Assessment

History

1. the nature of the bleeding

2. related symptoms [suggestive of uterine cavity abnormality, histological abnormality, adenomyosis or fibroids]

   persistent intermenstrual bleeding
   pelvic pain
   pressure symptoms

3. impact on her quality of life

4. comorbidities or previous treatment for HMB

History + no related symptoms —-> commence pharmacological treatment for HMB

If the woman has a history of HMB without other related symptoms, consider pharmacological treatment without carrying out a physical examination

unless the treatment chosen is levonorgestrel-releasing intrauterine system [LNG IUS].

History + related symptoms —> physical examination

If the woman has a history of HMB with other related symptoms offer a physical examination.

Carry out a physical examination before all investigations or LNG-IUS[1] fittings. [2007]

History, no related symptoms, normal physical examination —> commence pharmacological treatment for HMB

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.

Laboratory tests

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

Testing for coagulation disorders (for example, von Willebrand's disease) if:

• have had HMB since their periods started and

• have a personal or family history suggesting a coagulation disorder.

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

If cancer is suspected—> REFER to secondary care

Be aware that pain associated with HMB may be caused by endometriosis rather than adenomyosis

First-line secondary care investigations

Recommend pelvic ultrasound if:

• uterus is palpable abdominally

• history or examination suggests a pelvic mass

• examination is inconclusive or difficult, for example in women who are obese

• bulky, tender uterus on examination that suggests adenomyosis.

• significant dysmenorrhoea (period pain)

Recommend outpatient hysteroscopy if:

Suspected submucosal fibroids, polyps or endometrial pathology (persistent intermenstrual bleeding or risk factors for endometrial pathology)

• Vaginoscopy is the standard diagnostic technique, using miniature hysteroscopes (3.5 mm or smaller)

• 'See-and-treat' hysteroscopy

• Obtain a ‘directed’ endometrial sample only in the context of diagnostic hysteroscopy.

• Do not offer 'blind' endometrial biopsy to women with HMB.

Recommend endometrial biopsy

• persistent intermenstrual or persistent irregular bleeding

• infrequent heavy bleeding who are obese or have polycystic ovary syndrome

• tamoxifen

• treatment for HMB has been unsuccessful.

Secondary care second-line investigations

1. Saline infusion sonography as a first-line diagnostic tool for HMB

2. MRI

Treatment options

1. The presence or absence of fibroids (including size, number and location), polyps, endometrial pathology or adenomyosis

2. Treatments for women with fibroids of 3 cm or more in diameter: refer to specialist

3. Consider symptoms such as pressure and pain, and the desire to preserve fertility and or preserve the uterus

Treatments for women with no identified pathology, fibroids less than 3 cm in diameter (not distorting uterine cavity), or suspected or diagnosed adenomyosis

1. LNG-IUS--changes in bleeding pattern, particularly in the first few cycles and maybe lasting longer than 6 months

2. non-hormonal:tranexamic acid, NSAIDs - offer these treatments while investigations and definitive treatment are being organised

3. hormonal: combined hormonal contraception, cyclical oral progestogen, progestogen-only contraception

Other treatments where the potential for fertility (and uterus) is preserved

• Myomectomy (hysteroscopic if submucous fibroids, laparoscopic, abdominal)

• Uterine artery embolisation

Fertility not preserved, Uterus not preserved

• Second-generation endometrial ablation
  Avoid subsequent pregnancy and use effective contraception, if needed, after endometrial ablation)
  Use hysteroscopy before inserting the ablation device, to establish the condition of the uterus (and exclude any perforation or false passage)
  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.

• Hysterectomy
  Small risk of possible loss of ovarian function and its consequences, even if their ovaries are retained during hysterectomy)
  Vaginal, Laparoscopic, Abdominal; subtotal or total; ovaries preserved or removed

Fibroid treatments

1. Take into account the size, location and number of fibroids, and the severity of the symptoms.

2. Be aware that the effectiveness of pharmacological treatments for HMB (excluding ulipristal acetate) may be limited in women with fibroids that are substantially greater than 3 cm in diameter.

3. 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.

4. 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.

5. Pretreatment with a gonadotrophin-releasing hormone analogue or ulipristal acetate before hysterectomy and myomectomy should be considered if uterine fibroids are causing an enlarged or distorted uterus.

Treatment options

• LNG-IUS

• ulipristal acetate

• combined hormonal contraception

• cyclical oral progestogens

• uterine artery embolisation

• myomectomy

• hysterectomy

Ulipristal acetate

Risk of rare but serious liver injury:

• Monitor liver function for the first 2 treatment courses, and as clinically indicated, in line with current prescribing guidance

• Offer ulipristal acetate 5 mg (up to 4 courses) to women with HMB and fibroids of 3 cm or more in diameter, and a haemoglobin level of 102 g per litre or below.

• Consider ulipristal acetate 5 mg (up to 4 courses) for women with HMB and fibroids of 3 cm or more in diameter, and a haemoglobin level above 102 g per litre.