Information for healthcare services - Heavy Menstrual Bleeding Clinical Care Standard

Guidance for healthcare services on the eight quality statements from the Heavy Menstrual Bleeding Clinical Care Standard, as well as helpful resources.

What healthcare services need to know

The Heavy Menstrual Bleeding Clinical Care Standard includes eight evidence-based quality statements to ensure that women with heavy menstrual bleeding are offered the least invasive and most effective treatment appropriate to their clinical needs and have the opportunity to make an informed choice from the range of treatments suitable to their individual situation.

A set of indicators is provided to support clinicians and healthcare services to monitor how well they are implementing the care recommended in this clinical care standard and to support local quality improvement activities.

What the quality statements mean for healthcare services

Quality statement 1 – Assessment and diagnosis

The initial assessment of a woman presenting with heavy menstrual bleeding includes a thorough history, assessment of impact on quality of life, a physical examination (where clinically appropriate), and exclusion of pregnancy, iron deficiency and anaemia. Further investigations are based on the initial assessment.

What this means for healthcare services

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.

Quality statement 2 – Informed choice and shared decision making

A woman with heavy menstrual bleeding is informed about her treatment options and their potential benefits and risks. She is supported to participate in shared decision making based on her preferences, priorities and clinical situation.

What this means for healthcare services

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.

Quality statement 3 – Initiating medical management

A woman presenting with heavy menstrual bleeding is offered medical management, taking into account evidence‑based guidelines, her individual needs and preferences and any associated symptoms. Oral treatment is offered at first presentation when clinically appropriate, including when a woman is undergoing further investigation or waiting for other treatment.

What this means for healthcare services

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.

Quality statement 4 – Quality ultrasound

When a woman requires an ultrasound to investigate the cause of her heavy menstrual bleeding, she is offered a pelvic (preferably transvaginal) ultrasound, which assesses all pelvic structures, including the uterus and endometrium, and is ideally performed in days 5–10 of her menstrual cycle.

What this means for healthcare services

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)55
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.

Quality statement 5 – Intrauterine hormonal devices

When medical management options are being considered, a woman is offered a 52 mg levonorgestrel‑releasing intrauterine device if clinically appropriate, as it is currently the most effective medical option for managing heavy menstrual bleeding.

What this means for healthcare services

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.

Quality statement 6 – Specialist referral

A woman with heavy menstrual bleeding is referred for early specialist review when there is a suspicion of malignancy or other significant pathology based on clinical assessment or ultrasound. Referral is also offered to a woman who has not responded to medical management.

What this means for healthcare services

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.

Quality statement 7 – Uterine‑preserving alternatives to hysterectomy

A woman who has heavy menstrual bleeding of benign causes and who is considering non‑medical management is offered uterine‑preserving procedures that may be suitable (such as endometrial ablation, uterine artery embolisation or surgical removal of local pathology). She is supported to make an informed decision and is referred appropriately.

What this means for healthcare services

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.

Quality statement 8 – Hysterectomy

Hysterectomy to manage heavy menstrual bleeding is considered when other treatment options are ineffective or are unsuitable, or at the woman’s request. A woman considering a hysterectomy is fully informed about the potential benefits and risks of the procedure before making a decision.

What this means for healthcare services

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.

Resources for healthcare services

The resources below have been developed to support healthcare services implementing the Standard. Also see our complete set of implementation resources including resources for consumers, clinicians and primary health networks, and other related resources relevant to the Standard.

Information for Healthcare Services – Heavy Menstrual Bleeding Clinical Care Standard

2024

Fact sheet or brochure

Heavy Menstrual Bleeding Clinical Care Standard (2024)

2024

Publication, report or update

Meeting the requirements of national standards

Implementing this clinical care standard as part of a quality improvement activity can help healthcare services meet the requirements of the National Safety and Quality Health Service (NSQHS) Standards, and the National Safety and Quality Primary and Community Healthcare Standards (Primary and Community Healthcare Standards)

Fact sheet 11: Applicability of Clinical Care Standards

2023

Fact sheet or brochure

The purpose of this fact sheet is to provide advice to health service organisations implementing Clinical Care Standards and assessors reviewing compliance with these actions.

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