Hysterectomy for Menorrhagia – Criteria Led Commissioning Statement

The CCGs do not commission Hysterectomy as a first line treatment for HMB in line with NICE guidance. https://www.nice.org.uk/guidance/CG44/chapter/Recommendations#choice

Therefore Hysterectomy for HMB will only be supported if other treatment options have failed or are contraindicated as outlined in NICE guidance [ Clinical Guidance CG44: Heavy Menstrual Bleeding: assessment and management: published January 2007: updated August 2016]

This means for women with fibroids of <3cm or no structural abnormality and history and examination deem that pharmaceutical treatment is appropriate and either hormonal or non-hormonal treatments are acceptable then at least 2 pharmaceutical options should be explored in the following order:

• levonorgestrel-releasing intrauterine system (LNG-IUS) provided long-term (at least 12 months) use is anticipated, and has been trialled for at least 6 cycles
• tranexamic acid or non-steroidal anti-inflammatory drugs (NSAIDs) or combined oral contraceptives (COCs)
• norethisterone (15 mg) daily from days 5 to 26 of the menstrual cycle, or injected long-acting progestogens.
• If hormonal treatments are not acceptable to the woman, then either tranexamic acid or NSAIDs can be used.
• Endometrial ablation can be considered as initial treatment if the HMB is having a severe impact on the quality of life and the patient does not wish to conceive and after full discussion of benefits and risks of other treatment options with the patient or after failure of pharmaceutical measures.
• In women with no structural abnormality or fibroids <3cm and a uterine size of less than a 10 week pregnancy, endometrial ablation is preferable to hysterectomy.

For women with HMB and with uterine fibroids of >3cm, pharmaceutical treatment should be considered if clinically appropriate as above. Additional pharmaceutical options recommended by NICE for women with large fibroids > 3cm include the following:

• Offer ulipristal acetate 5 mg (up to 4 courses) to women with heavy menstrual bleeding and fibroids of 3 cm or more in diameter, and a haemoglobin level of 102 g per litre or below.
• Consider ulipristal acetate 5 mg (up to 4 courses)[5] for women with heavy menstrual bleeding and fibroids of 3 cm or more in diameter, and a haemoglobin level above 102 g per litre
• In women with HMB and fibroids >3cm, Surgical intervention should be considered if HMB is having a severe impact on quality of life and there are associated significant symptoms including pressure symptoms or dysmenorrhoea.
• When surgery is being considered for fibroid related HMB then all surgical options of uterine artery embolization, myomectomy and hysterectomy should be considered and women should be advised of the benefits and risks associated with all methods.

In secondary care appropriate pre-operative investigation and assessment [ including with USS and MRI where appropriate] should be undertaken and pre-surgical treatment with GNRH analogues given where clinically appropriate

Note:

• 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
• For contra-indications to LNG-IUS please refer to manufacturers SPC guidance and FSRH guidance on the use if intra-uterine devices
• Use of a gonadotrophin-releasing hormone analogue could be considered by secondary care prior to surgery or when all other treatment options for uterine fibroids, including surgery or uterine artery embolisation, are contraindicated. If this treatment is to be used for more than 6 months or if adverse effects are experienced then hormone replacement therapy (HRT) 'add-back' therapy is recommended

Lifestyle Factors - Best Practice

Obesity

• Patients with a BMI >30 should be encouraged by their Clinician to lose weight prior to surgery and signposted to appropriate support to address lifestyle factors that would improve their fitness for surgery and recovery afterwards.
• There is a clinical balance between risk of surgical complications with obesity and the risk to delaying any surgery.
• See Weight Management Care Pathways

Smoking

• In line with 'Healthy Lives, Healthy People; a tobacco control plan for England', local authorities and health professionals are committed to encourage more smokers to quit.
• Smoking remains the leading cause of preventable morbidity and premature death in England.
• There is sufficient evidence to suggest that people who smoke have a considerably increased risk of intra- and post-operative complications such as chest infections, lung disorders, wound complications and impaired healing.
• See Smoking Cessation Care Pathways

Please Note: The life style factors above are not a restriction to the commissioning statements unless otherwise stated

Hysterectomy is a major operation and is associated with significant complications in a minority of cases¹. Since the 1990s the number of hysterectomies has been decreasing rapidly and it should not be used as a first-line treatment solely for HMB.. There are now a range of alternative treatment options for HMB

NICE clinical guidelines (2007)¹ emphasise that:

• The Mirena® device is effective in the treatment of menorrhagia and is considerably cheaper than a hysterectomy, even if required for many years (for contraception costs estimated at £207 including consultation; removal cost £26) and the fertility of the woman may be maintained. In a NICE study of long-acting reversible contraception3, the average annual cost of Mirena was estimated at £70. This compares to the average cost to the CCG of performing a hysterectomy of £2,362.
• Other effective conservative treatments are available as second line treatment after failure of Mirena or where Mirena is contra-indicated

A Cochrane systemic review showed that the Mirena® coil improved the quality of life of women with menorrhagia as effectively as hysterectomy (no ref provided)

Hysterectomy should be considered only when¹:

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

The supporting evidence is given in more detail in the evidence reviews and statements from the clinical guidelines on Heavy menstrual bleeding given below ^1,2, For details of the primary studies and systematic reviews that NICE used to make their recommendations and a full bibliography, see their full guideline at www.nice.org.uk

.

1. NICE. Heavy menstrual bleeding: Clinical Guideline 44. January
2. 2007. Available from:http://www.nice.org.uk/Guidance/CG44/NiceGuidance/pdf/English.
3. National Collaborating Centre for Women's and Children's Health (for NICE). Heavy menstrual bleeding: Clinical Guideline 44.January 2007. RCOG. Available from:http://www.nice.org.uk/Guidance/CG44/Guidance/pdf/English
4. Royal College of Obstetricians and Gynaecologists (1999). Management of Menorrhagia in Secondary Care

• This policy was developed on: 05.2017
• This policy was approved by: Clinical Strategy Group (NK) and Clinical Cabinet (WK)
• Date approved: 05.2017
• Publication Date: 05.2017
• Review Date: 04.2018
• Ref No: PA14 - 05.2017

Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk

Only the electronic version is maintained, once printed this is no longer a controlled document