Heavy Menstrual Bleeding - Referral for Surgical Management

This is a summary of the NHS Devon commissioning policy for Referral for the Surgical Management of Heavy Menstrual Bleeding.

NHS England Evidence-Based Interventions programme guidance, in line with the National Institute for Health and Care Excellence (NICE) Guideline 88 (Heavy Menstrual Bleeding: assessment and management), recommends consideration of specific surgical treatment options for heavy menstrual bleeding (HMB); including in women where bleeding is having a severe impact on quality of life or where other treatment options are declined.

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. NICE recommends a range of both hormonal and non-hormonal pharmaceutical treatment options, some of which provide additional benefits which may be desirable.

Levonorgestrel-releasing intrauterine system (LNG-IUS), which represents the first line hormonal treatment option, is more cost-effective than other medical or surgical treatment options considered by NICE. The evidence in this population showed that LNG-IUS is as effective, or more effective, than other treatments for HMB in terms of improving health-related quality of life, treatment satisfaction, discontinuation rates, and blood loss. After failure of a first pharmacological treatment, some women respond to a different form of pharmacological management and can obtain benefit therefore avoiding the need for surgery.

Although surgical treatment options were found to be clinically and cost-effective, they cost more for NHS Devon to commission than effective pharmacological treatments. Pharmacotherapy has been found to be effective, providing a good response in a proportion of women.

Supporting referral guidelines

Referral Criteria

Referral for specialist advice and surgery, if appropriate, will only be routinely commissioned in:

  • Women with significant fibroids, for example; fibroids which are palpable abdominally, measured as greater than 3cm in diameter at ultrasound, submucosal or intracavity fibroids
  • Women in whom there is suspicion of uterine cavity abnormalities or histological abnormalities (indications for a biopsy include, for example, persistent intermenstrual bleeding, and in women aged 45 and over treatment failure or ineffective treatment)
  • Women for whom appropriate pharmacotherapy has failed.

Hysterectomy should only be considered for heavy menstrual bleeding when:

  • other treatment options have failed, or are contraindicated AND
  • there is a wish for amenorrhoea (no periods) AND
  • the woman (who has been fully informed) requests it AND
  • the woman no longer wishes to retain her uterus and fertility

Referral Instructions

Where the circumstances of treatment for an individual patient do not meet the criteria described above exceptional funding can be sought. Individual cases will be reviewed by the appropriate panel of NHS Devon upon receipt of a completed application from the patient's GP, consultant or clinician. Applications cannot be considered from patients personally.

Exceptional /Individual Funding Requests (IFR)

Applications for consideration for funding approval should be sent to:

Email: d-icb.ifr-newsdt@nhs.net

​Supporting Information

Patient Information

Individual Funding Request (IFR)

Publication date: February 2020


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