Indications for specialist referral for heavy menstrual bleeding

If heavy menstrual bleeding has not settled after 6 months of pharmacotherapy, refer for specialist assessment and consideration of surgical options such as uterine artery embolisation, myomectomy, hysteroscopic resection of fibroids or polyps, or hysterectomy.

Early referral (before 6 months) in heavy menstrual bleeding is indicated for:

• concurrent severe dysmenorrhoea at baseline
• concurrent dysmenorrhoea that does not settle after 3 months of pharmacotherapy
• individuals who wish to conceive in whom fertility may be at risk (eg if endometriosis or adenomyosis is suspected)
• fibroids greater than 3 cm
• endometrial polyps
• increased risk of endometrial cancer due to risk factors such as:
  • oligomenorrhoea
  • polycystic ovary syndrome
  • a personal or family history of endometrial or colon cancer¹
  • use of unopposed estrogen or tamoxifen
  • obesity (particularly with diabetes or hypertension)
  • age older than 45 years
  • radiological findings (such as endometrial thickness greater than 12 mm in premenopausal individuals or 5 mm or greater in perimenopausal individuals, when measured in the first half of the menstrual cycle).

For any patient with an indication for specialist referral, arrange an ultrasound before referral.