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Heavy menstrual bleeding (menorrhagia) without structural or histological abnormality.
Referrals submitted without this information may be returned.
A referral proforma is available to download but its use is optional.
Referral for specialist advice and surgery, if appropriate, is only commissioned in women without significant fibroids or structural or histological abnormalities, if they have failed treatment with appropriate pharmacotherapy including intrauterine system (IUS).
Please note that LNG-IUD fits/refits can now be performed for non-contraceptive reasons at Devon Sexual Health in specified clinics and for HRT purposes only (see Management section).
This is not routinely commissioned in Devon for diagnosis or treatment of heavy menstrual bleeding.
Ultrasound scans and camera tests, with sampling of the lining of the uterus (hysteroscopy and biopsy), can be used to investigate heavy periods.
There is very little evidence to suggest that D&C works to treat heavy periods and the one study identified by NICE showed the effects were only temporary.
Medication and intrauterine systems (IUS) are more effective treatments for heavy periods
NICE guidance from March 2018 suggests it is reasonable to start treatment for HMB "without investigating the cause if the woman's history and/or examination suggest a low risk of fibroids, uterine cavity abnormality, histological abnormality or adenomyosis". This guidance outlines what treatment and investigation should be considered in such circumstances and when, if pharmacological treatment including IUS fails, it might be suitable to refer. Referral for specialist advice and surgery, if appropriate, is only commissioned in idiopathic HMB if certain criteria are met.
Commissioning policies
Patients with
Treatment aims are to improve quality of life and alleviate associated symptoms, not necessarily to cure heavy bleeding.
All patients should be strongly encouraged to keep BMI in health range; obesity contributes to high circulating oestrogens and heavy menstrual bleeding. Surgical management is likely to be declined if BMI is over 35.
Weight Management
Adult weight management pathway
Pharmaceutical Treatment
Appropriate when no suspicion of structural or histological abnormality, fibroids less than 3cm diameter and causing no distortion of the uterine cavity.
Determine whether hormonal contraception is acceptable before recommending treatment, preference for hormonal vs non-hormonal, and benefits vs risk of long term treatment should be considered.
Outcomes of ongoing medical therapy should be carefully monitored, and medications should be maintained for at least three cycles before considering alternative treatments.
First Line
Levonorgestrel-IUS should be offered.
Formulary chapter 7.3.2: Progestogen-only contraceptives
Second Line
Formulary chapter 7.3.1: Combined hormonal contraceptives
Third Line
Formulary Chapter 7.3.2: Progestogen-only contraceptives
Dilatation and curettage (D&C)
Dilatation and curettage (D&C) commissioning policy
This is not routinely commissioned in Devon for diagnosis or treatment of heavy menstrual bleeding.
Ultrasound scans and camera tests, with sampling of the lining of the uterus (hysteroscopy and biopsy), can be used to investigate heavy periods.
There is very little evidence to suggest that D&C works to treat heavy periods and the one study identified by NICE showed the effects were only temporary.
Medication and intrauterine systems (IUS) are more effective treatments for heavy periods.
Surgery
Referral for the surgical management of heavy menstrual bleeding commissioning policy
Surgery may be a more definitive and successful long term treatment than medication, but this must be weighed against surgical complications and fertility issues. Endometrial ablation, surgical management of fibroids, and hysterectomy are all options, though women should be counselled that hysterectomy is a last resort and the other options should have been tried first.
Referral for specialist advice and surgery, if appropriate, is only commissioned in women without significant fibroids or structural or histological abnormalities, if they have failed treatment with appropriate pharmacotherapy including IUS.
Required in referral letter
Referrals submitted without this information may be returned.
A referral proforma is available to download but its use is optional.
e-Referral Service selection:
MyHealth patient information - HMB
This guideline has been signed off on behalf of NHS Devon.
Publication date: November 2018
Updated: May 2024