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• Idiopathic heavy menstrual bleeding negatively affects women's quality of life. • The stepped care approach shows practice variation between Dutch hospitals. • Women underwent 0.63 treatments (range, 0.36–1.00) before endometrial ablation. • Women underwent 0.96 treatments (range, 0.56–1.45) before hysterectomy. • Scope exists to reduce hysterectomy rates by implementing less invasive therapies. Heavy menstrual bleeding (HMB) affects a quarter of all women, with half having no structural cause. Dutch guidelines recommend a stepped care approach to the management of such idiopathic HMB, starting with medication or a levonorgestrel-releasing intrauterine device (LNG-IUD), before progressing to endometrial ablation, and ultimately, hysterectomy. However, practice variation between hospitals could lead to suboptimal health outcomes and increased healthcare costs for some women. To evaluate adherence to stepped care for women with idiopathic HMB and to identify practice variation among Dutch hospitals. This population-based cross-sectional study used Dutch insurance claims data from primary and secondary care for all women with idiopathic HMB referred to a gynecologist between January 2019 and December 2020. We calculated the average number of treatments in the 3 years before each treatment step at each hospital, making adjustments for age, socioeconomic status, and ethnicity. Variation in medical practice was measured by the coefficient of variation (CV). We studied 20,715 women treated with LNG-IUDs (56%), endometrial ablation (36%), laparoscopic hysterectomy (13%), or vaginal hysterectomy (4%) in 93 hospitals. Before endometrial ablation, on average 47% used medication (hospital range 27%–71%; CV 0.17) and 16% used an LNG-IUD (hospital range 8%–29%, CV 0.32). Before hysterectomy, 52% (hospital range 28%–65%, CV 0.16) used medication, 21% (hospital range 6%–38%, CV 0.35) used an LNG-IUD, and 23% underwent endometrial ablation (hospital range 0%–59%, CV 0.55). On average, women underwent 0.63 (hospital range 0.36–1.00, adjusted rate 0.40–0.98, CV 0.17) and 0.96 (hospital range 0.56–1.45, adjusted rate 0.56–1.44, CV 0.18) treatments before endometrial ablation and hysterectomy, respectively. Considerable practice variation exists among Dutch hospitals in the stepped care approach to idiopathic HMB. Improving adherence to this approach could improve quality of care and reduce costs. [ABSTRACT FROM AUTHOR]