Refer more women with heavy menstrual bleeding for hysteroscopy, NICE says

GPs should refer more women with heavy menstrual bleeding for hysteroscopy, according to new NICE guidance.

The updated guidance on the assessment and management of heavy menstrual bleeding says that women with suspected submucosal fibroids, polyps or endometrial pathology should be referred to outpatient hysteroscopy.

NICE said the new recommendation will mean that the number of women having hysteroscopy will increase from around 5,000 to 15,000 a year. It added that changes to services will be needed to allow direct booking into hysteroscopy services and that, ideally, more hysteroscopies should be delivered in primary care. GPs and practice nurses could be trained to perform the procedure, NICE said.

NICE said that the cost of providing more hysteroscopies would be 'offset by savings from fewer ultrasound investigations and fewer appointments following the diagnostic test.'

If a woman declines outpatient hysteroscopy, they should be offered hysteroscopy under general or regional anaesthesia, the guideline says. If the patient still declines the procedure, GPs should refer them for pelvic ultrasound, 'explaining the limitations of the technique'.


An endometrial biopsy should also be considered at the time of hysteroscopy for women at high-risk of endometrial pathology, including women with persistent intermenstrual or irregular bleeding, women with infrequent heavy bleeding who are obese or have polycystic ovary syndrome, those taking tamoxifen and women for whom treatment for heavy menstrual bleeding has been unsuccessful.

GPs should refer women for pelvic ultrasound if they suspect larger fibroids following a physical examination, the guidance says. Those with suspected adenomyosis should be referred for transvaginal ultrasound.

NICE still recommends that all women with heavy menstrual bleeding should have a full blood count test. GPs should also consider starting pharmacological treatment without investigations if the patient’s history and examination suggest a low risk of fibroids, uterine cavity abnormality, histological abnormality or adenomyosis.

In such cases a LNG-IUS should be first-line treatment, NICE says. If a woman declines an LNG-IUS, tranexamic acid, NSAIDs, combined hormonal contraception or cyclical oral progestogens should be considered.

Around 1 in 20 women aged between 30-49 years see their GP about heavy periods and menstrual problems each year, NICE said.

Professor Mark Baker, director of the centre for guidelines at NICE, said: ‘Heavy menstrual bleeding is a common condition that can have a major impact on a woman’s quality of life. Since we published our original guideline in 2007 there have been significant advances in diagnostic techniques which have been reflected in the new guideline.

‘In many circumstances ultrasound has been replaced with hysteroscopy as a first line investigative test as it provides a more accurate diagnosis. This change should help ensure women with underlying endometrial diseases or conditions are more effectively diagnosed and can therefore receive better treatment. Not only this but the cost of additional hysteroscopy will be offset by savings from fewer ultrasound investigations and fewer appointments following the diagnostic test.'

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