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Heavy menstrual bleeding (HMB)

Find assessment and management information at Brisbane South HealthPathways under:

Useful management information

Refer to HealthPathways or local guidelines

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. View the Heavy Menstrual Bleeding Clinical Care Standard.

  • Consider increased risk of hyperplasia or malignancy if:
    • endometrial thickness greater than 12mm (transvaginal USS ideally day 4-7)
    • irregular endometrium or focal lesion
    • weight >90kg
    • PCOS / diabetes / unopposed oestrogen
    • age >45yrs
    • intermenstrual or post-coital bleeding
  • Medical treatment prior to or while waiting for specialist review if no suspicion of malignancy:
    • Progesterone releasing IUD
    • Tranexamic acid
    • OCP
    • NSAIDS
    • Oral progestogens-start with oral progesterone in Paediatric and Adolescent Gynaecology
      (PAG) age group
  • Referral is also arranged for a woman who has not responded after six months of medical treatment.

Minimum referral criteria (Does your patient meet the minimum criteria?)

Category 1
(appointment within 30 calendar days)

If you feel your patient meets Category 1 criteria, please mark "urgent" on your referral

  • Suspicion of malignancy (See Useful management information)
  • Heavy Menstrual Bleeding (HMB) with anaemia (Hb<85) or requiring transfusion
Category 2
(appointment within 90 calendar days)
  • HMB with anaemia (Hb>85)In paediatric and adolescent patients the impact on
    quality of life with missing school, tiredness, anxiety and depression necessitates
    referral to SPAG services as category 2, and not category 3 if not responding to
    primary medical management. There is a significant risk of having an underlying
    bleeding disorder that needs to be excluded
Category 3
(appointment within 365 calendar days)
  • HMB without anaemia not responding to medical management

If your patient does not meet the minimum referral criteria

  • Assessment and management information can be found on a range of conditions at Brisbane South HealthPathways
  • If the patient does not meet the criteria for referral but the referring practitioner believes the patient requires specialist review, a clinical override may be requested:
    • Please explain why (e.g. warning signs or symptoms, clinical modifiers, uncertain about diagnosis, etc.)
    • Please note that your referral may not be accepted or may be redirected to another service

Standard referral information (To be included in all referrals)

Reason for request

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

Relevant clinical information about the condition

  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • All conservative options that have been pursued unsuccessfully prior to referral
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes, BMI), noting these must be stable and controlled prior to referral
  • Any special care requirements where relevant (e.g tracheostomy in place, oxygen required)
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use
  • A comprehensive capture of information in relation to MSH Referral Criteria

Clinical modifiers

  • The presence of clinical modifiers may impact the categorisation of the patient.
  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living functioning – low/medium/high
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and/or Torres Strait Islander

Patient's Demographic Details

  • Full name (including aliases)
  • Date and country of birth
  • Residential and postal address including whether patient resides at an aged care facility
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Name of delegate and contact details (Department of Corrective Services)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander
  • Any special needs, access requirements and/or disability relevant to the referral

Referring Practitioner Details

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature
  • Nominated general practitioner’s details (if known), if the nominated general practitioner is different from the referring practitioner

Other relevant information

  • Willingness to have surgery (where surgery is a likely intervention)
  • Choice to be treated as a public or private patient
  • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)

 

Essential referral information for Heavy menstrual bleeding (HMB) referrals (Referral will be returned without this)

  • Brief description of periods
  • Medical management to date
  • Most recent or current cervical screening results if indicated (not a requirement for adolescents)
  • FBC, Serum ferritin results
  • Pelvic USS (TVS preferable)
  • Adolescent patient - Coag profile including von Willebrand's disease (vWD) platelet function disorders screen, TFT. TA Scan in the first instance *NB patients <16years to be referred to Paediatric and Adolescent Gynaecology Service or Mater Adolescent Gynaecology

If a specific test result is unable to be obtained due to access, financial, religious, cultural or consent reasons a Clinical Override may be requested. This reason must be clearly articulated in the body of the referral.

Additional referral information for Heavy menstrual bleeding (HMB) referrals

  • BMI
  • TSH if symptomatic of thyroid disease
  • Previous management modalities, iron utilisation if deficient

Emergency

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.

  • Ectopic pregnancy
  • Ruptured haemorrhagic ovarian cyst
  • Torsion of uterine appendages (ovarian)
  • Acute/severe pelvic pain
  • Significant or uncontrolled vaginal bleeding
  • Severe infection
  • Abscess intra pelvis or PID
  • Bartholin’s abscess / acute painful enlargement of a Bartholin’s gland/cyst
  • Acute trauma including vulva/vaginal lacerations, haematoma and/or penetrating injuries
  • Post-operative complications within 6 weeks including wound infection, wound breakdown, vaginal bleeding/discharge, retained products of conception post-op, abdominal pain
  • Urinary retention
  • Acute urinary obstruction
  • Unstable molar pregnancy
  • Inevitable and / or incomplete abortion
  • Hyperemesis gravidarum
  • Ascites, secondary to known underlying gynaecological oncology

Out of catchment

Metro South Health is responsible for providing public health services to the people who reside within its boundaries. Special consideration is made for patients requiring tertiary care or services that are not provided by their local Hospital and Health Service. If your patient lives outside the Metro South Health area and you wish to refer them to one of our services, inclusion of information regarding their particular medical and social factors will assist with the triaging of your referral.

Last updated 18 December 2023