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Hysterectomy Menorrhagia – Information for GPs

OPCS codes

Abdominal Hysterectomy
Q071 Abdominal hysterocolpectomy and excision of periuterine tissue
Q072 Abdominal hysterectomy and excision of periuterine tissue NEC
Q073 Abdominal hysterocolpectomy NEC
Q074 Total abdominal hysterectomy NEC
Q075 Subtotal abdominal hysterectomy
Q076 Excision of accessory uterus
Q078 Other specified abdominal excision of uterus
Q079 Unspecified abdominal excision of uterus

Vaginal Hysterectomy
Q081 Vaginal hysterocolpectomy and excision of periuterine tissue
Q082 Vaginal hysterectomy and excision of periuterine tissue NEC
Q083 Vaginal hysterocolpectomy NEC
Q088 Other specified vaginal excision of uterus
Q089 Unspecified vaginal excision of uterus

Laparoscopic Abdominal Hysterectomy
Any of Q071 to Q079
Y751 Laparoscopically assisted approach to abdominal cavity
Y752 Laparoscopic approach to abdominal cavity NEC

Laparoscopic Vaginal Hysterectomy
Any of Q081 to Q089
Y751 Laparoscopically assisted approach to abdominal cavity
Y752 Laparoscopic approach to abdominal cavity NEC

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 and 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:

a. tranexamic acid

b. NSAIDs (non-steroidal anti-inflammatory drugs)

hormonal:

a. combined hormonal contraception

b. cyclical oral progestogens

c. 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 bleeding

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.

Summary of evidence / rationale

Hysterectomy is a major operation and is associated with significant complications in a minority of cases. 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 NG88 Heavy menstrual bleeding: assessment and management (2018)1 suggests consider an LNG-IUS as the first treatment for HMB in women with:

  • no identified pathology or
  • fibroids less than 3 cm in diameter, which are not causing distortion of the uterine cavity or
  • suspected or diagnosed adenomyosis

(Previous NICE guidance in 2007 stated that the Mirena® device is effective in the treatment of menorrhagia and is considerably cheaper than a hysterectomy, even if required for many years, and allows the fertility of the woman to be maintained.)

If a woman with HMB declines an LNG-IUS or it is not suitable, it suggests considering other pharmacological treatments (non-hormonal or hormonal).

If treatment is unsuccessful, the woman declines pharmacological treatment, or symptoms are severe, it suggests considering referral to specialist care for appropriate investigations and alternative treatment choices, including endometrial ablation.

A recent Cochrane review compared the effectiveness, safety and acceptability of surgery versus medical therapy for heavy menstrual bleeding4. It states that hysterectomy, endometrial surgery and the LNG-IUS were all effective in reducing heavy menstrual bleeding. Although hysterectomy will stop heavy menstrual bleeding, it is associated with serious complications and most women should probably try a less radical treatment as first-line therapy. Both conservative surgery and LNG-IUS appear to be safe, acceptable and effective.

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 guidance at www.nice.org.uk

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