been tried.

In any situation where a woman is being referred for specialist care, she should receive written information and not be left without treatment (either NSAIDs or tranexamic acid) while she waits for an appointment.

Specialist care

While GPs will not provide specialist treatments, they must be aware of the options and criteria for their use. The four surgical options recommended in the guideline are:

Endometrial ablation

Endometrial ablation aims to destroy or remove the endometrium and superficial myometrium (uterine muscle). By doing this it is expected that most or all of the glands that the endometrium develops from will be destroyed, greatly reducing or completely stopping menstrual blood loss.

• Used where no pathology or small fibroids (<3cm diameter) are found

• Not suitable if a woman wants to become pregnant in the future

• Increasingly performed as a day case

• Amenorrhoea induced in many women

Uterine artery embolisation

Uterine artery embolisation is performed by an interventional radiologist, with the patient under conscious sedation. Both uterine arteries are blocked with particles, injected through a catheter via the femoral artery. This causes the fibroids to shrink, but it is believed to have no permanent effect on the rest of the uterus.

• Used where large fibroids (>3cm diameter) are found

• A woman may potentially be able to become pregnant in the future

• Increasingly performed as a day case

• Risk that fibroids (and symptoms) will recur

Myomectomy

Myomectomy is the surgical removal of uterine fibroids and the suturing of resulting wounds in the uterus. It can be performed using either an abdominal, vaginal or laparoscopic route.

• Used where large fibroids (>3cm diameter) are found

• A woman may potentially be able to become pregnant in the future

• Requires several days in hospital

• Risk that fibroids (and symptoms) will recur

Hysterectomy

Hysterectomy is the surgical removal of the uterus. This can be performed using either an abdominal, vaginal or laparoscopic route.

• Used for any indication, but only where other options have been considered and rejected by health professionals and the patient

• There is no possibility of a woman becoming pregnant after the procedure

• Requires several days in hospital

• Results in amenorrhoea.

Conclusion

Many women with heavy menstrual bleeding where no organic pathology has been identified can be successfully managed in primary care if the recommendations of the NICE guideline are followed.

The guideline and its supporting documentation (such as the algorithm4 and patient information sheet5) should give GPs the framework and tools with which to manage heavy menstrual bleeding to both their own and the woman's satisfaction.

GPs should find the full guideline1 helpful as it covers a condition that forms a significant percentage of their daily workload.

Key points Figure 2: Care pathway for heavy menstrual bleeding (and location of management) men tab1 Table 1: Potential unwanted outcomes from treatment Useful information

All versions of the NICE guideline on heavy menstrual bleeding can be downloaded from the NICE website.
nice.org.uk/CG044

Authors

Professor Mary Ann Lumsden
BSc MB BS MD FRCOG
Professor of Gynaecology and honourary consultant gynaecologist, University of Glasgow, and chair of the NICE guidelines development group on heavy menstrual bleeding

Mr Jiri Chard
BSc MSc
research fellow, National Collaborating Centre for Women's and Children's Health, RCOG, London

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