Quality Standard Details
Heavy Menstrual Bleeding: Care for Adults and Adolescents of Reproductive Age
- Publication Date
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2024-August-01
- Status
- Published
- Topic Area
- Reproductive System and Hormones
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Heavy menstrual bleeding refers to an excessive amount of blood loss during menstruation, which disrupts a person’s physical, social, emotional, and/or material quality of life. Survey data suggest that heavy menstrual bleeding affects 18% to 32% of people of reproductive age, but clinical administrative data show that much fewer seek treatment. In Ontario, only 2.5% of women aged 13 to 55 years have sought care for heavy menstrual bleeding within the past five years. The quality of care for heavy menstrual bleeding varies across Ontario.
This quality standard includes 14 quality statements addressing areas that were identified by the Heavy Menstrual Bleeding Quality Standard Advisory Committee as having high potential for quality improvement in the way that care for heavy menstrual bleeding is currently provided in Ontario. It focuses on adults and adolescents of reproductive age presenting with either acute or chronic heavy menstrual bleeding in any care setting, regardless of the underlying cause of the bleeding. However, it does not cover the management of cancer or endometriosis once diagnosed. This quality standard does not apply to people who are pregnant or postmenopausal, or who have had a delivery, miscarriage, or abortion in the past three months.
Quality Standard in Brief
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Quality Statement 1: Comprehensive Initial Assessment
People with symptoms of heavy menstrual bleeding have a detailed history taken, a gynecological examination, a complete blood count test, and a pregnancy test (if pregnancy is possible) at their initial assessment.
Quality Statement 2: Shared Decision-Making
People with heavy menstrual bleeding are provided with information about all potential treatment options and are supported in making an informed decision about the most appropriate treatments for them based on their values, preferences, and goals, including their desire for future fertility. People receive information about treatment objectives, side effects, risks, impact on fertility, and anticipated out-of-pocket costs for all potential options.
Quality Statement 3: Pharmacological Treatments
People with heavy menstrual bleeding are offered a choice of non-hormonal and hormonal pharmacological treatment options.
Quality Statement 4: Endometrial Biopsy
People with heavy menstrual bleeding who exhibit risk factors for endometrial cancer or endometrial hyperplasia undergo an endometrial biopsy.
Quality Statement 5: Imaging
People with heavy menstrual bleeding who have suspected structural abnormalities based on a gynecological examination, or who have tried pharmacological treatment but have not had substantial improvement in their symptoms, are offered imaging of their uterus.
Quality Statement 6: Referral to a Gynecologist
People with heavy menstrual bleeding have a comprehensive initial assessment and pharmacological treatments offered prior to referral to a gynecologist. Once the referral has been made, people are seen by the gynecologist within 3 months.
Quality Statement 7: Endometrial Ablation
People with heavy menstrual bleeding are offered endometrial ablation. In the absence of structural abnormalities, patients have access to non-resectoscopic endometrial ablation techniques.
Quality Statement 8: Acute Heavy Menstrual Bleeding
People presenting acutely with uncontrolled heavy menstrual bleeding receive interventions to stop the bleeding, therapies to rapidly correct severe anemia, and an outpatient follow-up appointment with a clinician at or immediately following their next period (roughly 4 weeks).
Quality Statement 9: Dilation and Curettage
People with heavy menstrual bleeding do not receive dilation and curettage unless they present acutely with uncontrolled bleeding and medical therapy is ineffective or contraindicated.
Quality Statement 10: Offering Hysterectomy
People with heavy menstrual bleeding are offered hysterectomy only after a documented discussion about other treatment options, or after other treatments have failed.
Quality Statement 11: Least Invasive Hysterectomy
People with heavy menstrual bleeding who have chosen to have a hysterectomy have it performed by the least invasive route possible.
Quality Statement 12: Surgical Procedures for Fibroids Causing Heavy Menstrual Bleeding
People with heavy menstrual bleeding related to fibroids are offered uterine artery embolization, myomectomy, and hysterectomy as surgical treatment options.
Quality Statement 13: Bleeding Disorders in Adolescents
Adolescents with heavy menstrual bleeding are screened for risk of inherited bleeding disorders using a structured assessment tool.
Quality Statement 14: Treatment of Anemia and Iron Deficiency
People with heavy menstrual bleeding who have been diagnosed with anemia or iron deficiency are treated with oral and/or intravenous iron.
Supporting Documents
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Patient guide for this quality standard
Know what to ask for in your care
Placemat for this quality standard
A quick-reference resource for clinicians that summarizes the quality standard and includes links to helpful resources and tools
Quality improvement tools and resources for health care professionals, including an action plan template
Supplementary information to support the data collection and measurement process
Additional Resources
If you would like to receive these resources, please send us a message using our contact form:
- Case for improvement (slide deck)
Share why this standard was created and the data behind it, to get the support you need to put it into practice - Technical specifications
See the technical specifications for the indicators within the quality standard - Summary of the public feedback we received
- Case for improvement (slide deck)
Last Updated: February 24, 2026
