Guidance

Recommendations

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Impact of heavy menstrual bleeding (HMB) on women

1.1.1

Recognise that heavy menstrual bleeding (HMB) has a major impact on a woman's quality of life, and ensure that any intervention aims to improve this rather than focusing on blood loss. [2007]

1.2 History, physical examination and laboratory tests

History

1.2.1

Take a history from the woman that covers:

  • the nature of the bleeding

  • related symptoms, such as persistent intermenstrual bleeding, pelvic pain and/or pressure symptoms, that might suggest uterine cavity abnormality, histological abnormality, adenomyosis or fibroids

  • impact on her quality of life

  • other factors that may affect treatment options (such as comorbidities or previous treatment for HMB). [2007, amended 2018]

1.2.2

Take into account the range and natural variability in menstrual cycles and blood loss when diagnosing HMB, and discuss this variation with the woman. If the woman feels that she does not fall within the normal ranges, discuss care options. [2007]

1.2.3

If the woman has a history of HMB without other related symptoms (see recommendation 1.2.1), consider pharmacological treatment without carrying out a physical examination (unless the treatment chosen is levonorgestrel-releasing intrauterine system [LNG IUS]). [2007, amended 2018]

Note that this is an off-label use for some LNG-IUSs. See NICE's information on prescribing medicines.

Physical examination

1.2.4

If the woman has a history of HMB with other related symptoms (see recommendation 1.2.1) offer a physical examination. [2007, amended 2018]

Laboratory tests

1.2.6

Carry out a full blood count test for all women with HMB, in parallel with any HMB treatment offered. [2007]

1.2.7

Testing for coagulation disorders (for example, von Willebrand's disease) should be considered for women who:

  • have had HMB since their periods started and

  • have a personal or family history suggesting a coagulation disorder. [2007]

1.2.8

Do not routinely carry out a serum ferritin test for women with HMB. [2007]

1.2.9

Do not carry out female hormone testing for women with HMB. [2007]

1.2.10

Do not carry out thyroid hormone testing for women with HMB unless other signs and symptoms of thyroid disease are present. [2007]

1.3 Investigations for the cause of HMB

Before starting investigations

1.3.1

Consider starting pharmacological treatment for HMB without investigating the cause if the woman's history and/or examination suggests a low risk of fibroids, uterine cavity abnormality, histological abnormality or adenomyosis. [2018]

Investigations

1.3.3

Take into account the woman's history and examination when deciding whether to offer hysteroscopy or ultrasound as the first-line investigation. [2018]

Women with suspected submucosal fibroids, polyps or endometrial pathology
1.3.4

Offer outpatient hysteroscopy to women with HMB if their history suggests submucosal fibroids, polyps or endometrial pathology because:

  • they have symptoms such as persistent intermenstrual bleeding or

  • they have risk factors for endometrial pathology (see recommendation 1.3.10). [2018]

1.3.5

Ensure that outpatient hysteroscopy services are organised and the procedure is performed according to best practice, including:

  • advising women to take oral analgesia before the procedure

  • vaginoscopy as the standard diagnostic technique, using miniature hysteroscopes (3.5 mm or smaller). [2018]

1.3.6

Ensure that hysteroscopy services are organised to enable progression to 'see-and-treat' hysteroscopy in a single setting if feasible. [2018]

1.3.7

Explain to women with HMB who are offered outpatient hysteroscopy what the procedure involves and discuss the possible alternatives. [2018]

1.3.8

If a woman declines outpatient hysteroscopy, offer hysteroscopy under general or regional anaesthesia. [2018]

1.3.9

For women who decline hysteroscopy, consider pelvic ultrasound, explaining the limitations of this technique for detecting uterine cavity causes of HMB. [2018]

1.3.10

Consider endometrial biopsy at the time of hysteroscopy for women who are at high risk of endometrial pathology, such as:

  • women with persistent intermenstrual or persistent irregular bleeding, and women with infrequent heavy bleeding who are obese or have polycystic ovary syndrome

  • women taking tamoxifen

  • women for whom treatment for HMB has been unsuccessful. [2007, amended 2018]

1.3.11

Obtain an endometrial sample only in the context of diagnostic hysteroscopy. Do not offer 'blind' endometrial biopsy to women with HMB. [2018]

Women with possible larger fibroids
1.3.12

Offer pelvic ultrasound to women with HMB if any of the following apply:

  • their uterus is palpable abdominally

  • history or examination suggests a pelvic mass

  • examination is inconclusive or difficult, for example in women who are obese. [2018]

Women with suspected adenomyosis
1.3.13

Offer transvaginal ultrasound (in preference to transabdominal ultrasound or MRI) to women with HMB who have:

  • significant dysmenorrhoea (period pain) or

  • a bulky, tender uterus on examination that suggests adenomyosis. [2018]

1.3.14

If a woman declines transvaginal ultrasound or it is not suitable for her, consider transabdominal ultrasound or MRI, explaining the limitations of these techniques. [2018]

Other diagnostic tools

1.3.16

Do not use saline infusion sonography as a first-line diagnostic tool for HMB. [2007]

1.3.17

Do not use MRI as a first-line diagnostic tool for HMB. [2007]

1.3.18

Do not use dilatation and curettage alone as a diagnostic tool for HMB. [2007]

For a short explanation of why the committee made the 2018 recommendations and how they might affect practice, see the rationale and impact section on investigations for the cause of HMB.

Full details of the evidence and the committee's discussion are in evidence review A: diagnostic test accuracy in investigation for women presenting with heavy menstrual bleeding.

1.4 Information for women about HMB and treatments

1.4.2

Provide information about all possible treatment options for HMB and discuss these with the woman (see section 1.5). Discussions should cover:

  • the benefits and risks of the various options

  • suitable treatments if she is trying to conceive

  • whether she wants to retain her fertility and/or her uterus. [2018]

Levonorgestrel-releasing intrauterine system (LNG-IUS)

1.4.3

Explain to women who are offered an LNG-IUS:

  • about anticipated changes in bleeding pattern, particularly in the first few cycles and maybe lasting longer than 6 months

  • that it is advisable to wait for at least 6 cycles to see the benefits of the treatment. [2007]

    Note that this is an off-label use for some LNG-IUSs. See NICE's information on prescribing medicines.

Impact of treatments on fertility

1.4.4

Explain to women about the impact on fertility that any planned surgery or uterine artery embolisation may have, and if a potential treatment (hysterectomy or ablation) involves loss of fertility then opportunities for discussion should be made available. [2007]

1.4.5

Explain to women that uterine artery embolisation or myomectomy may potentially allow them to retain their fertility. [2007]

Endometrial ablation

1.4.6

Advise women to avoid subsequent pregnancy and use effective contraception, if needed, after endometrial ablation. [2007]

Hysterectomy

1.4.7

Have a full discussion with all women who are considering hysterectomy about the implications of surgery before a decision is made. The discussion should include:

  • sexual feelings

  • impact on fertility

  • bladder function

  • need for further treatment

  • treatment complications

  • her expectations

  • alternative surgery

  • psychological impact. [2007]

1.4.8

Inform women about the increased risk of serious complications (such as intraoperative haemorrhage or damage to other abdominal organs) associated with hysterectomy when uterine fibroids are present. [2007]

1.4.9

Inform women about the risk of possible loss of ovarian function and its consequences, even if their ovaries are retained during hysterectomy. [2007]

1.5 Management of HMB

1.5.1

When agreeing treatment options for HMB with women, take into account:

  • the woman's preferences

  • any comorbidities

  • the presence or absence of fibroids (including size, number and location), polyps, endometrial pathology or adenomyosis

  • other symptoms such as pressure and pain. [2018]

Treatments for women with no identified pathology, fibroids less than 3 cm in diameter, or suspected or diagnosed adenomyosis

1.5.2

Consider an LNG-IUS as the first treatment for HMB in women with:

  • no identified pathology or

  • fibroids less than 3 cm in diameter, which are not causing distortion of the uterine cavity or

  • suspected or diagnosed adenomyosis. [2018]

    Note that this is an off-label use for some LNG-IUSs. See NICE's information on prescribing medicines.

1.5.3

If a woman with HMB declines an LNG-IUS or it is not suitable, consider the following pharmacological treatments:

  • non-hormonal:

    • tranexamic acid

    • NSAIDs (non-steroidal anti-inflammatory drugs)

  • hormonal:

1.5.5

Be aware that progestogen-only contraception may suppress menstruation, which could be beneficial to women with HMB. [2018]

1.5.6

If treatment is unsuccessful, the woman declines pharmacological treatment, or symptoms are severe, consider referral to specialist care for:

1.5.7

For women with submucosal fibroids, consider hysteroscopic removal. [2018]

Treatments for women with fibroids of 3 cm or more in diameter

1.5.8

Consider referring women to specialist care to undertake additional investigations and discuss treatment options for fibroids of 3 cm or more in diameter. [2018]

1.5.9

If pharmacological treatment is needed while investigations and definitive treatment are being organised, offer tranexamic acid and/or NSAIDs. [2007]

Note that this is an off-label use for NSAIDs. See NICE's information on prescribing medicines.

1.5.10

Advise women to continue using NSAIDs and/or tranexamic acid for as long as they are found to be beneficial. [2007]

Note that this is an off-label use for NSAIDs. See NICE's information on prescribing medicines.

1.5.11

For women with fibroids of 3 cm or more in diameter, take into account the size, location and number of fibroids, and the severity of the symptoms and consider the following treatments:

  • pharmacological:

    • non-hormonal:

      • tranexamic acid

      • NSAIDs

    • hormonal:

      • LNG-IUS

      • combined hormonal contraception

      • cyclical oral progestogens

      • ulipristal acetate (this is only indicated for some premenopausal women; see recommendations 1.5.13 and 1.5.14 for more information) [amended 2021]

  • uterine artery embolisation for fibroids

  • surgical:

1.5.13

Only think about ulipristal acetate for the intermittent treatment of moderate to severe symptoms of uterine fibroids in premenopausal women if:

  • surgery and uterine artery embolisation for fibroids are not suitable, for example, because the risks to a woman outweigh the possible benefits, or

  • surgery and uterine artery embolisation for fibroids have failed, or

  • the woman declines surgery and uterine artery embolisation for fibroids.

    See the MHRA drug safety update on ulipristal acetate. [2021]

1.5.14

Discuss with the woman the risks and possible benefits of intermittent treatment with ulipristal acetate.

  • Advise that ulipristal acetate can be associated with serious liver injury leading to liver failure, and the signs and symptoms to look out for.

  • Measure liver function before starting ulipristal acetate, monthly for the first 2 courses and once before each new treatment course when clinically indicated.

  • If there is no underlying liver injury, and surgery and uterine artery embolisation for fibroids are unsuitable or have failed, consider ulipristal acetate 5 mg (up to 4 courses) for premenopausal women with heavy menstrual bleeding and fibroids of 3 cm or more in diameter, particularly if the haemoglobin level is 102 g per litre or below.

  • If a woman shows signs and symptoms of liver failure, stop ulipristal acetate and perform liver function tests urgently. [2021]

1.5.15

Be aware that the effectiveness of pharmacological treatments for HMB may be limited in women with fibroids that are substantially greater than 3 cm in diameter. [2018, amended 2020]

1.5.16

Prior to scheduling of uterine artery embolisation or myomectomy, the woman's uterus and fibroid(s) should be assessed by ultrasound. If further information about fibroid position, size, number and vascularity is needed, MRI should be considered. [2007]

1.5.17

Consider second-generation endometrial ablation as a treatment option for women with HMB and fibroids of 3 cm or more in diameter who meet the criteria specified in the manufacturers' instructions. [2018]

Fluid-filled thermal balloon and microwave endometrial ablation are recommended as options in NICE technology appraisal guidance when the woman and her clinician have decided that surgical intervention is appropriate. For full details, see the guidance on fluid-filled thermal balloon and microwave endometrial ablation techniques for heavy menstrual bleeding (TA78, 2004).

1.5.18

If treatment is unsuccessful:

  • consider further investigations to reassess the cause of HMB (see section 1.3), taking into account the results of previous investigations and

  • offer alternative treatment with a choice of the options described in recommendation 1.5.11. [2018]

1.5.19

Pretreatment with a gonadotrophin-releasing hormone analogue before hysterectomy and myomectomy should be considered if uterine fibroids are causing an enlarged or distorted uterus. [2007, amended 2020]

Note that this is an off-label use for some gonadotrophin-releasing hormone analogues. See NICE's information on prescribing medicines.

Route and method of hysterectomy

1.5.20

When discussing the route of hysterectomy (laparoscopy, laparotomy or vaginal) with the woman, carry out an individual assessment and take her preferences into account. [2007, amended 2018]

1.5.21

Discuss the options of total hysterectomy (removal of the uterus and the cervix) and subtotal hysterectomy (removal of the uterus and retention of the cervix) with the woman. [2007, amended 2018]

Removal of ovaries (oophorectomy) with hysterectomy

1.5.22

Only remove ovaries with hysterectomy with the express wish and informed consent of the woman, after discussion of all associated risks and benefits. [2007, amended 2018]

Dilatation and curettage

1.5.23

Do not offer dilatation and curettage as a treatment option for HMB. [2007]

1.5.24

If dilatation is needed for non-hysteroscopic endometrial ablation:

  • confirm that there is no evidence of uterine perforation or false passage

  • use hysteroscopy before inserting the ablation device, to establish the condition of the uterus

  • ultrasound may be used to ensure correct uterine placement of the ablation device; if the device uses a balloon, keep this inflated during the ultrasound scan. [2007, amended 2018]

For a short explanation of why the committee made the 2018 recommendations and how they might affect practice, see the rationale and impact section on management of HMB.

Full details of the evidence and the committee's discussion are in evidence review B: management of heavy menstrual bleeding.