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Community Red Secondary

GP Actions
Services Flags Care

Menorrhagia - Clinical Pathway KS13/14


Treatment Access Policy:
GP Assessment
item 2.5 Hysterectomy for Determine whether bleeding is excessive and adversely affects patient’s daily life
Heavy Menstrual Bleeding Presence of heavy cyclical loss over 3 or more consecutive cycles
is a Restricted Access Undertake physical examination (abdominal palpation + pelvic if indicated)
Procedure.

*This Pathway is a guideline.


Please screen patients for
FBC, treat anaemia if Haemoglobin < 10
contraindications before any if pt <20yo, consider clotting studies/Von Willebrand Factor (discuss with haematologist if
prescribing (BMI, Smoking). any abnormalities)
Relevant Information:

Clinical Evidence Source

NICE CG 044 Suspected structural Persistent


No suspected structural abnormality
Based on NICE (2007). Clinical abnormality Intermenstrual
Guideline 44: Heavy menstrual AND patient ≤45 years bleeding.
or patient >45 years.
bleeding. [Accessed online
2013]
1st Line Treatments
CCG Sub Committee Approvals Combined oral contraceptive*
Mefenamic acid / tranexamic acid Ultrasound Ultrasound
Date Designed: March 2013
Approver: AD Transformation Cerazette® (if oestrogen contra- Smear Test Smear Test
indicated) +/- STI screen
Date Presented: 11/04/2013
Approver:North Bexley Locality Cyclical Progesterone treatments
(N.B. Cyclical ≠ contraceptive)
Date Approved: 11/04/2013
Approver: Quality & Safety
working Group Poor Response
Date for Review: 07/05/2013
Approver: Medicines 2nd Line Treatment
Management Working Group
IUS (intra-uterine system) i.e. Mirena®
Next Review Due:
01/10/2013 for 2014
Refer to specialist
*Oct 2013 – Community Surgical options include:
Service Procurement:
Add community services Uterine fibroid embolisation
details, Transcervical fibroid resection
Embed Consultant In- Endometrial ablation
reach service to facilitate NB: refer to relevant site
direct listing,
Myomectomy
Add Ultrasound in Hysterectomy which provides the service as
Community Gynae service not all sites offer the same.
ideally by operating
consultant (in-reach) for
Attach all test results. Red Flags
efficiency and continuity Sudden increase in
of care. Referral Management & Booking Service fibroid size &
GP Triage 2 week wait guidance.

Referral Challenge Community Gynae Clinic


Quality of Referral
Secondary Care
Missing Information Due Oct 2013*
Exceptional Rx, See Review dates notes
Supplementary Information
To be used in conjunction with:
Menorrhagia - Clinical Pathway KS13/14

NICE Guidance Updates expected Q3 2013


(details below from the 2004 guidance will be updated in response)

Impact on women
For clinical purposes, heavy menstrual bleeding (HMB) should be defined as excessive menstrual blood loss
which interferes with the woman’s physical, emotional, social and material quality of life, and which can occur
alone or in combination with other symptoms. Any interventions should aim to improve quality of life measures.

History taking, examination and investigations


If appropriate, a targeted hysteroscopy may be taken to exclude endometrial cancer or atypical hyperplasia.
Indications for a biopsy include, for example, persistent intermenstrual bleeding, and in women aged 45 and
over treatment failure or ineffective treatment.
Ultrasound is the first-line diagnostic tool for identifying structural abnormalities.

Education and information provision


A woman with HMB referred to specialist care should be given information before her outpatient appointment.
The Institute’s information for patients (‘Understanding NICE guidance’) is available from www.nice.org.uk/
G044publicinfo

Pharmaceutical treatment
If history and investigations indicate that pharmaceutical treatment is appropriate and either hormonal or non-
hormonal treatments are acceptable, treatments should be considered in the following order:
– tranexamic acid or non-steroidal anti-inflammatory drugs (NSAIDs) or combined oral contraceptives
– norethisterone (15 mg) daily from days 5 to 26 of the menstrual cycle, or injected long-acting progestogens.
– levonorgestrel-releasing intrauterine system provided long-term (at least 12-months use is anticipated)

If hormonal treatments are not acceptable to the woman, then either tranexamic acid or NSAIDs can be used.

Non-hysterectomy surgery
In women with HMB alone, with uterus no bigger than a 10-week pregnancy, endometrial ablation should be
considered preferable to hysterectomy. Consider Age and any age limitations.

Hysterectomy
Taking into account the need for individual assessment, the route of hysterectomy should be considered in the
following order: first-line laparoscopic, second-line abdominal.third line vaginal.

Competencies
Maintenance of surgical, imaging or radiological skills requires a robust clinical governance framework including
audit of numbers, decision making, case-mix issues and outcomes of all treatments at both individual operator
and organisational levels. These data should be used to demonstrate good clinical practice.

Patient Information Leaflet


http://www.patient.co.uk/pdf/4418.pdf

Patient Involvement GP Lead Referral Management Secondary Care Lead


& Booking Service
Miss Sally Watkinson MRCOG
Sandra Wakeford & Dr Ricky Gondhia Charmaine Stephens Consultant Obstetrician & Gynaecologist
Ann-Louise Gardner Crayford Town Surgery Medinova Unit Divisional Director of Medical Education
Bexley CCG Crayford Road Queen Mary’s
221 Erith Road DA1 4ER Hospital South London Healthcare NHS Trust
Bexley Bexley Queen Elizabeth Hospital
DA7 6HZ Stadium Road,
0208 269 3444 Woolwich, SE18 4QH
0203 298 6000 Fax 0208 298 6768
Secretary: Margaret Richardson
020 8836 4378