Mr Pratik N Shah MD MRCOG Clinical Director for Womens Services Barnet and Chase Farm Hospitals NHS Trust NOTES FOR PRESENTERS You can add your own organisation’s logo alongside the NICE logo The clinical guideline implementation tools symbol found in the bottom right hand corner of slides throughout this presentation is used to clearly differentiate between the implementation advice and the key priority recommendations from the guideline. These slides highlight suggested actions that may be useful when implementing recommendations. DISCLAIMER This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.

Heavy menstrual bleeding Implementing NICE guidance NOTES FOR PRESENTERS: You can add your own organisation’s logo alongside the NICE logo. The clinical guideline implementation tools symbol found in the bottom right-hand corner of slides throughout this presentation is used to clearly differentiate between the implementation advice and the key priority recommendations from the guideline. Slides with the tools symbol highlight suggested actions that may be useful when implementing recommendations. DISCLAIMER This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself. January 2007 NICE clinical guideline 44

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 Impact on women For clinical purposes, heavy menstrual bleeding should be defined as excessive menstrual blood loss that interferes with the woman’s physical, emotional, social and material quality of life, and that can occur alone or in combination with other symptoms. Any interventions should aim to improve quality of life.

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 The annual prevalence of heavy menstrual bleeding is approximately 880,000 women in England, this equates to 4000 to 9000 women per 100,000. The table presented shows the annual rate of women with HMB presenting to healthcare services, it identifies that 398,000 women aged 30 to 51 years present to primary care annually with heavy menstrual bleeding.

HMB – underlying causes Dysfunctional uterine bleeding Gynaecological conditions such as: uterine fibroids adenomyosis or endometriosis endometrial hyperplasia endometrial polyps endometrial cancer – rare before age 45 Endocrine and clotting disorders It is important to note the risk factors associated with heavy menstrual bleeding. However, the guideline does not discuss treatment for symptoms of these conditions. Uterine fibroids are a common cause of heavy menstrual bleeding. There are other gynaecological conditions such as adenomyosis or endometriosis where menorrhagia maybe associated with other menstrual symptoms as part of the presenting complaint. Evidence shows that an increase in age is linked to the likelihood of women having HMB, and that rates differ between ethnic groups. Sociocultural factors can also influence an individual woman’s response to menstrual blood loss, and this should be taken into account during consultation.

Investigations Ultrasound to identify structural abnormalities Hysteroscopy with biopsy only if ultrasound outcomes are inconclusive Endometrial biopsy if: intermenstrual bleeding persists > 3 months medical treatment fails or is not effective in women aged 45 and older Investigations for heavy menstrual bleeding Investigations are recommended if the woman’s history suggests structural abnormalities and the uterus is palpable on examination. Ultrasound is the first-line diagnostic tool for identifying structural abnormalities. Hysteroscopy should be used as a diagnostic tool only if ultrasound results are inconclusive; for example, to determine the exact location of a fibroid or the exact nature of the abnormality. If appropriate, a biopsy should be taken to exclude endometrial cancer or atypical hyperplasia. Indications for a biopsy include persistent intermenstrual bleeding and (in women aged 45 and older) treatment failure or ineffective treatment.

Pharmaceutical treatment Depends on fertility requirements but in general should be 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 Pharmaceutical treatment for heavy menstrual bleeding 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 use is anticipated (at least 12 months) tranexamic acid or non-steroidal anti-inflammatory drugs (NSAIDs) or combined oral contraceptives (COCs) norethisterone (15 mg) daily from days 5 to 26 of the menstrual cycle, or injected long-acting progestogens. In a review of the evidence for pharmaceutical treatments, a high value was placed on the use of levonorgestrel-releasing intrauterine system (LNG-IUS) as the first-line treatment for reducing menstrual blood loss and minimising adverse effects. For further information please refer to the quick reference guide for this guideline, which can be found at www.nice.org.uk/CG044

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 Non-hysterectomy surgery In women with HMB alone, with uterus no bigger than a 10-week pregnancy, endometrial ablation should be considered preferable to hysterectomy. All women should have access to a second-generation ablation technique. Hysterectomy Hysterectomy should not be used as a first-line treatment solely for HMB. Consider only when: other treatment options have failed, are contraindicated or are declined by the woman there is a wish for amenorrhoea the woman (who has been fully informed) requests it the woman no longer wishes to retain her uterus and fertility. Taking into account the need for individual assessment, the route of hysterectomy should be considered in the following order: first line, vaginal; second line. abdominal. Under circumstances such as morbid obesity or the need for oophorectomy during vaginal hysterectomy, the laparoscopic approach should be considered, and appropriate expertise sought.

Other abnormal bleeding Postcoital bleeding – Examine, exclude LGT infection and cervical lesion. Treat infection. If persists greater than 3 months refer. If >35 refer if persists for > 4 weeks refer on 2 week rule. Abnormal bleeding on HRT – stop HRT and reassess after 3 months. If still bleeding refer. Postmenopausal bleeding – single episode, examine if no abnormality, arrange ultrasound. If endometrium less than 4 mm reassure. If > 4mm or recurrent refer on 2 week rule.

Take home message Majority of women with menorrhagia should be managed in the community following these guidelines. Levonorgestrel-releasing intrauterine system should be first line Refer only if ultrasound abnormalities or failed treatment with Mirena Hysteroscopy should not be diagnostic but therapeutic You may wish to consider the following actions to support the use of pharmaceutical treatments. Where there are alterations to prescribing practices use NICE guidance, local protocols and formularies to support prescribing. The NICE guideline recommends consideration of levonorgestrel-releasing intrauterine system (LNG-IUS). Use your baseline assessment to review your current provision of facilities and specialised skills to perform this intervention. It could be carried out by trained general practitioners, family planning nurses and appropriately trained practice nurses, for example. Encourage development of services locally as appropriate.

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