Microsoft word - heavy_menstrual_bleeding_ius_protocol v2 final march 201

Heavy Menstrual Bleeding: Criteria for use of the Intra-
Uterine System (IUS) Protocol

3. Criteria for use of IUS for menorrhagia 4. Indications for referral/further investigations 5. Consideration of two-week rule referral 6. Pharmaceutical treatment for heavy menstrual bleeding Appendix A: Algorithm for use of IUS for management of menorrhagia Overview and purpose:
This protocol provides guidance for practitioners treating patients presenting with heavy menstrual bleeding as part of the Sexual Health Service Teesside contract delivered by Assura Stockton LLP. The purpose of the protocol is to ensure that women who are offered the levonorgestrel-releasing intrauterine system (IUS) are treated in accordance with best clinical practice and NICE Clinical Guideline 44 (January 2007) Heavy menstrual bleeding. Within Sexual Health Service Teesside, the following women should be offered the IUS: Presenting with Menorrhagia and are clinically suitable within the guidelines for the IUS to be the treatment of choice Presenting with Menorrhagia and choose an Intrauterine device (IUD) as their Sexual Health Service Teesside Version 2 Final. March 2011 Women choosing an IUD/IUS as their preferred method of contraception in the
absence of menorrhagia should have the advantages and disadvantages of
both devices clearly explained to them to enable them to make an informed

Definition of menorrhagia:
Heavy menstrual bleeding (HMB)/ menorrhagia is defined as excessive menstrual blood loss over several cycles which interferes with a woman’s physical, social, emotional and/or quality of life, and which can occur alone or in combination with other symptoms. Any intervention should aim to improve quality of life measures. Criteria for use of IUS for menorrhagia:
Cyclical bleeding without inter-menstrual or post-coital bleeding Duration> 3 cycles Heavy bleeding- clots/flooding/soaking through/accidents/nocturnal change of All women with a history of HMB should have FBC, abdominal examination and cervical smear, if due, as minimal investigation. The IUS system is recommended as first line treatment for women with heavy menstrual bleeding and no underlying pathology (dysfunctional uterine bleeding) and in some women with heavy menstrual bleeding and identified benign pathology such as small fibroids (less than 3 cm in diameter which are causing no distortion of the uterine cavity) provided that long-term use is anticipated (at least 12 months). The IUS may also be recommended, following gynaecological investigation, for the management of conditions such as endometriosis. Indications for referral/ further investigations
Gynaecological referral - USS /Endometrial biopsy: All women with persistent inter-menstrual and/or post-coital bleeding Sexual Health Service Teesside Version 2 Final. March 2011 Irregular bleeding Women aged >45 years with treatment failure Women aged >45 years with ineffective treatment Uterus palpable abdominally or pelvic mass History of bleeding gums/ easy bruising (check LFTs and blood clotting History and/or symptoms suggestive of possible sexually transmitted infection Consider two-week rule referral:

Persistent inter-menstrual and/or post-coital bleeding (all should have Pelvic mass (which is not obviously fibroids on USS). Note: endometrial cancer is uncommon in pre-menopausal women. Risk factors for endometrial cancer include: Tamoxifen or unopposed oestrogen treatment Polycystic ovaries Pharmaceutical treatment for heavy menstrual bleeding:

First Line:
IUS - provided this method will be accepted for at least 12 months
Second Line:
Tranexamic acid, NSAID, or combined oral contraception
Third Line:
Norethisterone 15mg daily –day 5-26 of cycle or injectable progesterone
Follow-up arrangements:
Patient information and follow-up arrangements include: Sexual Health Service Teesside Version 2 Final. March 2011 All women should be advised about the type of device that has been inserted and when it needs to be removed and/or replaced. Written information should be provided, such as a FPA leaflet. All women should be advised to seek immediate medical advice if they develop symptoms of fever, pelvic pain, irregular bleeding or vaginal discharge which might indicate infection. All women should be advised to seek medical advice if threads are not palpable or they can feel the stem of the IUD. A routine follow-up appointment should be made after first menses or 3-6
All the above should be recorded in the patient record.
Routine annual follow-up is NOT recommended.
NICE clinical guideline 44 (January 2007) Heavy Menstrual Bleeding. Referral guidelines for suspected cancer – gynaecological cancers NICE (2005a) Referral guidelines for suspected cancer: quick reference guide. Clinical guideline 27. National Institute for Health and Clinical NICE (2005b) Long-acting reversible contraception (NICE guideline). National Institute for Health and Clinical Excellence. NICE (2007a) Heavy menstrual bleeding: understanding NICE guidance. National Institute for Health and Clinical Excellence. NICE (2007b) Audit criteria: heavy menstrual bleeding. National Institute for Sexual Health Service Teesside Version 2 Final. March 2011 RCOG (1998) The initial management of menorrhagia. Evidence-based clinical guidelines no.1. Royal College of Obstetricians and Gynaecologists. FFPRHC (2006) UK medical eligibility criteria for contraceptive use [Superseded]. Faculty of Family Planning and Reproductive Health Care. Sexual Health Service Teesside Version 2 Final. March 2011 Appendix A: Algorithm for use of IUS for management of

Criteria for heavy menstrual bleeding met Sexual Health Service Teesside Version 2 Final. March 2011



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