Heavy menstrual bleeding — new Clinical Care Standard released

Hysterectomy rates have fallen by 20% over eight years as women likely opt for less invasive treatments to manage heavy periods, according to the Australian Commission on Safety and Quality in Health Care (ACSQHC).

As against this, there has been a 10% increase in the rate of the less invasive procedure endometrial ablation (removal of the uterus lining using heat), one of several alternatives for treating heavy periods.

Even though one in four Australian women experience significantly heavy periods that can seriously affect their quality of life, the issue can be hidden and there can be shame in talking about menstruation. The condition remains under-recognised and under-treated. Around 50% of women do not seek medical care¹ despite the debilitating impact on daily life, which can be because they don’t know their period is not ‘normal’ or due to the stigma of menstruation, according to the ACSQHC. 

An updated Clinical Care Standard

The Commission’s latest national trend data report reveals that more than 24,000 women had a hysterectomy for non-cancer reasons in 2021–22. The report examines two procedures commonly used for heavy menstrual bleeding — hysterectomy and the less invasive option of endometrial ablation². It indicates geographical areas with the highest and lowest rates, building on earlier findings of the Australian Atlas of Healthcare Variation series.

The Commission has also released an updated Heavy Menstrual Bleeding Clinical Care Standard (2024) to ensure that women with this condition can make an informed choice about the most appropriate treatment for their individual situation.

The updated Standard continues to support greater choice of treatment options and was first developed in 2017 in response to unexplained variation in rates of hysterectomy across Australia.

The new data and revised Standard aim to build understanding of the risks and benefits of treatments for heavy menstrual bleeding, empowering women to make informed choices about their own health care.

One size does not fit all

The findings are positive, but Associate Professor Liz Marles, Clinical Director for the Commission and a GP, said there is a long way to go to ensure that women with heavy menstrual bleeding can access the full range of treatment options.

The data also revealed a rural–urban disparity, with both hysterectomy and endometrial ablation rates higher in regional areas than major cities and remote areas, indicating that some treatments for heavy menstrual bleeding are not being consistently accessed across Australia.

“Every woman should have access to care that is tailored to her needs. Yet we know that women’s concerns about heavy menstrual bleeding can be overlooked and it can be hard to access suitable care. The fact that treatment differs based on where people live suggests there is more work to do,” she said.

“Heavy periods are a hidden problem that a lot of women live with,” Marles said.

“It can be a sensitive topic that some women do not feel comfortable raising with their doctor. The Commission’s work advocates on behalf of these women, many of whom have had their life substantially affected.”

She also said it was concerning that Australia’s rate of hysterectomy remains significantly higher than comparable OECD countries like New Zealand and the United Kingdom³, suggesting women who seek help may have a more invasive procedure than is necessary.

Three key outcomes

Marles said the Commission was seeking three important outcomes. “Firstly, we want women to know they don’t have to put up with symptoms, to feel comfortable talking about their periods and to be aware that there are a range of treatments, which don’t necessarily involve a major operation.

“Let’s also upskill the healthcare workforce so women are offered the full suite of treatment options, and practitioners can deliver minimally invasive treatments if appropriate, such as the hormonal IUD.

“Finally, health practitioners need to ask women about their menstrual health and tailor care to individual needs, so they receive the most suitable treatment, which differs for each woman,” she said.

Higher hysterectomy rates among First Nations women emphasised the need for culturally appropriate care, Marles said, with the new Standard offering guidance to help improve equity.

“While some women may choose hysterectomy, we want to avoid them going straight to the most invasive procedure, without being offered less invasive and effective alternatives and information on the risks and benefits. Hysterectomy cannot be reversed and has increased risk of complications,” she said.

Impact under-recognised

Professor Kirsten Black, a gynaecologist with the University of Sydney and a member of expert advisory groups for the Standard and the Women’s Health Focus Report, said the impact of heavy menstrual bleeding on a woman’s health and quality of life remains under-recognised.

“It has been great that we have seen a shift towards less invasive gynaecology procedures since the first Heavy Menstrual Bleeding Clinical Care Standard was introduced in 2017,” she said.

“We know that many women with heavy menstrual bleeding can be successfully managed by their GP or other primary care practitioner using medical treatments like the hormonal IUD.”

Black said it was important to do a proper initial assessment to identify whether there is a specific cause that may need to be addressed and to check for iron deficiency⁴ and anaemia.

“Healthcare providers need to understand their patient’s menstrual history and whether the bleeding prevents them from going about daily activities and interacting socially. Some women feel they can’t leave the house when they've got their period because of fear of excessive bleeding,” she said.

“For women with heavy menstrual bleeding, finding the right treatment has potential to be life-changing.”

Quality of life

Assistant Minister for Health and Aged Care Ged Kearney MP said, “Women’s health has for too long been overlooked, ignored and dismissed.

“Heavy periods can seriously impact a woman’s quality of life. I know, I have had very personal experience of this, along with one in four women.

“As a former nurse, I implore all women who are concerned to talk to a trusted healthcare provider about menstrual bleeding. You don’t need to suffer in silence, there are many options to get help.”

<sup>1. Henry C, Filoche S. Reflections on access to care for heavy menstrual bleeding: Past, present, and in times of the COVID-19 pandemic. International Journal of Gynecology & Obstetrics. 2023 Aug;162 Suppl 2:23-28.
2. ACSQHC. Women’s Health Focus Report 2024. Hysterectomy and endometrial ablation trends at national, state and territory, Primary Health Network and local area level.
3. OECD. Healthcare utilisation: surgical procedures – hysterectomy. [cited 2023 March 14].  In 2019, there were 215 hysterectomies per 100,000 women in Australia, compared with 126 in New Zealand and 132 in the United Kingdom (for cancer and non-cancer diagnoses)
4. Percy L, Mansour D, Fraser I. Iron deficiency and iron deficiency anaemia in women. Best Practice & Research Clinical Obstetrics & Gynaecology. 2017 Apr; 40:55-67</sup>

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