• Health, Standard 17/10/2018

The Australian Commission on Safety and Quality in Health Care has produced the Heavy menstrual bleeding clinical care standard indicators to assist with local implementation of the Heavy menstrual bleeding clinical care standard (ACSQHC 2017).

The Heavy menstrual bleeding clinical care standard relates to the care of patients with heavy menstrual bleeding. It covers management from first recognition of clinically significant heavy menstrual bleeding until its resolution either before or at the menopause. The Standard is relevant to the care provided in primary care settings, including general practice, family planning and sexual health services, as well as that provided in public and private specialist gynaecology clinics and practices, hospitals and radiology clinics.

Heavy menstrual bleeding may be secondary to specific structural abnormalities, including malignancy. The detailed management of these conditions is out of the scope of the Heavy menstrual bleeding clinical care standard. The management of acute heavy menstrual bleeding in an emergency context is also not covered by the clinical care standard, nor are other presentations of abnormal uterine bleeding, including post-coital, intermenstrual and post-menopausal bleeding.

A clinical care standard is a small number of quality statements that describe the clinical care that a patient should be offered for a specific clinical condition. The indicators included in this specification are each intended for local monitoring of compliance with a quality statement and are numbered accordingly. The quality statements that are included in the Heavy menstrual bleeding clinical care standard are as follows:

1. Assessment and diagnosis. The initial assessment of a patient presenting with heavy menstrual bleeding includes a detailed medical history, assessment of impact on quality of life, a physical examination, and exclusion of pregnancy, iron deficiency and anaemia. Further investigations are based on the initial assessment.
2. Informed choice and shared decision making. A patient with heavy menstrual bleeding is provided with consumer-focused information about treatment options and their potential benefits and risks. The patient is asked about their preferences to support shared decision making for their clinical situation.
3. Initial treatment is pharmaceutical. A patient with heavy menstrual bleeding is offered pharmaceutical treatment, taking into account evidence-based guidelines, their individual needs and any associated symptoms. Initial treatment is provided to a patient who is undergoing further investigations to exclude malignancy and significant pathology.
4. Quality ultrasound. A patient having an ultrasound to investigate the cause of their heavy menstrual bleeding has a pelvic (preferably transvaginal) ultrasound, which assesses endometrial thickness and uterine morphology in days 5–10 of their menstrual cycle.
5. Intra-uterine hormonal devices. When pharmaceutical treatment is being considered, the patient is offered the levonorgestrel intra-uterine system if clinically appropriate, as it is the most effective medical option for managing heavy menstrual bleeding.
6. Specialist referral. A patient with heavy menstrual bleeding is referred for specialist review when there is a suspicion of malignancy or other significant pathology based on clinical assessment or ultrasound findings. Referral is also arranged for a patient who has not responded to pharmaceutical treatment.
7. Uterine-preserving alternatives to hysterectomy. A patient who has heavy menstrual bleeding of benign causes and who is considering surgical management is offered a uterine-preserving procedure, if clinically appropriate. The patient receives information about procedures that may be suitable (such as endometrial ablation or removal of local pathology) and is referred appropriately.
8. Hysterectomy. Hysterectomy for management of heavy menstrual bleeding is discussed when other treatment options are ineffective or are unsuitable, or at the patient’s request. A patient considering a hysterectomy is given balanced information about the risks and benefits of the procedure before making a decision.