Trends in number of hysterectomies performed in England for menorrhagi
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《英国医生杂志》
1 Directorate of Obstetrics and Gynaecology, Luton and Dunstable Hospital NHS Trust, Luton LU4 0DZ
Correspondence to: P C Reid Peter.Reid@ldh-tr.anglox.nhs.uk
Twenty years ago 60% of patients with menorrhagia who were referred to a gynaecologist had a hysterectomy as treatment.1 Endometrial ablation was first described in the United Kingdom in 1989 and is a viable surgical alternative to hysterectomy.2 The levonorgestrel intrauterine system (Mirena, Schering Health) is highly effective in reducing menstrual bleeding and has been shown to reduce the numbers of patients proceeding to hysterectomy.3 It would be expected therefore that the numbers of hysterectomies would be falling. Nearly half of women referred to secondary care with menorrhagia, however, express a preference for hysterectomy,4 and it should be recognised that hysterectomy remains an excellent treatment for menstrual problems and brings high levels of patient satisfaction. We aimed to observe trends in the number of hysterectomies performed for menorrhagia in England.
Methods and results
We examined NHS hospital episode statistics compiled from data submitted by over 300 NHS trusts in England for the years 1989-90 to 2002-3. The figures for 2001-2 and 2002-3 have not been adjusted to account for shortfalls in the number of records submitted.
No single international classification of diseases (ICD) code exists for menorrhagia, so data included several codes, from both the ninth and tenth revisions (ICD-9: 626.2, 626.8, and 627.0; and ICD-10: N92.0, N92.1, N92.4, N92.5, and N92.6). Operation codes for hysterectomy are Q07, Q08. We used the codes Q17 and Q16 combined with Y114 (microwave endometrial ablation) and Y118 (thermal balloon ablation) to determine the number of endometrial ablations. We analysed data for patients aged 20 to 60 years.
From 1989-90 to 1994-5 an average of 23 056 hysterectomies a year were performed for menorrhagia in the NHS in England. Since 1995-6 there has been a sustained and substantial fall in this number (figure). In 2002-3, 8332 hysterectomies and 4921 endometrial ablations were performed, representing a reduction of 64% in the number of hysterectomies and a reduction of 43% (13 253 v 23 284) in the total number of operations for menorrhagia compared with 1989-90.
Number of hysterectomies for menorrhagia from 1989-90 to 2002-3 in NHS trusts in England
Comment
The number of hysterectomies for menorrhagia in England has fallen substantially to just over one third (36%) of the number of a decade ago. The fall in hysterectomies is not due to endometrial ablation alone as nearly 10 000 fewer operations are being performed a year.
Active education of good management of menorrhagia and promotion of effective medical management in primary care halves the number of referrals to secondary care but doubles the risk of surgery of those referred,5 suggesting a neutral effect on hysterectomy. The fall cannot be attributed to more operations being performed in the private sector as hysterectomy numbers are falling similarly in that sector (David Horwell, personal communication).
What is already known on this topic
Hysterectomy is a common and effective management for heavy periods
New technologies, including endometrial ablation and the levonorgestrel intrauterine system, have the potential to reduce the number of hysterectomies
What this study adds
The number of hysterectomies performed for heavy periods is only a third that of a decade ago
Although not licensed for treating menorrhagia until January 2001, Mirena has been used as a contraceptive method since May 1995, which coincides with the start of the fall in hysterectomies. The hypothesis is that Mirena is already in widespread use and having a considerable impact on the number of hysterectomies being performed. The epidemiology of Mirena for the management of menorrhagia in primary care remains to be elucidated and should be answered by the ECLIPSE study (International Standard Randomised Controlled Trial Number 86566246 (www.controlled-trials.com/isrctn)). Care should be taken with this interpretation as the use of Mirena for the management of menorrhagia is a relatively new development, and as over half of patients who have a Mirena inserted in randomised studies go on to have a hysterectomy4 we may yet see an increase in surgery over the next three or four years.
Being aware of this very substantial fall in hysterectomies is important and may be helpful in counselling patients before referral. The data also suggest that hysterectomy is no longer the usual management for menorrhagia in secondary care and have great implications for the future surgical training of gynaecologists.
This article was posted on bmj.com on 4 February 2005: http://bmj.com/cgi/doi/10.1136/bmj.38376.505382.AE
Contributors: PCR had the original idea for the study, analysed the data, wrote the paper, and is the guarantor. FM helped with the design and data acquisition.
Funding: None.
Competing interests: PCR has been the recipient of grants from the NHS for research into endometrial ablation and Schering Finland for research into the levonorgestrel intrauterine system (Mirena).
Ethical approval: None required.
References
Coulter A, Bradlow J, Agass M, Martin-Bates C, Tulloch A. Outcomes of referrals to gynaecology outpatient clinics for menstrual problems: an audit of general practice. Br J Obstet Gynaecol 1991;98: 789-96.
Aberdeen Endometrial Ablation Trials Group. A randomised trial of endometrial ablation versus hysterectomy for the treatment of dysfunctional uterine bleeding: outcome at four years. Br J Obstet Gynaecol 1999;106: 360-6.
Hurskainen R, Teperi J, Rissanen P, Aalto A-M, Grenman S, Kivel? A, et al. Clinical outcomes and costs with the levonorgestrel-releasing intrauterine system or hysterectomy for treatment of menorrhagia. Randomised trial 5-year follow-up. JAMA 2004;291: 1456-63.
Kennedy ADM, Sculpher MJ, Coulter A, Dwyer N, Rees M, Horsley S, et al. A multicentre randomised controlled trial assessing the costs and benefits of using structured information and analysis of women's preferences in the management of menorrhagia. Health Technology Assessment 2003;7(8): 1-45.
Fender GRK, Prentice A, Nixon RM, Gorst T, Duffy SW, Day NE, et al. Management of menorrhagia: an audit of practices in the Anglia menorrhagia education study. BMJ 2001;322: 523-4.(Peter C Reid, consultant gynaecologist1,)
Correspondence to: P C Reid Peter.Reid@ldh-tr.anglox.nhs.uk
Twenty years ago 60% of patients with menorrhagia who were referred to a gynaecologist had a hysterectomy as treatment.1 Endometrial ablation was first described in the United Kingdom in 1989 and is a viable surgical alternative to hysterectomy.2 The levonorgestrel intrauterine system (Mirena, Schering Health) is highly effective in reducing menstrual bleeding and has been shown to reduce the numbers of patients proceeding to hysterectomy.3 It would be expected therefore that the numbers of hysterectomies would be falling. Nearly half of women referred to secondary care with menorrhagia, however, express a preference for hysterectomy,4 and it should be recognised that hysterectomy remains an excellent treatment for menstrual problems and brings high levels of patient satisfaction. We aimed to observe trends in the number of hysterectomies performed for menorrhagia in England.
Methods and results
We examined NHS hospital episode statistics compiled from data submitted by over 300 NHS trusts in England for the years 1989-90 to 2002-3. The figures for 2001-2 and 2002-3 have not been adjusted to account for shortfalls in the number of records submitted.
No single international classification of diseases (ICD) code exists for menorrhagia, so data included several codes, from both the ninth and tenth revisions (ICD-9: 626.2, 626.8, and 627.0; and ICD-10: N92.0, N92.1, N92.4, N92.5, and N92.6). Operation codes for hysterectomy are Q07, Q08. We used the codes Q17 and Q16 combined with Y114 (microwave endometrial ablation) and Y118 (thermal balloon ablation) to determine the number of endometrial ablations. We analysed data for patients aged 20 to 60 years.
From 1989-90 to 1994-5 an average of 23 056 hysterectomies a year were performed for menorrhagia in the NHS in England. Since 1995-6 there has been a sustained and substantial fall in this number (figure). In 2002-3, 8332 hysterectomies and 4921 endometrial ablations were performed, representing a reduction of 64% in the number of hysterectomies and a reduction of 43% (13 253 v 23 284) in the total number of operations for menorrhagia compared with 1989-90.
Number of hysterectomies for menorrhagia from 1989-90 to 2002-3 in NHS trusts in England
Comment
The number of hysterectomies for menorrhagia in England has fallen substantially to just over one third (36%) of the number of a decade ago. The fall in hysterectomies is not due to endometrial ablation alone as nearly 10 000 fewer operations are being performed a year.
Active education of good management of menorrhagia and promotion of effective medical management in primary care halves the number of referrals to secondary care but doubles the risk of surgery of those referred,5 suggesting a neutral effect on hysterectomy. The fall cannot be attributed to more operations being performed in the private sector as hysterectomy numbers are falling similarly in that sector (David Horwell, personal communication).
What is already known on this topic
Hysterectomy is a common and effective management for heavy periods
New technologies, including endometrial ablation and the levonorgestrel intrauterine system, have the potential to reduce the number of hysterectomies
What this study adds
The number of hysterectomies performed for heavy periods is only a third that of a decade ago
Although not licensed for treating menorrhagia until January 2001, Mirena has been used as a contraceptive method since May 1995, which coincides with the start of the fall in hysterectomies. The hypothesis is that Mirena is already in widespread use and having a considerable impact on the number of hysterectomies being performed. The epidemiology of Mirena for the management of menorrhagia in primary care remains to be elucidated and should be answered by the ECLIPSE study (International Standard Randomised Controlled Trial Number 86566246 (www.controlled-trials.com/isrctn)). Care should be taken with this interpretation as the use of Mirena for the management of menorrhagia is a relatively new development, and as over half of patients who have a Mirena inserted in randomised studies go on to have a hysterectomy4 we may yet see an increase in surgery over the next three or four years.
Being aware of this very substantial fall in hysterectomies is important and may be helpful in counselling patients before referral. The data also suggest that hysterectomy is no longer the usual management for menorrhagia in secondary care and have great implications for the future surgical training of gynaecologists.
This article was posted on bmj.com on 4 February 2005: http://bmj.com/cgi/doi/10.1136/bmj.38376.505382.AE
Contributors: PCR had the original idea for the study, analysed the data, wrote the paper, and is the guarantor. FM helped with the design and data acquisition.
Funding: None.
Competing interests: PCR has been the recipient of grants from the NHS for research into endometrial ablation and Schering Finland for research into the levonorgestrel intrauterine system (Mirena).
Ethical approval: None required.
References
Coulter A, Bradlow J, Agass M, Martin-Bates C, Tulloch A. Outcomes of referrals to gynaecology outpatient clinics for menstrual problems: an audit of general practice. Br J Obstet Gynaecol 1991;98: 789-96.
Aberdeen Endometrial Ablation Trials Group. A randomised trial of endometrial ablation versus hysterectomy for the treatment of dysfunctional uterine bleeding: outcome at four years. Br J Obstet Gynaecol 1999;106: 360-6.
Hurskainen R, Teperi J, Rissanen P, Aalto A-M, Grenman S, Kivel? A, et al. Clinical outcomes and costs with the levonorgestrel-releasing intrauterine system or hysterectomy for treatment of menorrhagia. Randomised trial 5-year follow-up. JAMA 2004;291: 1456-63.
Kennedy ADM, Sculpher MJ, Coulter A, Dwyer N, Rees M, Horsley S, et al. A multicentre randomised controlled trial assessing the costs and benefits of using structured information and analysis of women's preferences in the management of menorrhagia. Health Technology Assessment 2003;7(8): 1-45.
Fender GRK, Prentice A, Nixon RM, Gorst T, Duffy SW, Day NE, et al. Management of menorrhagia: an audit of practices in the Anglia menorrhagia education study. BMJ 2001;322: 523-4.(Peter C Reid, consultant gynaecologist1,)