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Menorrhagia (PLCV)
Local Care Maps - NDCCG > NDCCG PLCV > Menorrhagia (PLCV)
Care map
information
Information resources
for patients and carers
Updates to this care
map
Heavy menstrual
bleeding - clinical
presentation
History and
examination
RED FLAG!
Refer urgently to
specialist care
R
Investigations
Consider possible
causes
Pharmaceutical
treatment options
Hormonal
Non-hormonal
Monitor and review
treatment response
Failure to respond to
treatment or suspicion
of pathology
Eligibility criteria
PLCV referral form
R
Published: 16-Oct-2015
Valid until: 30-Apr-2017
Printed on: 24-Nov-2015
© Map of Medicine Ltd
This care map was published by NDCCG and HCCG. A printed version of this document is not controlled so may not be up-to-date with the
latest clinical information.
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Menorrhagia (PLCV)
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1 Care map information
Quick info:
Scope:
• primary care management of:
• abnormal menstrual bleeding, including heavy menstrual bleeding (HMB), irregular menstrual bleeding, and intermenstrual
bleeding
• post-menopausal bleeding (PMB)
• post-coital bleeding (PCB)
Out of scope:
• primary care management of amenorrhoeaand criteria for referral into secondary care – see 'Amenorrhoea' care map
• non-menstrual bleeding associated with pregnancy or pregnancy loss:
• see 'Suspected ectopic pregnancy' care map
• see 'Threatened miscarriage' care map
• see 'Placenta praevia - diagnosis' care map
• premenstrual syndrome (PMS) – see 'Premenstrual syndrome (PMS)' care map
• chronic pelvic pain
• specific management of bleeding problems caused by contraceptive devices
• treatment of conditions underlying HMB, such as endometriosis and adenomyosis
Definitions:
• HMB, or menorrhagia, is excessive menstrual blood loss over several consecutive cycles which interferes with the woman's
physical, emotional, social, and material quality of life
• irregular menstrual bleeding is defined as between three and five episodes with fewer than three bleeding-free intervals of
length 14 days or more [2]
• oligomenorrhoea is defined as menstrual bleeding at intervals of between 35 days and 6 months [31]
• PMB is defined as:
• unexplained vaginal bleeding more than 12 months after menstruation has stopped because of the menopause [34]
• any breakthrough bleeding in a woman receiving cyclical hormone replacement therapy (HRT)
• breakthrough bleeding after the first 6 months of continuous HRT, or after full amenorrhoea has been established [3]
• intermenstrual bleeding is defined as bleeding between periods [4]
• PCB is defined as bleeding that occurs after sexual intercourse [7]
Prevalence of HMB:
• 10% of reproductive-aged women have objective evidence of HMB
• 30% of reproductive-aged women self-report HMB
References:
Please see the care map's Provenance.
2 Information resources for patients and carers
Quick info:
Recommended resources for patients and carers, produced by organisations certified by The Information Standard:
• 'Endometriosis' (URL) from Patient UK at http://www.patient.co.uk
• 'Fibroids' (URL) from Patient UK at http://www.patient.co.uk
• 'Heavy Periods (Menorrhagia)' (URL) from Patient UK at http://www.patient.co.uk
• 'Cervical cancer' (URL) from Patient UK at http://www.patient.co.uk
• 'Gynaecological cancer information leaflet' (PDF) from the Eve Appeal at www.eveappeal.org.uk
• 'Understanding NICE guidance: Treatment and care for women with heavy periods' (PDF) from National Institute of Health and
Clinical Excellence (NICE) at http://www.nice.org.uk
Published: 16-Oct-2015
Valid until: 30-Apr-2017
Printed on: 24-Nov-2015
© Map of Medicine Ltd
This care map was published by NDCCG and HCCG. A printed version of this document is not controlled so may not be up-to-date with the
latest clinical information.
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For details on how these resources are identified, please see Map of Medicine's document on Information Resources for Patients
and Carers (URL).
3 Updates to this care map
Quick info:
Local pathway enhanced by wording from international map. Date of publication: 31-Aug-2015
4 Heavy menstrual bleeding - clinical presentation
Quick info:
Heavy menstrual bleeding (HMB):
• defined as excessive menstrual blood loss which interferes with the woman's physical, emotional, social and material quality of
life (QoL) [6]
• difficulties exist in defining 'normal' menstrual blood loss and women's perceptions of HMB may vary considerably [5]
• interventions should focus on improving symptoms and QoL, rather than focusing on menstrual blood loss [5]
• measuring menstrual blood loss (MBL) is not routinely recommended for HMB − patient should use own judgement instead [5]
• in 40-60% of cases, no underlying cause is found – dysfunctional uterine bleeding (DUB) [6]
Patient may present with the following complaints [5,6]:
• 'flooding'
• clothes bloodstained
• painful periods
• anxiety/depression
• moodiness or irritability
• interference with social life, hobbies, or life in general
Common causes of HMB [6]:
• uterine fibroids (indicated by dysmenorrhoea and pelvic pain) [6]
• endometriosis and adenomyosis (indicated by dysmenorrhoea, dyspareunia, pelvic pain, and difficulty conceiving) [6]
• pelvic infection (eg chlamydia) and chronic pelvic inflammatory disease (indicated by vaginal discharge, pelvic pain,
intermenstrual/postcoital bleeding) [6] − see 'Post-coital bleeding and intermenstrual bleeding' page of this care map
• endometrial polyps (indicated by intermenstrual bleeding) [6]
• endometrial hyperplasia or carcinoma (indicated by postcoital bleeding and intermenstrual bleeding) [6]
• polycystic ovary syndrome [6] (HMB often accompanied by oligomenorrhoea) [28] − see 'Oligomenorrhoea and irregular
menstrual bleeding' page of this care map
• coagulation disorders (eg von Willebrand disease) [6]
• hypothyroidism (may also present with fatigue, constipation, intolerance of cold, and hair/skin changes) [6]
• liver or renal disease [6]
• anticoagulant treatment [6]
• chemotherapy [6]
• intrauterine copper contraceptive device (blood loss may be increased by 40-50% over 6-12 months) [6]
References:
Please see the care map's Provenance.
5 History and examination
Quick info:
Establish that the woman has menstrual bleeding that is, in both her opinion and your own, heavy − take into account the range and
natural variability in menstrual cycles and blood loss when diagnosing heavy menstrual bleeding (HMB) [5,6].
Take a thorough history to include [5]:
Published: 16-Oct-2015
Valid until: 30-Apr-2017
Printed on: 24-Nov-2015
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Menorrhagia (PLCV)
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• the nature of bleeding
• degree of blood loss (eg 'flooding' or passage of clots)
• impact on QoL
• menstrual cycle details, including:
• length of cycle
• duration of menstruation (including duration of heavy menstruation)
• variability of cycle
• any intermenstrual bleeding
• NB: for post-menopausal bleeding see the 'Post-menopausal bleeding' page of this care map
• presence of additional symptoms suggesting possible underlying pathology, such as:
• postcoital bleeding
• sudden increase in blood loss [28]
• dyspareunia
• dysmenorrhoea
• pelvic pain and pressure symptoms
• visible haematuria [34]
• unexplained vaginal discharge [34]
• inherited bleeding or clotting disorders
• current contraceptive method (including duration of use and compliance)
• medical history, including presence of co-morbidity
• current medications, concentrating on anticoagulation agents
• cervical screening history
• desire for pregnancy
• impact upon the woman's work, social, and personal relationships
Examination:
• if the patient history suggests the presence of structural or histological abnormality (eg symptoms include intermenstrual or
postcoital bleeding, pelvic pain, and/or pressure symptoms), a physical examination and/or other investigations (eg ultrasound)
should be performed prior to further investigation [5]
• if there is no reason to suspect structural or histological abnormality, pharmaceutical treatment can be started without carrying
out a physical examination at initial consultation in primary care, unless the treatment chosen is levonorgestrel-releasing
intrauterine system (LNG-IUS) [5]
• a pelvic examination should include [6]:
• vulval examination for evidence of external bleeding and signs of infection (eg vaginal discharge)
• speculum examination of vagina and cervix
• high vaginal, endocervical, and chlamydia swabs should be obtained if infection is suspected
• bimanual palpation to identify uterine or adnexal enlargement or tenderness.
• in addition to abdominal and pelvic examination, look for systemic signs of underlying disease, such as [6]:
• hirsutism, striae, thyroid enlargement or nodularity, or changes in skin pigmentation (indicative of endocrine disease)
• bruises or petechiae (indicative of coagulation disorders)
References:
Please see the care map's Provenance.
6 RED FLAG!
Quick info:
The following alarm symptoms and signs may be the first symptoms of cancer and indicate the need for a pelvic examination and/or
biopsy:
• sudden increase in blood loss [8]
• persistent intermenstrual bleeding [5,6]
Published: 16-Oct-2015
Valid until: 30-Apr-2017
Printed on: 24-Nov-2015
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This care map was published by NDCCG and HCCG. A printed version of this document is not controlled so may not be up-to-date with the
latest clinical information.
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Menorrhagia (PLCV)
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• post-coital bleeding [5,6]
• post-menopausal bleeding [34]
• visible haematuria [34]
• unexplained vaginal discharge [34]
• bulky uterus palpable abdominally (size more than a 10-week pregnancy) [5,6]
• pelvic mass [5]
• an unexplained vulval lump or vulval bleeding due to ulceration [6]
• dyspareunia [5]
• pelvic pain, tenderness, or pressure symptoms [5]
• severe anaemia (haemoglobin less than 8g/dL) [5]
Cervical and endometrial cancers are rare in women of reproductive age who are using hormonal contraception or who do not have
risk factors [2].
Risk factors for endometrial cancer include:
• age 45 years and over [5]
• nulliparity [5]
• family history [5]
• obesity [2,5]
• tamoxifen use [2,5]
• unopposed oestrogen treatments [2,5]
• polycystic ovary syndrome (PCOS) [2,5]
Risk factors for cervical cancer include [8]:
• abnormal cervical smear
• multiple sexual partners
• early sexual activity
• oral contraceptive use for more than 5 years
• previous exposure to other sexually transmitted infections (STIs), such as:
• Chlamydia trachomatis
• herpes virus type 2
If there is any suspicion of underlying cancer the woman should be urgently referred to a specialist within 2 weeks [5,6].
The National Institute for Health and Care Excellence (NICE) referral recommendations for suspected symptoms and examination
findings of gynaecological cancers are as follows [34]:
• arrange an urgent suspected cancer pathway referral (to be seen within 2 weeks) for:
• endometrial cancer:
• for women aged 55 years and older with post-menopausal bleeding (unexplained vaginal bleeding more than 12 months
after menstruation has stopped because of the menopause)
• NB: consider an urgent referral for endometrial cancer in women younger than age 55 years with post-menopausal
bleeding
• ovarian cancer:
• if physical examination identifies ascites and/or a pelvic or abdominal mass (which is not obviously uterine fibroids)
• consider an urgent suspected cancer pathway referral (to be seen within 2 weeks) for:
• cervical cancer if the appearance of their cervix on examination is consistent with cervical cancer
• vulval cancer in women with an unexplained vulval lump, ulceration, or bleeding
• for vaginal cancer in women with an unexplained palpable mass in or at the entrance to the vagina
Fibroids [5]:
• benign uterine tumours composed of muscle and connective tissue with a thin covering capsule [5]
• most common tumour found in the female reproductive system [5]
• four different subtypes:
• submucosal (most likely type to give rise to irregular or heavy menstrual bleeding) [5]
Published: 16-Oct-2015
Valid until: 30-Apr-2017
Printed on: 24-Nov-2015
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This care map was published by NDCCG and HCCG. A printed version of this document is not controlled so may not be up-to-date with the
latest clinical information.
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• intramural [5]
• subserosal [5]
• intra-cavity [28]
• occasionally present with symptoms similar to those associated with uterine cancer, such as [5]:
• intermenstrual or postcoital bleeding
• dyspareunia
• dysmenorrhoea
• bulky uterus (size greater than a 10-week pregnancy)
• pelvic mass
• pelvic pain or tenderness
• severe anaemia (haemoglobin less than 8g/dL) [5]
• offer immediate referral to a specialist if [5]:
• fibroids are palpable abdominally
• intra-cavity fibroids are present as measured by ultrasound or hysteroscopy
• uterine length as measured by ultrasound or hysteroscopy is greater than 12cm
References:
Please see the care map's Provenance.
8 Investigations
Quick info:
Take full blood count (FBC):
• often done in parallel with any treatments offered [5]
• iron deficiency anaemia occurs in about two-thirds of women with HMB [5]
• while iron deficiency anaemia is a strong indicator of HMB and identifies the need for oral iron supplements, normal
haemoglobin does not exclude HMB [5]
• anaemia should be treated if present [6]
Test for systemic causes, eg coagulation disorders [6]:
• perform as clinically indicated
• should be arranged in conjunction with the local haematology department, as many of the tests are not routine
• women who may require screening include those with:
• HMB since menarche
• a history of excessive bleeding after tooth extraction, operations, or childbirth
• family history of a coagulation disorder
Consider [6]:
• transvaginal pelvic ultrasound to identify structural abnormalities if woman has symptoms suggesting underlying cause for HMB
or:
• uterus is palpable abdominally
• pelvic mass of uncertain origin − consider urgent referral
• treatment has been ineffective
Consider a direct access ultrasound scan to assess for endometrial cancer in women aged 55 years and older with [34]:
• unexplained symptoms of vaginal discharge who:
• are presenting with these symptoms for the first time; or
• have thrombocytosis; or
• report haematuria
• visible haematuria and:
• low haemoglobin levels; or
• thrombocytosis; or
Published: 16-Oct-2015
Valid until: 30-Apr-2017
Printed on: 24-Nov-2015
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latest clinical information.
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• high blood glucose levels
Perform a cervical smear test if indicated or due [4,8].
Thyroid testing should only be carried out when other signs and symptoms of thyroid disease are present [5].
Consider blood glucose testing as high glucose levels may be associated with endometrial carcinoma [34].
NB: Serum ferritin and female hormone testing are not routinely indicated [4].
References:
Please see the care map's Provenance.
9 Consider possible causes
Quick info:
Consider the following underlying causes:
• gynaecological causes [5]:
• dysfunctional uterine bleeding − accounts for 40-50% of cases
• uterine fibroids (accounts for approximately 30% of cases)
• uterine polyps (accounts for approximately 10% of cases)
• endometrial hyperplasia
• endometrial cancer
• polycystic ovarian syndrome (PCOS)
• endometriosis
• pelvic inflammatory disease (PID)
• complications of early pregnancy or miscarriage − see 'Miscarriage' care map
• systemic causes, including [5]:
• bleeding disorders, eg von Willebrand's disease
• anticoagulation medication, eg warfarin
• hypothyroidism
• liver disease
• use of intrauterine contraceptive device (IUCD) may increase blood loss by 40-50% over the first 6-12 months compared with
pre-insertion [6]
References:
Please see the care map's Provenance.
10 Pharmaceutical treatment options
Quick info:
Offer pharmacotherapy as first-line treatment unless, after a full consultation, the patient would prefer surgery. The more definitive
and successful longer-term results of surgery than medication must be weighed against the [5]:
• surgical risks; and
• fertility issues posed by surgery
Pharmaceutical treatment should be considered where [5]:
• no structural or histological abnormality is present
• fibroids are less than 3cm in diameter and are not causing distortion of the uterine cavity
Determine whether hormonal contraception is acceptable to the woman before recommending treatment, eg she may wish to
conceive [5].
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 [5]:
• levonorgestrel-releasing intrauterine system (LNG-IUS) − provided long-term (at least 12 months) use is anticipated
• tranexamic acid (TA), non-steroidal anti-inflammatory drugs (NSAIDs), or combined oral contraceptives (COCs)
Published: 16-Oct-2015
Valid until: 30-Apr-2017
Printed on: 24-Nov-2015
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This care map was published by NDCCG and HCCG. A printed version of this document is not controlled so may not be up-to-date with the
latest clinical information.
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NB: The National Institute for Health and Clinical Excellence (NICE) states that oral norethisterone or injected long-acting
progestogens should be considered as a third-line pharmacological treatment for HMB; however, the Royal College of Obstetrician
and Gynaecologists (RCOG) Guidelines Committee members state that oral progesterones are ineffective but injectable
progesterones are highly effective in the treatment of HMB [5, 28].
If bleeding is very heavy or prolonged, consider stopping it abruptly by giving oral norethisterone at high doses (5mg, three times
daily) − usually stops bleeding in 24-48 hours [6].
If hormonal treatments are not acceptable to the woman, then either TA or NSAIDs can be used [5].
If pharmaceutical treatment is required while investigations and definitive treatment are being organised, either TA or NSAIDs should
be used [5].
References:
Please see the care map's Provenance.
11 Hormonal
Quick info:
Levonorgestrel-releasing intrauterine system (LNG-IUS):
• intrauterine, long-term progestogen-only method of contraception licensed for up to 5 years of use (consider if the woman plans
to use this method for at least 12 months) [5]
• first-line treatment in those who do not wish to conceive and for whom hormonal therapy is acceptable [5]
• may be used in patients with fibroids, but not the first treatment choice (due to the problems of possible abnormal uterine
anatomy or distortion) [5]
• up to 60% of women stop using an intrauterine system within 5 years [1]
• adverse effects are generally minor and transient, and include [5]:
• premenstrual syndrome (PMS) like symptoms − 2.9% of women discontinue use at 5 years due to symptoms including:
• breast tenderness
• mood swings
• headache − 8.3% experience headaches
• acne − causes 2.3% of women to discontinue use at 5 years
• amenorrhoea − is likely to occur by 1 year of use [1]
• spotting, bleeding, and intermenstrual bleeding are normal during the first few (up to 6) months and not a reason for
discontinuation [5]
• rarely, uterine perforation during intrauterine device (IUD) insertion may occur [5] (between 1/1000 and 1/10000 women) [2]
• prior to insertion [4]:
• a pelvic examination must be performed
• chlamydia screening should be considered
• a recent study found similar therapeutic effects to that of endometrial ablation techniques after 2 years of treatment [9]
• compared to thermal balloon endometrial ablation (TBEA) [23]:
• similar incidence of intermenstrual bleeding at 12 months
• TBEA resulted in faster reductions in blood loss than LNG-IUS
• the most cost-effective treatment for HMB [23]
Combined oral contraceptive (COC) pill [5]:
• considered as a second-line treatment after progestogen IUS
• given to patients who also wish to use this form of contraception
• common adverse effects include:
• breast tenderness
• nausea
• headaches
• mood disturbance
• fluid retention
• weight gain
Published: 16-Oct-2015
Valid until: 30-Apr-2017
Printed on: 24-Nov-2015
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This care map was published by NDCCG and HCCG. A printed version of this document is not controlled so may not be up-to-date with the
latest clinical information.
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• rare adverse effects include:
• deep vein thrombosis (DVT)
• stroke
• heart attack
NB: COCs taken continuously are an effective and safe alternative treatment option [28].
Progestogens − norethisterone (15mg) daily from days 5-26 of the menstrual cycle, or injected long-acting progesterones [5]:
• considered as a third-line treatment option in women who wish to have hormonal contraception, after consideration of the IUS
and COC
• there is reliable evidence to recommend against the use of luteal phase only oral progestogens (day 15-26 or day 19-26)
• adverse effects (usually minor and transient) include:
• irregular bleeding − 12% at year 1
• weight gain − around 2kg at year 1
• bloating and fluid retention
• breast tenderness
• headaches
• mood changes − controversy over whether progesterones cause this
• depression
• amenorrhoea (more commonly associated with injection than oral treatment)
• injected progestogen has also, less commonly, been associated with the potential for reduced bone density
• NB: the use of norethisterone for this indication is outside of its marketing authorisation (product licence) in the UK
References:
Please see the care map's Provenance.
12 Non-hormonal
Quick info:
Where hormonal therapy is inappropriate or declined, non-hormonal pharmaceuticals should be offered [5].
Tranexamic acid (TA):
• competitive inhibitor of plasminogen activation (antifibrinolytic agent) [5]
• inhibits factors associated with blood clotting without affecting coagulation within healthy blood vessels (no increase in the
overall rate of thrombosis) [5]
• does not appear to affect platelet numbers or aggregation but acts to reduce the breakdown of fibrin in a pre-formed clot [5]
• acceptable first-line treatment in those who wish to conceive − taken at the start of the menstrual cycle only and therefore does
not interfere with efforts to conceive or have effects on the embryo [6]
• decrease bleeding loss by 50% [23]
• does not [5]:
• treat dysmenorrhoea − advice on pain relief may be required
• regulate cycles − advice and suitable additional treatment should be given if required
• adverse effects (uncommon) include:
• gastrointestinal (GI) problems (eg indigestion, diarrhoea) [5,6]
• headaches [5,6]
• visual disturbances (occur rarely) [6]
• thromboembolic events (occur rarely) [6]
• may be taken in combination with non-steroidal anti-inflammatory drugs (NSAIDs) [5]
• take caution when offering to patients:
• at high risk of thromboembolism [4]
• taking the combined oral contraceptive (COC) pill (theoretically, there is an increased risk of thrombosis in these patients) [6]
• with moderate renal insufficiency − dose should be reduced (TA should be avoided altogether in more severe cases) [6]
Published: 16-Oct-2015
Valid until: 30-Apr-2017
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• ongoing use is recommended for as long as it is found to be beneficial by the woman [5,6]
NSAIDs:
• reduce prostaglandin synthesis by inhibition of cyclooxygenase − prostaglandins affect local tissue reactivity and are implicated
in inflammatory response, uterine bleeding, and uterine cramps [5]
• should be taken regularly from the onset of bleeding, or just before, until heavy loss has abated [5]
• acceptable first-line treatment in those who wish to conceive − taken at the start of the menstrual cycle only and
therefore should not interfere with efforts to conceive, or have effects on the embryo [6]
• there is some evidence to suggest that mefenamic acid and naproxen are more effective than ibuprofen [5]
• less effective than either TA or levonorgestrel releasing intrauterine system (LNG-IUS) [10]
• preferable to TA if dysmenorrhoea is also present [5]
• no significant difference in efficacy established between NSAIDs and medical treatments such as COCs or intrauterine
progesterone systems (eg LNG-IUS) [5]
• prescribe the minimal dose needed to improve symptoms [4]
• should not be:
• combined with other NSAIDs simultaneously [4]
• used where it is thought that HMB is caused by bleeding/coagulation disorders [5]
• may be prescribed in combination with TA to increase efficacy [5]
• contraindicated if:
• history of gastrointestinal complications, such as peptic ulcers [5,6]
• history of bronchospasm, urticaria, angioedema, rhinitis, or severe skin reaction with aspirin or an NSAID [6]
• history of asthma, hypertension, renal impairment, or heart failure [6]
• patient is pregnant [6]
• patient is receiving low-dose aspirin [6]
• potential for adverse effects, including indigestion and diarrhoea [5]
NB: There is limited evidence regarding the effect of TA [4] and NSAIDs [5] on heavy menstrual bleeding (HMB) in the presence of
uterine fibroids, as women with fibroids were excluded from trials.
References:
Please see the care map's Provenance.
13 Monitor and review treatment response
Quick info:
Monitor treatment response:
• trial oral treatments for 3 months and the levonorgestrel-releasing intrauterine system (LNG-IUS) for 6 months before
considering them to be ineffective [5]
• when a first pharmaceutical treatment has proved ineffective, a second pharmaceutical treatment should be considered rather
than immediate referral to surgery [5]
• oral norethisterone or depot medroxyprogesterone are often suitable if initial treatment has been ineffective [6]
References:
Please see the care map's Provenance.
14 Failure to respond to treatment or suspicion of pathology
Quick info:
Treatment failure can be an indication of potential endometrial cancer or atypical hyperplasia [5].
Make a routine referral to a gynaecologist if [5,6]:
• there has been inadequate response to drug treatment for menorrhagia
• the patient wishes to explore the possibility of surgical intervention in place of current drug treatment
Make an urgent referral to a gynaecologist/oncologist if there is suspicion of underlying pathology (eg uterine cancer, hyperplasia,
fibroids) due to:
Published: 16-Oct-2015
Valid until: 30-Apr-2017
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latest clinical information.
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• an abdominally palpable uterus (more than a 10 week pregnancy) [5,6]
• a mass palpable on vaginal examination [5,6]
• postcoital bleeding [5,6]
• persistent intermenstrual bleeding [5,6]
• significant change (eg sudden increase) in blood loss [5,6]
• dyspareunia [6]
• pelvic pain, tenderness, or pressure symptoms [6]
• severe anaemia (haemoglobin less than 8g/dL) [5,6]
If there is any suspicion of underlying cancer, the woman should be seen within 2 weeks [5,6].
References:
Please see the care map's Provenance.
15 Eligibility criteria
Quick info:
Please read the referral criteria before referring the patient.
The CCG will fund hysterectomy for heavy menstrual bleeding only when there has been an unsuccessful trial with a levonorgestrel
intrauterine system (e.g Mirena®) and it has failed to relieve symptoms unless it is medically inappropriate or contraindicated.
Criteria 1:
Both of the following criteria must apply:
• At least two of the following treatments have failed, are not appropriate or are contra-indicated in line with the National Institute
for Health and Clinical Excellence (NICE) guidelines (CG44 Heavy menstrual bleeding):
• Non-steroidal anti-inflammatory agents (such as naproxen).
• Tranexamic acid.
• Other hormone methods (injected progesterones, combined oral contraceptives).
• Surgical fitting of Mirena coil
Note that: In addition to the above criteria, hysterectomy is not funded unless surgical treatments such as endometrial ablation or
myomectomy have been offered and failed to relieve symptoms or are not appropriate, or are contraindicated.
Criteria 2:
All of the following must apply:
• The CCG will fund hysterectomy for heavy menstrual bleeding due to fibroids greater than 3cm when all of the following
apply:
• Other symptoms are present (eg pressure)
• There is evidence of severe impact on quality of life.
• Other pharmaceutical options have failed or are clinically inappropriate.
The following additional patient information must apply:
• The patient is willing to undergo a surgical procedure should it be offered.
• I have discussed with the patient the fact they will be referred for a possible procedure but there is no guarantee that a surgical
intervention will be the preferred outcome following the consultation with the secondary care specialist.
Published: 16-Oct-2015
Valid until: 30-Apr-2017
Printed on: 24-Nov-2015
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This care map was published by NDCCG and HCCG. A printed version of this document is not controlled so may not be up-to-date with the
latest clinical information.
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Menorrhagia
Obstetrics and gynaecology / Gynaecology
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Provenance certificate
Provenance Certificate for this International Map of Medicine pathway for Menorrhagia published on 31 August
2015.