Please click here to view the full Hysterectomy for Menorrhagia Commissioning Statement.  

Commissioning Position

Hysterectomy for menorrhagia is commissioned within a set of strict criteria and guidance which should be followed in determining when to refer patients to secondary care as follows.

‘Patient choice’ to opt for hysterectomy without any form of prior conservative treatment is not routinely commissioned.

NHS Scarborough & Ryedale and Vale of York CCGs will only fund hysterectomy for heavy menstrual bleeding (HMB) when ALL of the following conditions are satisfied:

• There has been an unsuccessful trial, of at least 6 cycles, with a levonorgestrel intrauterine system (LNG-IUS) (eg Mirena®) unless medically contra-indicated (see note 3)

AND

• A second pharmaceutical treatment (unless contra-indicated) has been tried for a clinically suitable number of cycles and has also failed. These pharmaceutical treatments include:

• Non-hormonal:
  • Tranexamic acid
  • NSAIDs (non-steroidal anti-inflammatory drugs)
• Hormonal:
  • Combined hormonal contraceptives
  • Cyclical oral progesterone
  • Injected progesterone

AND

• Endometrial ablation has been tried (unless the patient has fibroids >3cm, an abnormal uterus or other contraindications), or uterine artery embolization or myomectomy (if appropriate), and have failed to relieve symptoms or are contraindicated

OR

The CCGs will fund hysterectomy for heavy menstrual bleeding due to fibroids greater than 3cm when any of the following criteria are satisfied:

• Other symptoms (e.g. pressure symptoms) are present
• There is evidence of severe impact on quality of life
• Other pharmaceutical, surgical and radiological treatment options have failed, or are contraindicated
• Patient has been offered myomectomy and / or uterine artery embolization (unless medically contraindicated)
• There is structural / histological abnormality of the uterus
• The woman no longer wishes to retain her uterus and fertility

NOTES

1. Not all LNG-IUSs have a UK marketing authorisation for this indication; NSAIDs and some combined hormonal contraceptives do not have a UK marketing authorisation for this indication¹ .
2. Be aware that progestogen-only contraception may suppress menstruation, which could be beneficial to women with heavy menstrual bleeding²
3. Medical contra-indications to LNG-IUS coil insertion include:
   • Large fibroids (> 3cm) or distorted uterine cavity
   • Severe anaemia, unresponsive to transfusion or other treatment whilst an LNG-IUS trial is in progress or established
   • Marked immunosuppression
   • Pelvic inflammatory disease
   • Genital malignancy or active trophoblastic disease (rare causes of menorrhagia)
   • UK Medical Eligibility Criteria for Contraceptive Use category 3³
4. Endometrial ablation is suitable for women who do not want to conceive in the future and should only be offered after full discussion of risks and benefits and other treatment options.

Patient information menorrhagia

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