Treating heavy menstrual bleeding: is the new clinical care standard working?

Woman suffering from heavy menstrual bleeding

16 September 2024 Dr Jeannie Knapp, GP and Primary Health Care Improvement GP Adviser, NWMPHN

Heavy menstrual bleeding (HMB) affects an estimated 25 per cent of women during their menstrual lives.

The latest clinical care standard for HMB, published earlier in 2024 by the Australian Commission on Safety and Quality in Health Care (ACSQHC), lists several options for medical management of the condition. It also suggests uterine‑preserving procedures such as endometrial ablation, uterine artery embolisation or surgical removal of local pathology.

Hysterectomy is also an effective treatment, but this should only be utilised when other less invasive options are ineffective or inappropriate.

Hysterectomy is a major and expensive surgical procedure with significant risks compared to non-invasive options. Despite this, there is strong evidence that in Australia it is being used disproportionately often. The rate of hysterectomy in Australia is twice that of comparable OECD countries.

Long term data – including findings published by the ACSQHC – show that hysterectomy rates are higher in regional areas than in urban or remote locations. The data also show that 60 per cent of women admitted to hospital for hysterectomies are privately funded.

Stepwise approach to managing HMB

Instead of resorting to hysterectomy as a first option, the clinical care standard recommends taking a stepwise approach to managing HMB.

Assessment and diagnosis
Informed choice and shared decision making
Initiating medical management
Quality ultrasound
Intrauterine hormonal devices
Specialist referral
Uterine‑preserving alternatives to hysterectomy
Hysterectomy

Note that haemodynamic compromise and suspicion of endometrial cancer or hyperplasia are red flags.

Initial assessment

This should include a thorough history, assessment of impact on quality of life, physical examination (where clinically appropriate), and exclusion of pregnancy, iron deficiency and anaemia. Further investigations are based on the initial assessment.

What medical treatments are available?

The standard recommends considering commencing medical treatments immediately for women with HMB while awaiting investigations or access to other treatments. This can relieve symptoms and limit complications such as iron deficiency.

Medical treatments include:

tranexamic acid
non-steroidal anti-inflammatories such mefenamic acid and naproxen
the oral contraceptive pill
progesterone.

Ultrasound

The standard outlines when an ultrasound is required to investigate the cause of HMB. Indications include:

Where there is an increased risk of malignancy based on history – for example, older age, personal or family history of endometrial or colorectal cancer, use of unopposed oestrogen or tamoxifen, obesity, young age at menarche or older age at menopause, nulliparity, diabetes or endometrial hyperplasia.
Features suggestive of pathology on examination such as an enlarged or irregular uterus
Symptoms such as deep dyspareunia, severe dysmenorrhoea or secondary heavy menstrual bleeding.
Those who have not responded to a reasonable duration of medical management.

This should preferably be a transvaginal ultrasound and ideally performed in days 5–10 of the menstrual cycle.

Intrauterine hormone devices

A 52mg levonorgestrel‑releasing intrauterine device (known as LNG‑IUD and under the brand name Mirena), in addition to its contraceptive action, is the most effective medical therapy for HMB in women without significant pathology. It is also a cost effective intervention.

When to refer?

Referral is recommended when:

There is a suspicion of malignancy or other significant pathology, based on clinical assessment or ultrasound.
No response to medical management.

What invasive alternatives are there to hysterectomy?

When bleeding is from benign causes uterine‑preserving procedures may be suitable. These include:

endometrial ablation
uterine artery embolisation
surgical removal of local pathology.

Hysterectomy is considered when other treatment options are ineffective or are unsuitable, or at the woman’s request. A woman considering a hysterectomy should be fully informed about the potential benefits and risks of the procedure before making a decision.

Where can my patients access Mirena insertions?

Many GPs insert IUDs and there may be a GP near you who provides that service.

Some public hospitals such at The Royal Women’s Hospital offer Mirena insertion via their contraceptive clinics.

Sexual Health Victoria (formally Family Planning Victoria) offer IUD insertions and training for practitioners wanting to learn how to insert IUDs.

The effects of the new clinical care standard

With its clear stepwise approach to managing HMB, it is hoped that the new clinical care standard will result in a reduction of the disproportionately high number of hysterectomies being performed.

NWMPHN is looking at several factors, including education and training, and barriers to access and equity, that might also be contributing to the present situation.