There is increasing emphasis on including patients in decision making about treatment. In order to do this, they need to have access to appropriate information about treatment options. The study reported here reports initial work carried out in the development of a decision analysis tool to assist women about treatment for menorrhagia. Women referred to secondary care with a diagnosis of heavy menstrual bleeding were interviewed. Our study shows that women had limited and often inaccurate knowledge of most treatment options. They expressed feelings of diagnostic uncertainty, the need for a ‘label’ for their symptoms and a perception of the failure of the general practitioner (GP) to provide this. The women in our study referred to secondary care with a diagnosis of menorrhagia do not seem to have had their concerns about their menstrual symptoms addressed prior to the referral. In addition, the women in this study do not feel that their GP has communicated a diagnosis to them. Women must be able to feel that they have been diagnosed in order that treatment options can then be properly discussed, and a shared management decision reached. Reasons for the apparent lack of adherence to guidelines are discussed. There is a need for a decision aid for use in primary care to assist women and their doctors in the management of menorrhagia.

Objective: To assess the impact of endometrial ablation on the utilization of hysterectomy in U.S. women with benign uterine conditions.

Methods: Data are from the State Inpatient and Ambulatory Surgery Databases of the Healthcare Cost and Utilization Project for six states, 1990–97. Women who underwent hysterectomy (ICD-9-CM codes 68.3, 68.4, 68.5, 68.51, 68.59, 68.9) and endometrial ablation (68.23, 69.29) and had benign uterine conditions (ICD-9-CM code 218.0 and CCS groupings 47, 171, 173, 175, 176, 215) were extracted. Comparative rates, length of stay, total charges, age, payer, hospital, and teaching status of the hospital are reported.

Results: The rates of hysterectomy decreased in three states: Colorado (37% decrease; 33 per 10,000 women in 1990 to 21 per 10,000 in 1997), Maryland (18% decrease; 17/10,000 in 1990 to 14/10,000 in 1997), and New Jersey (11% decrease; 9/10,000 to 8/10,000); were static in two states (Connecticut and New York) and increased in one state, Wisconsin (11% increase; 19/10,000 in 1994 to 21/10,000 in 1997). The rates for endometrial ablation increased in all states. The ratio of hysterectomy rates to endometrial ablation rates fell in each state across the 7 years. In two states (New York and New Jersey) the rate of endometrial ablation was equivalent to the rate of hysterectomies by 1997. The total combined rate for hysterectomy and endometrial ablation for women with benign uterine conditions for each state increased by more than 10%, with the exception of Maryland, which had an increase of only 5%, and Colorado, which had a decline of 23%.

Conclusions: In the six states studied, the diffusion of endometrial ablation has had a varying impact on hysterectomy rates among women with benign uterine conditions. However, endometrial ablation is used as an additive medical technology rather than a substitute.