Surgical management of heavy menstrual bleeding

Treatments for women with fibroids of 3 cm or more in diameter

• referral of women to specialist care should be considered (to undertake additional investigations and discuss treatment options) for fibroids of 3 cm or more in diameter
• if pharmacological treatment is needed while investigations and definitive treatment are being organised, offer tranexamic acid and/or NSAIDs
• advise women to continue using NSAIDs and/or tranexamic acid for as long as they are found to be beneficial

Non-pharmacological treatments for women with fibroids of 3 cm or more in diameter

• uterine artery embolisation
• surgical:
  • myomectomy
  • hysterectomy
    
    
• prior to scheduling of uterine artery embolisation or myomectomy, the woman's uterus and fibroid(s) should be assessed by ultrasound. If further information about fibroid position, size, number and vascularity is needed, MRI should be considered
  
  
• second-generation endometrial ablation should be considered as a treatment option for women with HMB and fibroids of 3 cm or more in diameter who meet the criteria specified in the manufacturers' instruction
  
  
• if treatment is unsuccessful:
  • consider further investigations to reassess the cause of HMB ), taking into account the results of previous investigations and
  • offer alternative treatment with a choice of the options described
    
    
• pretreatment with a gonadotrophin-releasing hormone analogue before hysterectomy and myomectomy should be considered if uterine fibroids are causing an enlarged or distorted uterus

Notes:

• Endometrial ablation (1):
  • a treatment option for women with HMB and fibroids of 3 cm or more in diameter who meet the criteria specified in the manufacturers' instructions
  • in women with HMB alone, with uterus no bigger than a 10-week pregnancy, endometrial ablation may be considered preferable to hysterectomy (1)
  • second-generation ablation techniques should be used where no structural or histological abnormality is present
    • impedance-controlled bipolar radiofrequency ablation
    • fluid-filled thermal balloon endometrial ablation
    • microwave endometrial ablation
    • free fluid thermal endometrial ablation
  • women should be advised to avoid subsequent pregnancy and use effective contraception, if needed, after endometrial ablation
    
    
• Further interventions for uterine fibroids associated with menorrhagia/HMB
  • if large fibroids and HMB, and other significant symptoms such as dysmenorrhoea or pressure symptoms, referral for consideration of surgery or uterine artery embolisation (UAE) as first-line treatment can be recommended (1)
  • UAE, myomectomy or hysterectomy should be considered in cases of HMB where large fibroids (greater than 3 cm in diameter) are present and bleeding is having a severe impact on a woman's quality of life
  • myomectomy is recommended for women with HMB associated with uterine fibroids and who want to retain their uterus
  • UAE is recommended for women with HMB associated with uterine fibroids and who want to retain their uterus and/or avoid surgery
  • pretreatment before hysterectomy and myomectomy with a gonadotrophin-releasing hormone analogue for 3 to 4 months should be considered where uterine fibroids are causing an enlarged or distorted uterus
    • if a woman is being treated with gonadotrophin-releasing hormone analogue and UAE is then planned, the gonadotrophin-releasing hormone analogue should be stopped as soon as UAE has been scheduled
      
      
• Hysterectomy - with conservation of the ovaries; occasionally the Fallopian tubes and ovaries are also removed e.g. if the patient is over 45 years of age and elects to have removal of ovaries to protect against ovarian carcinoma (3)
  
  
• There is no evidence that dilatation and curettage has any role in the treatment of menorrhagia (1,2,4).

Reference:

1. NICE (August 2016). Heavy menstrual bleeding.
2. NICE (March 2018). Heavy menstrual bleeding.
3. Drug and Therapeutics Bulletin (2000), 38 (10), 77-80.
4. Royal College of Obstetricians and Gynaecologists (July 1999). The Management of Menorrhagia in Secondary Care. Evidence-based Clinical Guidelines no. 5. London: RCOG Press