Heavy Menstrual Bleeding Clinical Care Standard

When assessing a patient with heavy menstrual bleeding, consider the diverse possible causes as per the PALM‑COEIN classification system (refer to Table 1), and other possible diagnoses such as endometriosis or miscarriage.

Take a detailed history that includes:

• the nature of bleeding, including duration, frequency, heaviness and pattern (regular or irregular) (note: post‑coital, intermenstrual and postmenopausal bleeding require specific investigation)
• the impact on quality of life, including impact on mental health and limitations on work, exercise and social functioning
• related symptoms such as pelvic pain or pressure
• symptoms suggestive of iron deficiency, with or without anaemia
• sexual and reproductive health, including parity, desire for future fertility, contraception use, likelihood of pregnancy or miscarriage, risk of sexually transmitted infection and cervical screening status
• history or symptoms suggestive of systemic causes of bleeding, such as a bleeding disorder, polycystic ovary syndrome (PCOS) or thyroid disease
• relevant family history, such as history of bleeding disorders, endometriosis or endometrial or colorectal cancer
• current medications and use of over‑the‑counter supplements that may be associated with ovulation or bleeding
• other factors that may affect treatment options, such as comorbidities or previous treatments for heavy menstrual bleeding.

Conduct a physical examination if appropriate and with consent. This will usually include a speculum examination, and a bimanual pelvic examination to identify any palpable mass or abnormal uterine size. Situations in which pelvic examination may be inappropriate include for women and adolescents who are not sexually active, women who have been sexually assaulted in the past, women who have experienced birth trauma, or women who decline for cultural reasons.

Exclude pregnancy with a urinary beta HCG if indicated. Routinely evaluate iron deficiency and anaemia with serum ferritin and a full blood count.

Arrange other investigations based on a careful history and presentation. These might include testing for bleeding disorders or thyroid dysfunction, a cervical screening test (if clinically indicated), genital swab tests (if clinically indicated) or ultrasound or assessment of uterine abnormalities. Refer to current guidelines such as Therapeutic Guidelines.

Consider using a validated health‑related quality‑of‑life questionnaire to help inform clinical decision‑making and monitor treatment effectiveness, and to inform quality improvement.

Discuss and arrange referral for any other support the patient may require, such as counselling, acknowledging the effect that heavy menstrual bleeding can have on emotional wellbeing and mental health.

In healthcare services involved in the assessment of patients with heavy menstrual bleeding, ensure that guidelines and protocols are in place to support: 

• a thorough history, assessment of the nature of the bleeding and its impact on quality of life, a physical examination where appropriate, and exclusion of pregnancy, iron deficiency and anaemia
• systematic assessment of the structural and non‑structural causes of heavy menstrual bleeding based on history and presentation, with relevant investigations recommended according to this assessment
• appropriate testing for bleeding disorders or thyroid dysfunction, cervical screening and pelvic ultrasound; these are not routinely required
• patients to see a particular type of clinician if that is their preference – for example, someone of the same gender
• referral and access to additional services that the patient may require, including counselling or other services to support their emotional wellbeing and mental health as appropriate.

If you have heavy menstrual bleeding, your clinician will carry out a thorough assessment to help find the cause. They will ask questions to understand more about your bleeding and how it affects your life, including your physical and emotional wellbeing, your mental health, and your ability to work, exercise and take part in social events. They will also ask about your past general health and any family medical problems. They may ask about your sexual health, previous pregnancies and births, current sexual activity, and whether you wish to become pregnant in the future.

With your consent, your clinician will carry out a physical examination. This may involve an internal examination where your clinician will use a tool called a speculum to help look at your vagina and cervix. They may also place one or two gloved fingers inside your vagina while pressing gently on the outside of your abdomen to be able to feel your pelvic organs, including your uterus. If you do not feel comfortable about having an internal examination, let your clinician know.

Your clinician will recommend a pregnancy test if there is any chance you are pregnant, and blood tests for iron deficiency (a lack of iron) and anaemia (a lack of red blood cells). Whether you need any other tests will depend on your individual assessment, but these may include other blood tests, a cervical screening test, internal swab tests for infection or an ultrasound.

For clinicians 

• Recognise the social and cultural factors influencing a woman’s access to, and experience of, health care related to their heavy menstrual bleeding. These can include attitudes and norms that prevent the open discussion of menstruation, generate feelings of shame and embarrassment, and limit access to health information about menstruation.
• Be aware of Women’s Business and the wishes of many Aboriginal women to keep women’s health issues private and separate from other health issues.
• If appropriate, offer Aboriginal and Torres Strait Islander women access to culturally safe models of care, such as those offered through, or in partnership with, Aboriginal Community Controlled Health Organisations or Aboriginal and Torres Strait Islander health and medical services.
• Recognise that a history of trauma may affect a person’s experience of care.
• Consider the needs of trans and non-binary people who menstruate, who may find it difficult discussing menstrual issues or undergoing clinical examination.
• Recognise the diverse needs of women with disabilities and ensure they are assessed similarly to women without disabilities, including a comprehensive history, and appropriate examinations and investigations. Where required, make reasonable adjustments to support women with disabilities to access appropriate care.
   

For healthcare services 

• Ensure that systems support the assessment of women in a way that is free from racism, bias and assumptions.
• Consider developing pathways and models of care that involve working collaboratively with Aboriginal Community Controlled Health Organisations and Aboriginal health workers or practitioners to improve access to care and continuity of care for women experiencing heavy menstrual bleeding.

For clinicians 

The Minymaku Kutju Tjukurpa Women’s Business Manual is a Remote Primary Health Care Manual containing evidence‑based protocols to help manage the health of Aboriginal and Torres Strait Islander women in remote Australia.

Shared decision making enables individuals’ preferences and priorities to be considered alongside the best available evidence. It can lead to improved satisfaction and better‑quality decisions. To support informed choice and shared decision making:

• discuss the patient’s condition, their treatment options and the benefits, risks and probable outcomes of possible treatments, including side effects and complications, and the possibility of treatment failure
• discuss the patient’s treatment goals and their preferences and priorities, including desire for pregnancy and/or future fertility
• provide high‑quality patient information in the most appropriate format based on their needs and preferences – for example, a fact sheet or link to a website
• consider the use of decision aids to systematically address options and support informed choice
• accept and acknowledge that the patient’s informed view on the balance of benefits, risks and probable outcomes of treatments may differ from yours as a healthcare professional.

Ensure that policies, protocols and procedures support informed choice and shared decision making. Specifically: 

• ensure that high‑quality patient information resources are available in a range of formats and are clinically accurate, evidence based and easy to understand
• ensure that resources provide information about both benefits and risks of relevant treatment options offered through referral or by the service; consider making a decision aid available to support shared decision making
• provide ready access to information for clinicians on the benefits, risks and probable outcomes of the various treatment options for heavy menstrual bleeding
• provide clinicians with training and professional development to ensure they have the skills, knowledge and confidence to participate in, and support patients to participate in, shared decision making
• put in place policies to facilitate referral and access to services that a woman may prefer, but that are not offered in the health service
• in rural and remote areas, adapt service delivery models to support patients to access appropriate care – for example, through the use of telehealth and other models of care.

There are several ways to treat heavy menstrual bleeding and each woman has different needs and preferences.

Your clinician will discuss your condition with you and will ask questions to understand what is important to you. For example, they will ask questions about your goals for treatment, and whether you want to become pregnant in the future. They will explain the treatment options that are available to you and discuss the expected benefits and potential risks of each option. Together, you and your clinician should decide about the care that is best for you.

If you are not sure about understanding the information in English, you can ask for an interpreter.

You may also be given printed information or directed to useful electronic resources. Information should be provided in a format that suits you and that you can understand.

For clinicians 

• Recognise the woman’s personal and cultural beliefs that may influence decisions about investigations and treatments for heavy menstrual bleeding.
• Ensure that the information and education you provide is culturally appropriate and culturally safe.
• Use an interpreter if needed and provide written information in the patient’s preferred language. Consider whether any aids are needed (for example, visual resources such as videos or flip charts).
• Offer women access to culturally appropriate services such as those offered through, or in partnership with, Aboriginal Community Controlled Health Organisations or Aboriginal and Torres Strait Islander health and medical services.
• Attend cultural safety training provided by your healthcare service or professional organisation.
• Recognise that women with disability have the same healthcare rights as women without disability, including the right to be offered the same options and to be involved in decisions about their care. As for any patient, consider any specific communication needs, and their decision‑making capability. If needed, make reasonable adjustments to support their understanding and facilitate their involvement in decision‑making, even for women with a nominated substitute decision‑maker. Assess whether a multidisciplinary approach is required.
   

For healthcare services 

• Provide patient information about heavy menstrual bleeding in a variety of languages and formats appropriate to your service’s patient population.
• Consider developing or adapting pathways and models of care that support women to access culturally safe and appropriate services and community supports in a timely way.
• Ensure that policies and procedures support the rights of women with disabilities. Make reasonable adjustments for women with disabilities to ensure their access to appropriate care and active participation in shared decision making about management of heavy menstrual bleeding.

For patients

• Jean Hailes for Women’s Health – various resources on periods web page including
  • Heavy periods fact sheet
  • Periods and heavy bleeding – easy read fact sheet for women with disabilities
• Royal Australian and New Zealand College of Obstetricians and Gynaecologists – Heavy Menstrual Bleeding fact sheet
• Choosing Wisely Australia – 5 questions to ask your doctor or other healthcare provider before you get any test, treatment or procedure – available in multiple languages
• Healthdirect – Questions to ask your doctor
   

For clinicians 

• Therapeutic Guidelines – Menstrual Management and Contraception in Females with Developmental Disability (subscriber content)
• Australian Commission on Safety and Quality in Health Care – Shared decision making resources and tools
• Australian Commission on Safety and Quality in Health Care – Informed consent in health care

Consider medical management of heavy menstrual bleeding before more invasive treatment options. In the absence of significant pathology, many patients with heavy menstrual bleeding may be effectively managed with medical therapy alone.

Discuss the medical options available, including hormonal and non‑hormonal therapy, and explain what to expect from each, including benefits, risks and probable outcomes. The choice of therapy will be influenced by the woman’s preferences and priorities, including her need for contraception, the cause(s) of bleeding, coexisting conditions, and associated symptoms requiring further investigation, including pressure and pain.

Medical options include:

• non‑hormonal options, including tranexamic acid (an antifibrinolytic) and non‑steroidal anti‑inflammatory drugs (NSAIDs) such as ibuprofen, mefenamic acid or naproxen, which reduce blood flow and/or provide analgesia during menstruation
• hormonal options, including combined oral contraceptives, oral progestogens or depot medroxyprogesterone; oral hormones may be taken intermittently (during a menstrual cycle) or continuously after discussion of issues, implications for contraception and side effects
• a 52 mg levonorgestrel‑releasing intrauterine device (LNG‑IUD), which is currently the most effective medical therapy for heavy menstrual bleeding in women without significant pathology, in addition to its contraceptive action (see Quality statement 5 – Intrauterine hormonal devices).

When clinically appropriate, offer initial oral treatment such as tranexamic acid and/or NSAIDs at first presentation to relieve symptoms and limit complications (for example, from iron deficiency) if the patient’s preferred treatment option is not immediately apparent or available, when further investigations are recommended, or the patient needs to wait for further appointments (for example, for insertion of the LNG‑IUD).

Support patients to participate in shared decision making about their treatment options.

Advise patients they should return for review if their initial chosen treatment option is unsatisfactory.

Refer to Therapeutic Guidelines, the Australian Medicines Handbook or clinical guidelines for information regarding efficacy, contraindications, adverse effects and treatment regimens.

In primary health care and other services where patients first present for management of heavy menstrual bleeding, ensure that guidelines and protocols are in place to support: 

• medical management as the first treatment option in the absence of significant pathology
• offering initial oral treatment to relieve symptoms and limit complications (such as iron deficiency) even if the patient is being referred for further investigations or awaiting other treatment
• clinicians to access relevant evidence‑based prescribing guidelines for the choice of therapy and dosing.

Your clinician will usually suggest medicine as the first treatment option to relieve your heavy menstrual bleeding. Which medicine is suitable for you will depend on several factors, including your preferences, the cause of your bleeding, whether you need contraception and any other health conditions you may have. Depending on your situation, options may include:

• tranexamic acid, which comes as a tablet that you take during your period. It helps your blood to clot and can reduce menstrual blood loss. It does not provide contraception
• anti‑inflammatory medicines, including ibuprofen, mefenamic acid and naproxen, which come as tablets or capsules and are taken during your period. They can reduce inflammation, pain and blood loss. Some anti‑inflammatories are available without a prescription. Anti‑inflammatories do not provide contraception.
• a combined oral contraceptive pill which contains synthetic hormones similar to the natural hormones oestrogen and progesterone. These thin the lining of the uterus and can reduce your period flow. The active hormones in the combined oral contraceptive pill may be taken for 21–24 days of a 28‑day menstrual cycle but can also be taken continuously, which can avoid your period altogether. As its name suggests, this option also provides contraception.
• other hormonal treatments that contain progestogen which is similar to the natural hormone, progesterone. These may be in tablet form (oral progestogens) or given as an injection every three months (depot medroxyprogesterone). Some of these treatments also provide contraception.
• a hormone‑releasing intrauterine device (IUD), which is a small plastic device that is placed inside your uterus and continuously releases a small amount of progestogen. This thins the lining of the uterus and is very effective at reducing bleeding. This device also provides contraception. (See Quality statement 5 – Intrauterine hormonal devices).

Your clinician will explain your treatment options, their expected benefits and possible side effects, and ask about your preferences. If the first medicine you try is not satisfactory, you can return to your clinician to discuss other options.

If you need further tests to investigate your bleeding, such as a blood test or an ultrasound, or if you need to see a different clinician for your preferred treatment, your clinician will offer you medicine that you can start straight away to provide relief while you wait for other appointments. Later, you may decide on a different treatment.

Based on the initial assessment, an ultrasound may be required to investigate structural causes of heavy menstrual bleeding, such as in patients: 

• with an increased risk of malignancy based on history (for example, risk factors such as 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)
• with features suggestive of pathology on examination (for example, an enlarged or irregular uterus, suggesting fibroids)
• with symptoms such as deep dyspareunia, severe dysmenorrhoea or secondary heavy menstrual bleeding
• who have not responded to a reasonable duration of medical management. 

Whether ultrasound is required prior to insertion of the LNG‑IUD depends on the patient’s age and likelihood of pathology or of structural abnormalities that could influence appropriate positioning of the device.

When ultrasound is indicated, offer transvaginal ultrasound as first‑line imaging to allow a more detailed assessment of the pelvic structures, including the uterus and endometrium. Transvaginal ultrasound is usually performed in conjunction with a transabdominal ultrasound. 

Before a transvaginal ultrasound is conducted or requested, the patient should be advised about how it will be performed so they have the opportunity to decline. If transvaginal ultrasound is inappropriate, or the woman chooses not to have it, then offer transabdominal ultrasound alone; referring clinicians should note this on the request form. Transvaginal ultrasound may be inappropriate for some women – for example, non‑sexually active adolescents and women, women with a history of sexual assault, women with an experience of birth trauma, or women who decline for cultural reasons. 

Sonographers and sonologists should ensure that patients provide informed consent in relation to ultrasound.

When referring for ultrasound, request that it be performed on days 5–10 of the menstrual cycle. This allows the most accurate measurement of endometrial thickness, which is used in risk assessment for endometrial hyperplasia and malignancy and improves detection of polyps. Bear in mind that it may be difficult for some women to arrange an ultrasound at this time (for example, those with unpredictable or irregular cycles and those in areas with limited access to imaging services). When referring, communicate requirements to support appropriate access. Offer initial oral treatment where clinically appropriate to relieve symptoms and limit complications while the woman is waiting for an appointment.

In healthcare services that refer for pelvic ultrasound, ensure that protocols, procedures and pathways: 

• support transvaginal ultrasound as the preferred method when pelvic ultrasound is recommended and clinically appropriate
• ensure that patients are advised about how a transvaginal ultrasound is conducted and if they decline, or it is not appropriate for any other reason, then a transabdominal ultrasound only is requested
• encourage patients to arrange for their ultrasound to be conducted in the first half of their menstrual cycle where possible, ideally on days 5–10, and clinicians to specify this in ultrasound requests
• take into account any challenges patients may experience in accessing ultrasound locally
• ensure that patients are offered initial oral treatment where clinically appropriate while waiting for appointments.

In healthcare services performing gynaecological ultrasound, ensure that policies, protocols and procedures support: 

• appropriate high‑quality transvaginal and transabdominal ultrasound (see, for example, the Australasian Society for Ultrasound in Medicine guidelines)
• optimal scheduling of appointments so that scans are taken on days 5–10 of a patient’s menstrual cycle where possible
• women to make informed decisions and provide informed consent in relation to their ultrasound, based on timely and accurate information about the process, including an understanding of how transvaginal ultrasound is conducted
• high‑quality reporting of ultrasound results, taking into account the need to accurately measure and report endometrial thickness (in millimetres), uterine dimensions, including volume, and the presence and location of structural abnormalities.

You may have an ultrasound of your pelvic area to look for some common causes of heavy menstrual bleeding, such as polyps or fibroids, and to check the size and shape of your uterus. There are two ways of doing the ultrasound and they are often done together:

• transvaginal ultrasound, where the ultrasound operator places a narrow ultrasound probe in your vagina – this is the preferred way because it provides a better picture of the uterus and pelvic structures
• transabdominal ultrasound, where the ultrasound probe is placed on the outside of your lower abdomen, while you have a full bladder – this way does not show the uterus and pelvic structures as well as the transvaginal scan because the probe is not as close to the reproductive organs.

For some women, a transvaginal ultrasound may not be appropriate – for example, for women who have not been sexually active, those who have been sexually assaulted in the past, those who have experienced birth trauma, or those who decline for cultural reasons. If you do not want to have a transvaginal ultrasound for any reason, discuss this with your clinician when they are organising your referral. 

It is best if you can book to have the scan done 5–10 days after the first day of your period. This is when the lining of the uterus is thinnest, and the reading will be most accurate. Talk to your clinician if timing the scan will be difficult for any reason – for example, because your periods are very irregular, or because you live in an area where it is not easy to access an ultrasound. Your clinician may offer you medicine that you can start straight away to provide relief while you wait for your appointment.

When considering medical management: 

• offer a 52 mg levonorgestrel‑releasing intrauterine device (LNG‑IUD) to the patient whenever it is clinically suitable – evidence supports the use of the LNG‑IUD to treat heavy menstrual bleeding in patients without malignancy or other significant pathology because it is more effective and provides greater improvements in quality of life compared with other medical treatments.
• discuss the benefits and risks of the LNG‑IUD and explain what to expect, including that it may take three to six months or more to experience the full benefit of the treatment (see Therapeutic Guidelines or Australian Medicines Handbook for more information)
• if necessary, refer the patient to a trained practitioner for insertion of the LNG‑IUD. 

Consider whether pelvic ultrasound is indicated before or at the same time as inserting the LNG‑IUD, such as when other treatments have not been effective or if the patient has risk factors for gynaecological disease, including age or findings on examination or history.

If the patient requires an ultrasound and/or further assessment before the LNG‑IUD is inserted, offer initial oral treatment where clinically appropriate to relieve symptoms and limit complications (such as iron deficiency) while they wait. (See Quality statement 3 – Initiating medical management).

In primary health care and other services where medical management may be initiated, ensure that: 

• guidelines and protocols are in place to support patients being offered a 52 mg levonorgestrel‑releasing intrauterine device (LNG‑IUD) if it is clinically appropriate
• arrangements are in place to provide the LNG‑IUD, either within the service or through referral to an appropriate practitioner.

If it is suitable for you, your clinician may suggest a 52 mg levonorgestrel‑releasing intrauterine device (LNG‑IUD). This is a hormonal treatment that is released from a small plastic device placed inside your uterus. It can be left in place for up to five years (and can be removed earlier if it is no longer a suitable option). 

The LNG‑IUD also acts as a contraceptive. It is usually recommended because it is the most effective medical treatment for treating heavy menstrual bleeding.

If it is suitable for you to consider, your clinician will explain how it works, and its benefits, risks and side effects to help you decide if you want to have it. They will explain that it may take three to six months or more to get the full benefit of the treatment.

The device needs to be placed in the uterus by a health professional who has been trained to insert intrauterine devices. This means that if you choose the LNG‑IUD, you may be referred to another clinician to have it inserted. Depending on the services available in your area, you may be referred to a general practice, a family planning clinic or another specialist service.

Your clinician may recommend that you have an ultrasound before the device is inserted. If you have to wait for an ultrasound or other appointment before the device can be inserted, your clinician may offer you medicine that you can start straight away to provide relief while you wait.

From primary care, offer early referral to appropriate specialist care for patients with:

• suspicious clinical findings on assessment or ultrasound. Consider risk factors for endometrial cancer such as:
  • age, with increased suspicion warranted in a woman aged over 45
  • personal or family history of endometrial cancer or colorectal cancer
  • use of unopposed oestrogen or tamoxifen
  • obesity
  • young age at menarche or older age at menopause
  • nulliparity
  • diabetes
  • endometrial hyperplasia.
• significant pelvic pathology on ultrasound such as large fibroids or endometrial polyps
• severe symptoms at initial presentation.

Early referral is also warranted if medical management is unsuitable, or if a patient
requests procedural treatment options.

For patients who have not responded to medical management, offer referral for further investigation and treatment. 

When referring to specialist care, arrange for appropriate investigations, including cervical screening and ultrasound, to be completed. 

In primary healthcare services, establish protocols and pathways to ensure that: 

• patients with possible or suspected malignancy, or with significant pelvic pathology, are offered early referral to an appropriate specialist for review
• patients who have not responded to medical management are offered referral to an appropriate specialist for assessment and treatment. 

In secondary health services with referral protocols or criteria, use those protocols to advise referring clinicians of referral requirements and timeframes.

Heavy menstrual bleeding can often be managed in primary care, usually by a general practitioner (GP) or family planning doctor. However, you may be referred to another clinician if your ultrasound or other history suggests further assessment would be helpful. For example, the ultrasound might identify fibroids or polyps, which are common types of non‑cancerous growths that may be contributing to your bleeding. While it is rare for heavy menstrual bleeding to be caused by cancer, your clinician may also want to order tests or other investigations to rule this out. 

You might also be referred to a specialist if your bleeding is not improving with prescribed medical treatments. It may take time to get the full benefit of some treatment options. If you are concerned about your treatment at any time, go back to your primary care clinician and discuss your situation.

For clinicians 

• Cancer Australia – Diagnostic guide for GPs and gynaecologists for abnormal vaginal bleeding

When non‑medical management options are being considered, discuss uterine‑preserving procedures that may be suitable for the patient’s clinical situation. These may include: 

• Endometrial ablation – a minimally invasive surgical procedure for women without substantive structural uterine pathology and who have no desire for future pregnancy. It involves the removal or destruction of the endometrium including the basal layer using one of a variety of techniques including resection and/or ablation, laser, bipolar radiofrequency or thermal balloon ablation. Women must be informed about the need for contraception following endometrial ablation.⁶⁰
• Uterine artery embolisation (UAE) – a minimally invasive treatment option for women with fibroids. The procedure is done by an interventional radiologist. It involves a small incision in the groin or wrist through which a catheter is taken to the uterine arteries. Embolisation is performed by injecting particles to the arteries supplying the fibroids. Successful pregnancy may be possible after UAE. However, myomectomy is preferred, if clinically appropriate, for women who desire future pregnancy. Women considering UAE and desiring fertility should be counselled based on current available evidence regarding future pregnancy and potential risks.
• Myomectomy – the surgical removal of uterine fibroids. Myomectomy preserves the uterus and is an option for women who wish to retain their fertility. Myomectomy can be conducted using laparotomy, laparoscopy, or hysteroscopy.
• Hysteroscopic resection of intracavitary pathology (such as polyps or myomas) where these are considered to be causing or contributing to heavy menstrual bleeding. In this procedure, a hysteroscope is passed into the uterine cavity through the vagina. Pathology can be removed using electrosurgical, mechanical, laser or thermal energy. 

Consider appropriateness, contraindications and possible complications for each procedure in the context of the patient’s specific uterine pathology and clinical presentation, and their preferences and priorities, including their desire for future fertility. 

Discuss the relevant options fully with the patient. If they would prefer to consider a treatment choice that you are unable to provide, offer referral for assessment, and/or to discuss the procedure, with a suitably qualified specialist or service.

In primary and secondary healthcare services where women are considering non‑medical management of their heavy menstrual bleeding, ensure that protocols and pathways are in place to: 

• provide patients with access to appropriate uterine‑preserving procedures, including endometrial ablation, hysteroscopic resection, myomectomy or uterine artery embolisation, as clinically appropriate, either within the healthcare service or by referral to an appropriately skilled clinician
• support the provision of information about the benefits, risks and probable outcomes of potential treatments. 

In healthcare services that provide surgical and non‑surgical procedures to patients with heavy menstrual bleeding, ensure that protocols and pathways are in place so that patients can access uterine‑preserving alternatives to hysterectomy as appropriate.

If you are considering options other than medicines for your heavy menstrual bleeding, the first procedures to consider are those that will leave your uterus in place. The procedures that may be suitable for you will depend on the cause of your bleeding and other factors such as whether you want to be able to get pregnant in the future. Depending on your situation, suitable options may include:

• Endometrial ablation, which is a common procedure that involves removing or destroying the lining of the uterus (the endometrium) using heat. A long, narrow instrument is put inside the uterus (through the vagina) to apply heat or cut out the uterus lining. After this procedure, it is not safe to get pregnant, so you must avoid any future pregnancy by using effective contraception.
• Uterine artery embolisation (UAE), which may be suitable for women with fibroids larger than 3 cm. UAE involves blocking off the blood flow to the fibroids so that the fibroids shrink in size and produce less bleeding. A small tube is placed in an artery near the groin or wrist to access the blood vessels to the uterus. The tube delivers particles to block the blood vessel and is removed after the procedure. You can be referred to an interventional radiologist to discuss UAE in more detail. If you wish to become pregnant in the future you should discuss the specific risks with your doctor.
• Myomectomy, which is an operation to surgically remove fibroids from the uterus. It leaves the uterus intact and it may be suitable for women who are planning to have children. There are different types of myomectomy depending on how the surgeon accesses the uterus including abdominal (through a cut made in your lower abdomen), laparoscopic (through a keyhole incision) or hysteroscopic (through the vagina – see also Hysteroscopic removal below)
• Hysteroscopic removal, which is a procedure to remove any growths such as polyps or fibroids that may be causing the heavy menstrual bleeding, or to remove the lining of the uterus. A thin, flexible instrument with a small camera (a hysteroscope) is inserted into the uterus through the vagina and specialised instruments are used through the hysteroscope to cut, burn or destroy the growths.

The suitability of these procedures will differ for each woman. Your clinician will discuss the benefits and risks with you, and other features such as recovery times, based on your individual situation. Some specialists may not conduct these procedures themselves, in which case they may instead refer you to another specialist for further assessment and treatment.

When discussing the range of treatment options for heavy menstrual bleeding, support the patient to consider less invasive alternatives prior to considering hysterectomy, as appropriate to their clinical situation and personal circumstances. 

Hysterectomy is generally considered when alternative medical and procedural options are unsuitable, have proven to be ineffective or intolerable, or when it is the patient’s preference. 

When the patient is considering hysterectomy, ensure that they understand the benefits, risks and probable outcomes of the surgery. Discuss minimally invasive approaches to hysterectomy (vaginal or laparoscopic) where clinically appropriate. 

When the patient is making their decision, allow them the time and opportunity to consider this information. 

The discussion should cover the irreversible nature of the surgery, consequences for childbearing, risks including infection, organ damage and blood loss, the time in hospital and the recovery period. Explain any particular risks associated with the type(s) of hysterectomy being considered.

In services where women may be considering their treatment options, ensure that systems and processes are in place to: 

• support the systematic consideration of less invasive alternatives to hysterectomy, as appropriate to a woman’s clinical needs and preferences, in a way that is meaningful to her, so that she can make an informed choice about hysterectomy
• provide women with information about the benefits, risks and consequences of hysterectomy, and about suitable approaches to hysterectomy.

For women who choose hysterectomy, support consideration of minimally invasive approaches (vaginal or laparoscopic) whenever clinically appropriate.

Hysterectomy (surgery to remove the uterus) stops heavy menstrual bleeding because it permanently stops your periods. Hysterectomy involves removing part or all of the uterus, often with the fallopian tubes. When it is considered clinically appropriate, the ovaries may also be removed.

Hysterectomy can be done in different ways, including abdominal (through a cut in the lower abdomen), laparoscopic (keyhole surgery performed through small cuts in your abdomen), or vaginal (surgery performed through your vagina). Hysterectomy is a major surgical operation, and it has a higher risk of complications than other treatments for heavy menstrual bleeding.

Hysterectomy will be discussed as an option to consider if alternative treatments are not suitable for your situation, if alternatives have not worked for you, or if it is your preference. Your doctor will explain what the surgery involves, the types of hysterectomy available to you, the expected benefits and the possible complications or unwanted effects. This is so you can make an informed choice about whether to go ahead with the procedure.

After a hysterectomy, you can no longer become pregnant. While complications are uncommon, there is a risk of infection, blood loss, damage to the ovaries, bowel or bladder, and other surgical complications. If your ovaries are removed, then you will experience early menopause. Different risks may apply according to your situation and the way the hysterectomy is done, and your doctor will discuss these with you.

For patients

• Royal Australian and New Zealand College of Obstetricians and Gynaecologists – Hysterectomy
• Jean Hailes for Women’s Health – Hysterectomy

Overall indicator

• Ensure systems and processes support people to self-report their Aboriginal and Torres Strait Islander status and to record self-identification.
• Ensure all staff engage regularly in cultural safety training.
• Implement the six actions for Aboriginal and Torres Strait Islander Health from the NSQHS Standards.

• Provide flexible service delivery to optimise attendance and help develop trust with individual Aboriginal and Torres Strait Islander people and communities.
• Establish robust communication channels and referral pathways with primary healthcare providers (including Aboriginal Community Controlled Health Organisations [ACCHOs]).
• Where possible, provide outreach services close to home, on Country or in collaboration with ACCHOs or other community healthcare providers.

• Take a collaborative approach to ensure that interventions are suitably tailored to the individual’s personal needs and preferences for care.
• Encourage the inclusion of support people, family and kin or the person’s trusted healthcare provider (such as their ACCHO) in all aspects of care, including decision making and planning treatment and management.
• Engage culturally appropriate interpreter services and cultural translators when this will assist the patient.
• Involve Aboriginal and Torres Strait Islander Health Workers or Aboriginal and Torres Strait Islander Health Practitioners as part of a patient’s multidisciplinary team and involve Aboriginal and Torres Strait Islander Liaison Officers in hospital settings.
• Use culturally and linguistically appropriate materials to aid in communication and discussion, accounting for varying levels of health literacy.

Heavy Menstrual Bleeding Clinical Care Standard - Fact sheet for clinicians

Information for Healthcare Services – Heavy Menstrual Bleeding Clinical Care Standard

Presentation - Heavy Menstrual Bleeding Clinical Care Standard - Slide pack for local delivery 

Webinar for clinicians

Dr Phoebe Holdenson Kimura, GP and Medical Advisor for the Commission, and Professor Kirsten Black, Academic Gynaecologist, provide an overview of the Standard for primary care clinicians. They discuss why the Standard is so important and introduce each of the quality statements before going on to discuss the practical application of the Standard in three case studies.

Heavy menstrual bleeding algorithm 

• Initial assessment and management - health professional algorithm - Jean Hailes for Women’s Health 

Informed consent, shared decision making 

• Shared decision-making resources and tools - Australian Commission on Safety and Quality in Health Care
• Informed consent in health care fact sheet for clinicians - Australian Commission on Safety and Quality in Health Care 

Supporting delivery of culturally safe and equitable care

• The Minymaku Kutju Tjukurpa Women’s Business Manual is a Remote Primary Health Care Manual containing evidence‑based protocols to help manage the health of Aboriginal and Torres Strait Islander women in remote Australia.
• Menstrual Management and Contraception in Females with Developmental Disability (subscriber content) - Therapeutic Guidelines 

Abnormal vaginal bleeding 

• Diagnostic guide for GPs and gynaecologists for abnormal vaginal bleeding - Cancer Australia

Consumer Guide - Heavy Menstrual Bleeding Clinical Care Standard

Heavy Menstrual Bleeding Treatment Options 

Heavy Menstrual Bleeding - Hayley's story

In this video, Hayley explains the disruptive impact that heavy menstrual bleeding has had on her life, and her experience with different treatments. She shares her advice for other women who experience heavy menstrual bleeding.

About heavy menstrual bleeding 

• Heavy periods - Jean Hailes for Women’s Health
• Periods and heavy bleeding – Easy Read fact sheet - Jean Hailes for Women’s Health
• Heavy Menstrual Bleeding fact sheet - Royal Australian and New Zealand College of Obstetricians and Gynaecologists 

Making informed choices about care 

• Questions to ask your doctor - Healthdirect 

About hysterectomy

• Hysterectomy - Jean Hailes for Women’s Health
• Hysterectomy fact sheet - Royal Australian and New Zealand College of Obstetricians and Gynaecologists

Primary Health Networks (PHNs) can play a key role in improving care for women with heavy menstrual bleeding. By helping to drive awareness, and supporting local clinicians and healthcare services to implement the care described in the Heavy Menstrual Bleeding Clinical Care Standard, PHNs will contribute to improvements in:

• timely assessment and diagnosis of heavy menstrual bleeding and its underlying causes
• the physical, social and emotional wellbeing of women experiencing heavy menstrual bleeding
• access to effective, less invasive treatment options for heavy menstrual bleeding
• women’s ability to make informed choices about the treatments that are suitable for them. 

Activities and resources for Primary Health Networks (PHNs) to support local services and clinicians using the Standard

The following activities and resources are recommended for PHNs supporting local services and clinicians to implement the Heavy Menstrual Bleeding Clinical Care Standard.

• Primary Health Networks Implementation Guide - Heavy Menstrual Bleeding Clinical Care Standard

The Heavy Menstrual Bleeding Clinical Care Standard was first released in 2017 in response to the Atlas of Healthcare Variation series which found substantial variation in the rates of hysterectomy and endometrial ablation across Australia, with Australian women undergoing hysterectomy at a higher rate than women in comparable Organisation for Economic Co-operation and Development (OECD) countries.

The Women’s Health Focus Report 2024 examines trends in these procedures since the second Atlas in 2017. The Report shows:

• A decrease in hysterectomy rates of 20% nationally between 2014–15 and 2021–22
• An increase in endometrial ablation hospitalisation rates of 10% nationally between 2013–16 and 2019–22.

Despite these improvements, variation remains. Rates of hysterectomy remain high by international standards, and are higher in regional areas compared to major cities and remote areas. 

Read more about the scope and goal of this standard or see further background in the Heavy Menstrual Bleeding Clinical Care Standard.  

This Standard relates to care provided in: 

• primary and community healthcare settings, including general practice, women’s health, family planning and sexual health services and clinics
• public and private specialist gynaecology clinics and practices, radiology clinics and hospitals.

Not all quality statements in this Standard will be applicable to every healthcare service or clinical unit. Healthcare services should consider their individual circumstances in determining how to apply each statement. 

When implementing this Standard, healthcare services should consider:

• the context in which care is provided
• local variation
• quality improvement priorities of the individual healthcare service. 

In rural and remote settings, different strategies may be needed to implement the standard. For example, the use of:

• hub‑and‑spoke models integrating larger and smaller health services and ACCHOs
• telehealth consultations
• multidisciplinary teams including allied health involvement where clinically appropriate.

This Standard relates to the care of women of reproductive age with heavy menstrual bleeding. It covers management from first recognition of clinically significant heavy menstrual bleeding until its resolution in women before or at menopause.

National Safety and Quality Health Service Standards

Monitoring the implementation of Clinical Care Standards helps healthcare services to meet some of the requirements of the:

• National Safety and Quality Health Service Standards (NSQHS Standards) for acute services
• National Safety and Quality Primary and Community Healthcare Standards (Primary and Community Healthcare Standards) for services that deliver health care in a primary and/or community setting. 

Find out more about how healthcare services are expected to implement the national standards in How to use the Clinical Care Standards.

The Commission is committed to supporting healthcare services to provide culturally safe and equitable healthcare to all Australians. 

Person-centred care recognises and respects differences in individual needs, beliefs, and culture. The Commission: 

• is committed to supporting healthcare services to provide culturally safe and equitable healthcare to all Australians
• acknowledges that discrimination and inequity are significant barriers to achieving high‑quality health outcomes for some patients from culturally and linguistically diverse communities

Culturally safe service provision and environments are those where the places, people, policies and practices foster mutual respect, shared decision making, and an understanding of cultural, linguistic and spiritual perspectives and differences. Cultural safety is supported by organisations and individuals that recognise cultural power imbalances and actively address them by: 

• ensuring access to and use of interpreter services or cultural translators when this will assist the patient and aligns with their wishes
• providing visual or written information in a language that the patient, their family and carers will understand
• providing cultural competency training for all staff
• encouraging clinicians to review their own beliefs and attitudes when treating and communicating with patients
• identifying variation in healthcare provision or outcomes for specific patient populations, including those based on ethnicity, and responding accordingly.

The Heavy Menstrual Bleeding Clinical Care Standard has been endorsed by 21 key organisations:

• Australian College of Midwives
• Australian College of Nurse Practitioners
• Australasian Gynaecological Endoscopy and Surgery Society
• Australasian Menopause Society
• Australasian Society for Ultrasound in Medicine
• Australian College of Nursing
• Australian College of Rural and Remote Medicine
• Australian Primary Health Care Nurses Association
• Australian Women’s Health Nurse Association
• CRANAplus
• Endocrine Society of Australia
• Family Planning Alliance Australia
• Family Planning NSW
• Interventional Radiology Society of Australasia
• Jean Hailes for Women's Health
• Royal Australasian College of Physicians
• Royal Australian and New Zealand College of Obstetricians and Gynaecologists
• Royal Australian and New Zealand College of Radiologists
• Royal College of Pathologists of Australasia
• Rural Doctors Association of Australia
• True Relationships and Reproductive Health
• Women's Healthcare Australasia.

The Commission develops Clinical Care Standards taking into account:

• advice from multidisciplinary topic working groups which include clinicians, consumers, and researchers
• consultation with key stakeholders including consumer bodies, professional organisations, and state and territory health departments. 

The Heavy Menstrual Bleeding Clinical Care Standard Topic Working Group provided expert advice on the development and review of the Standard. In addition, a targeted consultation process was conducted with key stakeholders.

Topic Working Group - Heavy Menstrual Bleeding Clinical Care Standard

Many members of the Heavy Menstrual Bleeding Clinical Care Standard Topic Working Group were involved in the original development of the Standard in 2017. 

The main roles of the Topic Working Group were to:

• advise on the continued scope and key components of care within the Standard
• advise on the key sources of evidence to inform the review
• advise on revisions to quality statements and supporting indicators
• recommend strategies to support the implementation of the updated Standard
• actively support raising awareness of the updated Standard.

All members are required to disclose financial, personal and professional interests that could, or could be perceived to, influence a decision made, or advice given to the Commission. Disclosures are updated prior to each meeting and managed in line with the Commission’s Policy on Disclosure of Interests. 

The quality statements in the Standard are based on the best available evidence and guideline recommendations at the time of development. 

Further information is available on the evidence sources which underpin the Standard.

Evidence sources - Heavy Menstrual Bleeding Clinical Care Standard