Hysterectomy for heavy menstrual bleeding

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Heavy menstrual bleeding can significantly affect a person’s physical, emotional, social and material quality of life.1 Heavy menstrual bleeding impacts around 25% of women of reproductive age. Many people seek medical care for heavy menstrual bleeding due to its impact on daily life.1

There are a range of treatment options available to people with heavy menstrual bleeding. Determining the underlying cause is important to guide decision making around appropriate treatment options. Less invasive options should be considered first.

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Variations in care

There is an opportunity to address unwarranted clinical variation in the management of heavy menstrual bleeding in NSW.

Population rates of hysterectomy for heavy menstrual bleeding vary considerably across local health districts, ranging from 113 to 625 per 100,000 (age-standardised rate for the 5-year period from the financial year 2019–20 to 2023–24*). This could be explained by variation in population rates of heavy menstrual bleeding or by variation in treatment pathways.

International data indicates that patient satisfaction is higher, complication rates are lower and length of stay is reduced in laparoscopic and vaginal hysterectomy, as opposed to abdominal hysterectomy in suitable cases.2,3,4

The most common surgical approach for hysterectomies for heavy menstrual bleeding in NSW in 2023–24 was laparoscopic (70%), followed by abdominal (15%), lap-vaginal (9%) and vaginal (5%).

In NSW, the proportion of procedures performed laparoscopically has increased in recent years (from 16% in 2013–14 to 70% in 2023–24*) while the proportion performed abdominally has decreased (from 40% in 2013–14 to 15% in 2023–24*).

The dataset isolates hysterectomies performed for heavy menstrual bleeding by reporting cases with Australian Classification of Health Interventions hysterectomy procedure codes in combination with a principal diagnosis of heavy menstrual bleeding or abnormal menstrual bleeding.

*Source: NSW Admitted Patient Data Collection

Evidence-based management

The following management guidance is outlined in the 2024 Australian Commission on Safety and Quality in Healthcare (ACSQHC) Heavy Menstrual Bleeding Clinical Care Standard:

  1. Assessment and diagnosis

    Perform a comprehensive clinical assessment, including exclusion of pregnancy and consideration of bleeding disorders and any underlying gynaecological pathology. This includes evaluating the impact of symptoms on the patient’s quality of life.

  2. Informed choice and shared decision making

    Provide patients with clear, evidence-based information about all appropriate treatment options, including effectiveness, risks and benefits. Make collaborative decisions about management, incorporating clinical judgement alongside the patient’s values, preferences and treatment goals.

  3. Initiating medical management

    Evidence-based medical therapies should be the first-line treatment for people with heavy menstrual bleeding. These may include hormonal agents, e.g. a hormone‑releasing intrauterine device (IUD), combined oral contraceptives and progestogens, or non-hormonal options, e.g. tranexamic acid and nonsteroidal anti-inflammatory drugs (NSAIDs). Select the appropriate treatment based on patient suitability and contraindications. The levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective first-line, medical treatment for heavy menstrual bleeding.

  4. Quality ultrasound

    High-quality pelvic ultrasound performed by experienced clinicians identifies structural causes of heavy menstrual bleeding, such as fibroids, adenomyosis or endometrial pathology. Where appropriate, and with patient consent, transvaginal ultrasound is preferred.

  5. Intrauterine hormonal devices

    The LNG-IUD is the most effective first-line, medical treatment for heavy menstrual bleeding. It provides targeted endometrial suppression and significantly reduces menstrual blood loss. The LNG-IUD is suitable for many patients, including those seeking long-term, reversible contraception.

  6. Specialist referral

    Timely referral to a gynaecologist ensures access to advanced diagnostic and therapeutic options. Refer to a specialist when: medical management fails or is contraindicated; imaging or examination reveals significant structural abnormalities or suspicion of serious structural pathology.

  7. Uterine-preserving surgical alternatives to hysterectomy

    Offer uterine-sparing surgical interventions before considering hysterectomy, where appropriate, if medical management has failed, is contraindicated or has been declined by the patient. This includes endometrial ablation, hysteroscopic resection of pathology or uterine artery embolisation, depending on the underlying aetiology and the patient’s reproductive goals.

  8. Hysterectomy

    Reserve hysterectomy for patients with persistent heavy menstrual bleeding who have not responded to or have declined medical and less invasive surgical treatments. The decision must be based on a comprehensive assessment and made in the context of informed consent, with discussion of potential risks, benefits, reproductive goals and long-term consequences, including impact on fertility.

Adhere to clinical guidelines and shared decision-making with all patients to ensure appropriate use of hysterectomy as a management option for heavy menstrual bleeding.

Use the Australian Commission on Safety and Quality in Healthcare (ACSQHC) Heavy Menstrual Bleeding Clinical Care Standard to support the development of comprehensive, evidence-based treatment pathways that are tailored to the patient’s clinical presentation and preferences.

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) have endorsed the ACSQHC Heavy Menstrual Bleeding Clinical Care Standard.

Culturally safe care for Aboriginal patients

Reproductive health is a culturally sensitive topic, often regarded as private and recognised within many Aboriginal communities as ‘Women’s Business’. Barriers such as shame, stigma, historical trauma and mistrust of reproductive health services can impact Aboriginal women’s access to timely and appropriate care. Limited access to female clinicians, Aboriginal health workers and culturally safe services can further reduce engagement, particularly in rural and remote areas.

Incorporate female Aboriginal health workers and Aboriginal liaison officers into care pathways to support cultural safety, health system navigation, advocacy and communication for all patients. Where possible, Aboriginal patients should be supported to receive care from clinicians of their preferred gender.

Take the time to yarn about treatment options, including the benefits, risks and longer-term implications of treatment decisions. The Finding your way shared decision-making model can support discussions. Conversations should be guided by cultural protocols and communication preferences, using plain language and culturally appropriate resources.

Proceeding with hysterectomy for heavy menstrual bleeding

Hysterectomy for heavy menstrual bleeding is of limited value for certain patient cohorts. It should only be considered when less invasive treatments have been unsuccessful, are clinically inappropriate or are not aligned with the patient's informed preferences.

Before surgery, explore and address any patient concerns regarding less invasive options. If hysterectomy has been identified as the most appropriate treatment option, consider less invasive approaches (vaginal or laparoscopic) wherever clinically appropriate and ensure the patient’s preferences are incorporated into decision-making.

A review by a multidisciplinary panel is required for any of the value-based care procedures that do not meet the outlined criteria in the Planned Surgical Access Policy

Criteria for proceeding with hysterectomy for heavy menstrual bleeding

Use the following criteria when completing the ‘Recommendation for admission’ form.

  • A comprehensive clinical assessment has been completed (including history, physical examination and relevant investigations, including cervical screen testing if due).
  • The impact of the bleeding on the patient’s quality of life has been assessed (physical, emotional, social, material).
  • Pregnancy, iron deficiency and anaemia have been excluded or managed appropriately.
  • The patient has received clear, evidence-based information about all treatment options (medical and surgical).
  • Appropriate first-line medical treatments have been offered and trialled, e.g. LNG-IUD and oral medications.
  • Uterine-preserving alternatives to hysterectomy, e.g. endometrial ablation and uterine artery embolisation, have been discussed and considered.
  • Hysterectomy is being considered only after other options have been trialled, are unsuitable or have been declined by the patient.
  • Shared decision-making has taken place, with consideration of the patient’s preferences and goals.

The patient has been fully informed of the potential risks, benefits and long-term consequences of hysterectomy.

References

  1. Australian Commission on Safety and Quality in Healthcare. Heavy Menstrual Bleeding Clinical Care Standard. Sydney: ACSQH; 2024.
  2. Billfeldt NK, Borgfeldt C, Lindkvist H, et al. A Swedish population-based evaluation of benign hysterectomy, comparing minimally invasive and abdominal surgery. Eur J Obstet Gynecol Reprod Biol. 2018 Mar;222:113-118. DOI: 10.1016/j.ejogrb.2018.01.019.
  3. Agarwal M, Sinha S, Haripriya H, et al. Surgical Site Infection in Laparoscopic Hysterectomy versus Abdominal Hysterectomy in Gynecological Disease(s): An Overview. Gynecol Minim Invasive Ther. 2023 Dec 11;13(1):25-29. DOI: 10.4103/gmit.gmit_56_23.
  4. Bofill Rodriguez M, Dias S, Jordan V, et al. Interventions for heavy menstrual bleeding; overview of Cochrane reviews and network meta-analysis. Cochrane Database Syst Rev. 2022 May 31;5(5):CD013180. DOI: 10.1002/14651858.CD013180.pub2.
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