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Commissioning an endometrial ablation service

Endometrial ablation is a recommended treatment option for women with heavy menstrual bleeding (HMB), where surgical intervention is appropriate. It provides an alternative to hysterectomy in selected cases.

There is a wide variation in population-based rates of endometrial ablation. Procedure rates among primary care organisations in England vary by a factor of 14 - from fewer than 10 per 100,000 to nearly 140 per 100,000 population[1]. The Chief Medical Officer report in 2005 identified that if the average rate of hysterectomy in England could be reduced to that achieved in the 20% of the country with the lowest current rates, then 5,900 operations, costing £15 million, could be avoided per annum. Although the costs of alternative treatments would need to be taken into account, the financial savings would still be substantial[2].

HMB, also known as menorrhagia, affects around one in three women[3]. It is defined as excessive menstrual blood loss that interferes with the physical, emotional, social and material quality of a woman’s life. HMB is a common reason for GP consultation, referral to secondary care and subsequent surgery[4].

Pharmaceutical intervention, including the use of levonorgestrel-releasing intrauterine system (LNG-IUS), is usually the first-line treatment for women with HMB. Optimal medical management of HMB improves patient choice and provides an alternative to surgery. It also reduces the cost of HMB to health services and its detrimental effects on quality of life[5]. Ineffective treatment of HMB is likely to lead to referral and a high chance of hysterectomy[6].

Surgery may be indicated for women with failed pharmaceutical treatments or for whom medical treatment is contraindicated. For some women, endometrial ablation offers a less invasive alternative to hysterectomy, which has been traditionally regarded as the definitive surgical treatment for HMB.

Endometrial ablation is associated with shorter operation times, shorter hospital stays, quicker recovery times and fewer postoperative complications than hysterectomy, and the satisfaction rate is comparable with that of hysterectomy.

Through developing integrated care pathways and effective commissioning of services for women with HMB based on NICE clinical guideline CG44 on heavy menstrual bleeding, it is anticipated that where women are given the choice of clinically appropriate treatment options, hysterectomy rates will be reduced further[6].

Benefits

The potential benefits of robustly commissioning an appropriate endometrial ablation service for the care of women with HMB include:

  • Reducing the need for hysterectomy[6], which is associated with perioperative and postoperative complications. Any interventions for the care of women with HMB should aim to improve quality of life measures through implementing the recommendations outlined in NICE clinical guideline CG44 on heavy menstrual bleeding and NICE technology appraisal TA78 on endometrial ablation techniques for heavy menstrual bleeding.
  • Improving patient-centred care and providing efficient clinical management of the care of women with HMB by optimising pharmaceutical management and reducing the need for referral onto specialist services[4],[6]. See also the commissioning guides on intrauterine devices and the intrauterine system and hysterectomy service.
  • Reducing inequalities, and improving access to services that provide endometrial ablation.
  • Increasing patient choice of treatment options, and improving partnership working, patient experience and engagement.
  • Better value for money, through helping commissioners to manage their commissioning budgets more effectively and implementing more cost effective treatments – this may include opportunities for clinicians to undertake local service redesign to meet local requirements in novel ways.

Key clinical issues

Key clinical issues in providing an effective endometrial ablation service for the care of women with HMB are:

  • Accurately diagnosing and assessing all women presenting with HMB, and ensuring there is access to, and sufficient capacity for, ultrasound and hysteroscopy.
  • Ensuring that women have access to information on clinically appropriate treatment options prior to their outpatient appointment. Women should have adequate time and support from healthcare professionals in the decision making process, and be made aware of the impact on fertility of any planned procedure.
  • Ensuring that appropriate referral pathways are in place to support equity of access to endometrial ablation services.
  • Ensuring that care is integrated with other services for women with HMB to ensure continuity of care.
  • Providing a quality assured service.

National priorities

National priorities and initiatives relevant to commissioning an endometrial ablation service for the care of women with HMB include:

Although many or all of these priorities may be relevant to the services nationally, your local service redesign may address only one or two of them.

References

1. Information from hospital episode statistics. The Information Centre for Health and Social Care 2007.

2. Department of Health (2006) The Chief Medical Officer on the state of the public health. Annual report 2005. London: Stationery Office

3. Kennedy ADM, Sculpher MJ, Coulter A et al. (2003) 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 7(8).

4.Grant C, Gallier L, Fahey T et al (2000) Management of menhorrhagia in primary care - impact on referral and hysterectomy: data from the Somerset Morbidity Project. Journal of Epidemiology and Community Health 54: 709–13.

5. O’Leary JA, Tejura H (2005) Medical management of menorrhagia. Reviews in Gynaecological Practice 5: 159–65.

6. Nixon RM, Duffy SW, Fender GRK et al. (2001) Randomization at the level of primary care practice: use of pre-intervention data and random effects models. Statistics in Medicine 20: 1727-38.