Site navigation

Navigation

Specifying an endometrial ablation service

Service components

The key components of an endometrial ablation service are:

  • ensuring appropriate care and onward referral for women with heavy menstrual bleeding (HMB)
  • developing a high-quality endometrial ablation service.

Appropriate care and onward referral for women with HMB

The diagnosis and general management of HMB is described in detail in NICE clinical guideline CG44 on heavy menstrual bleeding. It is clearly important to identify women with HMB to ensure delivery of care based on the best available evidence.

The relationship between medical management, referral and surgery is complex. There are wide variations in patterns of referral into secondary care and in the number of endometrial ablation procedures carried out, despite clinically and cost effective alternatives. Some variation is likely to be due to symptom prevalence, the treatment preferences held by some women and clinical reasons. However, these are unlikely to account for all of the variation.

More effective management of HMB in primary care may reduce both the number of referrals into secondary care and surgery rates[1],[2]. Commissioners may wish to compare local GP referral rates and procedure rates for endometrial ablation with hospital trusts to identify outliers. This provides the opportunity to review current practice and develop an integrated care pathway with clinicians to inform local commissioning, optimise first-line medical management and identify thresholds for endometrial ablation and other surgical treatments. However, commissioners will need to consider the age and ethnicity of their population, as this will have an impact on suitability for treatment options. Changing clinical practice in primary care is likely to require education and training.

Surgical treatment is usually offered to women with HMB who do not respond to pharmaceutical treatment. Because hysterectomy is associated with perioperative and postoperative complications, it is important to identify those women for whom endometrial ablation is the most appropriate treatment option in order to prevent unnecessary invasive surgery and to manage service demand.

Second-generation endometrial ablation techniques offer simpler, quicker and more effective treatment options for HMB than hysterectomy and are associated with shorter hospital stays, which is likely to contribute to the management of patient waiting times. Pharmaceutical treatment should be considered where no structural or histological abnormality is present, or for fibroids less than 3 cm in diameter which are causing no distortion of the uterine cavity. Endometrial ablation is preferable to hysterectomy and suitable for women with HMB who have a normal uterus and also those with small uterine fibroids (less than 3 cm diameter).

The impact of second-generation endometrial ablation techniques on the NHS budget will depend on the number of women eligible for each technique and take up rates.

Developing a high-quality endometrial ablation service

Information on the detailed requirements of an endometrial ablation service is available from the NICE technology appraisal TA78 on endometrial ablation techniques for heavy menstrual bleeding and NICE clinical guideline CG44 on heavy menstrual bleeding, which recommends that:

  • endometrial ablation may be offered as an initial treatment for HMB after full discussion with the woman of the risks and benefits and of other treatment options
  • a woman with HMB referred to specialist care should be given information before her outpatient appointment (see Understanding NICE guidance)
  • all women considering endometrial ablation should have access to a second-generation ablation technique
  • maintenance of surgical imaging or radiological skills requires a robust clinical governance framework
  • providers should ensure when purchasing any second-generation technique from the list recommended by NICE for consideration (see NICE clinical guideline CG44) that they buy the least expensive available option.

Commissioners may wish to consider delivering an endometrial ablation service for the care of women with HMB in a number of different ways, and mixed models of provision may be appropriate across a local health economy. Second-generation endometrial ablation techniques are potentially less invasive than first-generation techniques, and they provide the opportunity to deliver endometrial ablation under local anaesthetic in an outpatient setting; however, this practice is not universal in the NHS. The Shifting care closer to home: care closer to home demonstration site – report of the speciality subgroups identifies innovative ways of delivering gynaecology services, whilst improving patient access. These include outpatient-based services, direct access to some procedures or a primary care led model of integrated care and consultants working in primary care, which could reduce the need for outpatient attendance while improving patient experience and maintaining quality of care[3]. The examples are offered in order to share local practice, but NICE makes no judgement on the compliance of services with its guidance.

Local stakeholders, including service users, should be involved in determining what is needed from an endometrial ablation service in order to meet local needs. The service should be patient-centred and integrated with other elements of care for women with HMB.

The service specification needs to consider:

  • the required competencies of, and training for, staff responsible for providing the service
  • the expected number of patients (this should take into account how quickly any changes in service provision are likely to take place)
  • ease of access to endometrial ablation within a geographical area; commissioners should engage with service users, and other relevant individuals and organisations locally
  • care and referral pathways
  • information and audit requirements, including IT support and infrastructure
  • planned service improvement, including redesign, quality, equitable access, and referral-to-treatment times according to the 18 week patient pathway or equitable waiting times locally for those services currently outside 18 weeks. See Choice of scan: guidance
  • service monitoring criteria.

Useful sources of information may include:

References

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

2. 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.

3. Julian S, Nicholas J, Naftalin et al. (2007) An integrated care pathway for menorrhagia across the primary–secondary interface: patient’s experience, clinical outcomes, and service utilisation. Quality and Safety in Health Care 16: 110-5.