Mr Pratik N Shah MD MRCOG

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Mr Pratik N Shah MD MRCOG Clinical Director for
Womens Services Barnet and Chase Farm Hospitals
NHS Trust
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Heavy menstrual bleeding
Implementing NICE guidance
January 2007
NICE clinical guideline 44
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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

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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

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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

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Investigations

• Ultrasound to identify structural abnormalities
• Hysteroscopy with biopsy only if ultrasound
  outcomes are inconclusive
• Endometrial biopsy if
• intermenstrual bleeding persists gt 3 months
• medical treatment fails or is not effective in
  women aged 45 and older

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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

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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

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Other abnormal bleeding

• Postcoital bleeding Examine, exclude LGT
  infection and cervical lesion. Treat infection.
  If persists greater than 3 months refer. If gt35
  refer if persists for gt 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 gt 4mm or
  recurrent refer on 2 week rule.

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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

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Thank you