1. Heavy menstrual bleeding Implementing NICE guidance January 2007 NICE clinical guideline 44

2. What this presentation covers: Background to the guideline Key recommendations and suggested actions Costs and savings Resources from NICE

3. Changing clinical practice NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations to work towards implementing guidelines Compliance with developmental standards will be monitored by the Healthcare Commission

4. Heavy menstrual bleeding Defined as excessive menstrual blood loss affecting quality of life: physical emotional social material Can occur alone or in combination with other symptoms

5. Need for this guideline Heavy menstrual bleeding (HMB): can affect women of reproductive age (post puberty and pre menopause) can have an adverse effect on quality of life is a common reason for referral to secondary care

6. Risk factors for HMB Gynaecological conditions such as: uterine fibroids adenomyosis or endometriosis endometrial cancer unopposed oestrogen use Increase in age Ethnic group Sociocultural factors

7. Incidence and prevalence Affects approximately 880,000 women in England Analysis performed by Information Centre for health and social care derived from IMS Health Disease Analyzer

8. What the guideline covers Investigations Education, information and choice for women Hormonal and non-hormonal pharmaceutical treatments Prescribing considerations Surgical management Competencies

9. Investigations Ultrasound to identify structural abnormalities Hysteroscopy with biopsy if ultrasound outcomes are inconclusive Endometrial biopsy if: intermenstrual bleeding persists medical treatment fails or is not effective in women aged 45 and older

10. Suggested actions Raise awareness of NICE recommendations and develop training opportunities to focus on key aspects Review local access and provision of diagnostic services, update referral and care pathways Ensure a robust governance structure to support training for ultrasound, hysteroscopy and endometrial biopsy Review workforce skill mix to support investigations

11. Education and information provision Before her outpatient appointment, provide the woman with information as a basis for discussion and informed choice

12. Suggested actions Promote clinicians working in partnership with women to support informed choice Enable women to take an active and informed role in decision-making by: using ‘Understanding NICE guidance’ giving time and support to reach a decision devising an individualised treatment plan

13. Pharmaceutical treatment When either hormonal or non-hormonal treatments are acceptable consider in the following order: levonorgestrel-releasing intrauterine system tranexamic acid or non-steroidal anti-inflammatory drugs or combined oral contraception norethisterone or injected long-acting progestogens

14. Non-hormonal treatment When hormonal treatment is not acceptable, for example if the woman wishes to conceive, consider using: tranexamic acid or non-steroidal anti-inflammatory drugs

15. Prescribing considerations If symptoms do not improve within 3 months stop: non-steroidal anti-inflammatory drugs tranexamic acid When treating HMB do not use: danazol etamsylate

16. Suggested actions Review prescribing policies and formularies, update in line with this guidance Raise awareness of effective prescribing treatment Review local provision and specialised skills needed for levonorgestrel-releasing intrauterine system

17. Surgical management Endometrial ablation methods Use for HMB alone with uterus no bigger than 10-week pregnancy Hysterectomy Should not be used as first-line treatment Consider route of hysterectomy in the following order: vaginal abdominal

18. Suggested actions Review access to and provision of surgical services locally Consider use of regional services when necessary Support training by providing access to advanced skills modules

19. Competencies Ensure a robust clinical governance framework to maintain: surgical imaging radiological skills Include individual and organisational audit of: numbers decision making case mix outcomes of all treatments

20. Suggested actions Demonstrate competence during training or practice Use structured process of formal assessment through recognised training schemes Refer to skilled professional when individual competency is limited Use audit data to commission services in line with NICE guidelines

21. Costs and savings Recommendations with significant resource impact Annual cost £millions full blood count investigations0.9 transvaginal ultrasound investigations10.4 endometrial biopsy for suspected endometrial cancer-0.9 pharmaceutical treatments levonorgestrel- releasing intrauterine system-0.6 substitution of hysterectomy with endometrial ablation-1.2 Total net cost of implementing the HMB guideline8.7

22. Access tools online Costing tools costing report costing template Implementation advice Audit criteria Available from: www.nice.org.uk/CG044

23. Access the guideline online Quick reference guide – a summary www.nice.org.uk/CG044quickrefguide NICE guideline – all of the recommendations www.nice.org.uk/CG044niceguideline Full guideline – all of the evidence and rationale www.nice.org.uk/CG044fullguideline ‘Understanding NICE guidance’ – a plain English version www.nice.org.uk/CG044publicinfo