This policy provides guidance on the commissioning of hysterectomy for the treatment of heavy menstrual bleeding which is not caused by a structural or pathological abnormality.
Heavy menstrual bleeding (HMB) is defined as excessive menstrual blood loss that occurs at regular intervals, which interferes with a woman’s physical, social, emotional and/or material
quality of life. It can occur alone or in combination with other symptoms. There is no underlying pathology associated with heavy menstrual bleeding.
Hysterectomy should be considered only when: other treatment options have failed, are contraindicated; there is a wish for amenorrhoea (no periods); the woman (who has been fully informed) requests it; the woman no longer wishes to retain her uterus and fertility.
Individual clinical judgement will continue to be used when offering hysterectomy for structural abnormalities such as Uterine prolapse, precancerous changes, fibroids >3cm, persistent CIN adenomyosis and endometriosis could also be indications for hysterectomy in a woman with HMB.
Eligibility
Threshold Criteria
| LLR ICB Hysterectomy for heavy menstrual bleeding is NOT ROUTINELY FUNDED unless ALL of the following criteria are met. – Two treatments from Nice Guidance 44 (as long as no contraindications) have been tried and continued for at least 3 months to assess response unless side effects are unacceptable. – A clear offer of an IUS should be made as this is a first line treatment for HMB. If this is declined or contraindicated this should be clearly documented. It is recommended that IUS is kept in for 6 months to assess effectiveness as per NICE guideline. – We would recommend the use of a menstrual diary template in the assessment of HMB and evaluation of treatment options. – Thereafter there has been a failure to relieve symptoms (unless medically inappropriate or contraindicated) AND The following treatments have either failed, are not appropriate or are contraindicated in line with the National Institute for Health and Clinical Excellence (NICE) guideline NG88 Heavy Menstrual Bleeding: • Tranexamic acid and/or non-steroidal anti-inflammatory drugs (NSAIDs), such as naproxen • Oral hormonal methods, such as combined oral contraceptives, cyclical oral progesterone AND There is evidence of severe impact on quality of life OR If treatment is unsuccessful, the woman declines pharmacological treatment, or symptoms are severe, consider referral to specialist care for: investigations to diagnose the cause of HMB, if needed, taking into account any investigations the woman has already had and alternative treatment choices, including: pharmacological options not already tried (as previous), alternative surgical options |
Guidelines
Additional Information
Gynaecology Pathway Finder
Managing Unscheduled Bleeding
Suspected Endometrial Pathology (SEP) Pathway
| ARP 72 Review Date: 2027 |
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