The study used routinely-collected hospital data to investigate the care of 51,456 women who had surgery for heavy menstrual bleeding. Overall, 4 in 10 had a hysterectomy. However, there was also regional variation in the type of surgery performed, with the proportion of women having a hysterectomy ranging from 25% to 54%.
In England, around one in 20 women aged 30 to 49 years see their GPs each year because of heavy menstrual bleeding. There is a range of effective treatments and the National Institute for Health and Clinical Excellence (NICE) recommends that women are provided with evidence-based information about their treatment options prior to considering irreversible operations such as hysterectomy. The variation in the use of surgery suggests this information is lacking. The RCOG, in partnership with the London School of Hygiene and Tropical Medicine (LSHTM) and Ipsos-Mori, will soon begin a national audit into the hospital-based treatment of heavy menstrual bleeding. One aim of the audit is to provide better information about treatment options.
Dr Tahir Mahmood, RCOG Vice President of Standards, said “This research shows how current NICE guidelines may not always be followed. Why this is the case has been the object of some speculation but we have good evidence now of the substantial variation in surgical treatment across the regions.
“There is a move to more conservative treatment, where appropriate, but this research has highlighted the important role of information provision in gynaecological surgery. Women need to be informed of the risks and benefits of each surgical option before decisions are made.”
The research is published in the September 2009 edition of BJOG: An International Journal of Obstetrics and Gynaecology.
For more information on the study, speak to Dr David Cromwell by emailing firstname.lastname@example.org or call 020 7869 6608. To speak to Dr Tahir Mahmood, call 020 7772 6446.
The Office for Research and Clinical Audit (ORCA) is a collaboration between the Royal College of Obstetricians and Gynaecologists (RCOG) and the London School of Hygiene and Tropical Medicine (LSTMH) http://www.lshtm.ac.uk/ .
Heavy menstrual bleeding is defined as excessive menstrual blood loss, which interferes with the woman’s physical, emotional, social and material quality of life, and which can occur alone or in combination with other symptoms.
A hysterectomy is defined as surgery to remove the womb. This operation occurs when a woman is suffering from heavy periods, fibroids or some gynaecological cancers.
Data for the study was extracted from Hospital Episode Statistics (HES), the database that holds information on all admissions to NHS hospitals in England. The study covered women aged between 25 and 59 years at the time of their first surgery for heavy menstrual bleeding, included procedures performed between 1 April 2003 and 31 March 2006.
In this study, researchers found substantial variation in surgical rates among PCTs. There was less variation in the rates of PCTs within the same SHA. PCTs in London were noted to have had lower surgical rates. There was also considerable variation in the surgical techniques used. The proportion of women who underwent endometrial ablation ranged from 46% to 75% between the SHAs. Among the PCTs, the use of the procedures was even more varied for endometrial ablation, the range being from 16% to 92%. Rates of surgery were found to be higher in PCTs with greater deprivation and in PCTs where a greater proportion of endometrial ablations were performed. Surgery rates were lower in SHAs which had more consultants.
The NICE guidance on the treatment of heavy menstrual bleeding was published in 2007 and is available at http://www.nice.org.uk/
Cromwell D, Mahmood T, Templeton A, van der Meulen J. Surgery for menorrhagia within English regions: variation in rates of endometrial ablation and hysterectomy. BJOG 2009;116:1373–1379