Taking Control of Heavy Periods: NICE on Menorrhagia

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I will go through the NICE guideline on “Heavy menstrual bleeding: assessment and management”, or NICE guideline [NG88.

I will summarise the guidance from a Primary Care perspective only.

I am not giving medical advice; this video is intended for health care professionals; it is only my interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The NICE guideline NG88 “Heavy menstrual bleeding: assessment and management” can be found here:

·      https://www.nice.org.uk/guidance/ng88/chapter/Recommendations

The Menorrhagia mind map or flow chart can be downloaded here:

·      https://1drv.ms/i/s!AiVFJ_Uoigq0mFegr4-vdKdhitAI?e=BJRIDK

Thumbnail photo: from Freepik: https://www.freepik.com/

·      Image by benzoix on Freepik

·      a href="https://www.freepik.com/free-photo/young-woman-with-pain-stomach-holding-hands-belly-feeling-terrible-ache-menstrual-cramps-stand_34232826.htm#query=heavy%20periods&position=17&from_view=search&track=ais"Image by benzoix/a on Freepik

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• Music provided by Audio Library Plus  
• Watch: https://youtu.be/aBGk6aJM3IU 
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Transcript

Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through the NICE guideline on menorrhagia or, to be precise, “Heavy menstrual bleeding: assessment and management” and I will summarise the guidance from a Primary Care perspective only.

So, let’s jump into it.

We will obviously start with the history including the nature and impact of the bleeding and we will particularly pay attention to what NICE refers to as “related symptoms”. These are symptoms such as:

·      Persistent intermenstrual bleeding

·      Pelvic pain and/or

·      Pressure symptoms, because

they might suggest a uterine abnormality.

What may come as a surprise is that NICE says that if none of these symptoms are present, that is, no IMB, no pain and no pressure symptoms, we will consider pharmacological treatment without necessarily carrying out a physical examination.

But the converse is true, a physical examination is recommended if such symptoms exist or if we are considering a levonorgestrel-releasing intrauterine system [LNG IUS], that is, a Mirena coil or similar. 

In terms of blood tests:

·      we will perform a FBC for all patients and

·      we will consider testing for coagulation disorders if they have had heavy periods since they started and there is a personal or family history suggestive of it

·      However, NICE says that there is no need for routine ferritin, hormone or thyroid testing

We will then consider investigations for the cause of the HMB but

We will also consider starting pharmacological treatment without investigating the cause if we feel that there is a low risk of uterine abnormality.

If we do investigate further, we will consider the need for:

·      Hysteroscopy

·      A pelvic USS or

·      A transvaginal USS

And we will choose each investigation depending on whether we suspect:

·      submucosal fibroids, polyps or endometrial pathology (in which case a hysteroscopy would be needed)

·      larger fibroids (in which case a pelvic USS would be needed) or

·      adenomyosis (when a transvaginal USS would be recommended)

And we will use our clinical judgement to decide which one of those we should consider as most likely. For example:

·      We will suspect submucosal fibroids, polyps or endometrial pathology (and therefore the need to refer for possible hysteroscopy plus / minus biopsy) if, for example:

o  They are taking tamoxifen

o  They have persistent intermenstrual or irregular bleeding,

o  They have infrequent heavy bleeding and are obese or have PCOS or if

o  They have not responded to treatment. 

·      We will think about larger fibroids (and therefore the need to request a pelvic USS) if:

o  there is a palpable uterus on abdominal examination,

o  a Pelvic mass is suspected and

o  we will also consider a pelvic USS if the examination is inconclusive or difficult, because, for example, obesity

·      And we will think about adenomyosis (and therefore the need for a transvaginal USS) if:

• There is a bulky, tender uterus on examination or
• There is significant dysmenorrhoea or period pain but we also need to be aware that pain may be caused by endometriosis rather than adenomyosis

If hysteroscopy is declined, we will consider a pelvic ultrasound, explaining its limitations

If a transvaginal ultrasound is declined or unsuitable, we will consider a transabdominal ultrasound or MRI, also explaining their limitations.

Let’s now look at the management of menorrhagia. As we have previously said, we will refer for hysteroscopy those patients in whom we suspect an endometrial pathology, so we will leave their management in the hands of secondary care. 

So, from a Primary Care perspective, and for the purpose of their management we need to group the remaining patients into two types:

·      Patients with no identified pathology, with fibroids less than 3 cm in diameter, or with adenomyosis and

·      Patients with fibroids of 3 cm or more in diameter

For the first group, that is, patients with no identified pathology, with small fibroids, or adenomyosis, we will consider an LNG-IUS first line, as long as, if there are small fibroids, they do not cause distortion of the uterine cavity 

On offering this treatment, we will explain to them:

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

·      that it is advisable to wait for at least 6 cycles to see the benefits of the treatment. 

If LNG-IUS is declined or unsuitable, we will consider pharmacological treatments, either:

·      non-hormonal like:

o  tranexamic acid and

o  NSAIDs or

·      Hormonal like:

o  combined hormonal contraception and

o  cyclical oral progestogens, also bearing in mind that

o  Progestogen-only contraception may suppress menstruation, which could be beneficial for some patients too

If the symptoms are severe or do not respond to pharmacological treatment, or the patient declines pharmacological treatment, we will refer.

For the second group, that is, patients with fibroids of 3 cm or more in diameter

We will consider referral and, if pharmacological treatment is needed while waiting investigations, we will consider tranexamic acid and/or NSAIDs, but we need to be aware that the effectiveness of pharmacological treatments may be limited if fibroids are substantially greater than 3 cm in diameter. 

Depending on the size, location and number of fibroids, and the severity of the symptoms a number or other treatments may be considered by secondary care, including further pharmacological or surgical treatments.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guideline. You must always use your clinical judgement.

Thank you for listening and goodbye.