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									    Heavy menstrual bleeding
          Implementing NICE guidance

     January 2007

NICE clinical guideline 44
       What this presentation covers:

Background to the guideline

Key recommendations and suggested actions

Costs and savings

Resources from NICE
           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
          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
               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
                    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
                                        Incidence and prevalence
Affects approximately 880,000 women in England
                                     Annual rate of women with heavy menstrual bleeding
                                                     presenting to services

                             5.00%                                                     4.47%           4.64%
      Rate of presentation

                             3.00%             2.58%
                                                       1.94%           2.10%
                             2.00%                             1.73%

                             1.00% 0.67%

                                       12 to   15 to 20 to     25 to 30 to 35 to       40 to 45 to     50 to
                                        14      19    24        29    34    39          44    49        51
                                                                  Age range

Analysis performed by Information Centre for health and social care derived from IMS Health Disease Analyzer
             What the guideline covers


Education, information and choice for women

Hormonal and non-hormonal pharmaceutical treatments

Prescribing considerations

Surgical management


Ultrasound to identify structural abnormalities

Hysteroscopy with biopsy if ultrasound outcomes are

Endometrial biopsy if:

  • intermenstrual bleeding persists
  • medical treatment fails or is not effective in women
    aged 45 and older
                       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
              Education and information

Before her outpatient appointment, provide the woman
with information as a basis for discussion and informed
                      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
             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
             Non-hormonal treatment

When hormonal treatment is not acceptable, for example
if the woman wishes to conceive, consider using:

  • tranexamic acid
  • non-steroidal anti-inflammatory drugs
         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
                        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
              Surgical management
Endometrial ablation methods

Use for HMB alone with uterus no bigger than 10-week


Should not be used as first-line treatment

Consider route of hysterectomy in the following order:

  • vaginal
  • abdominal
                       Suggested actions

Review access to and provision of surgical services

Consider use of regional services when necessary

Support training by providing access to advanced skills
Ensure a robust clinical governance framework to

  • surgical
  • imaging
  • radiological skills

Include individual and organisational audit of:

  •   numbers
  •   decision making
  •   case mix
  •   outcomes of all treatments
                         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
                             Costs and savings
Recommendations with significant resource         cost
impact                                          £millions

full blood count investigations                        0.9

transvaginal ultrasound investigations                10.4
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
guideline                                              8.7
                    Access tools online
Costing tools

   • costing report
   • costing template

Implementation advice

Audit criteria

Available from:
       Access the guideline online
Quick reference guide – a summary

NICE guideline – all of the recommendations

Full guideline – all of the evidence and rationale

‘Understanding NICE guidance’ – a plain English version

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