Abstract
OBJECTIVE—To investigate the management of menorrhagia in primary care and its impact on referral and hysterectomy rates. DESIGN—Prospective observational study. SETTING—11 general practices from the Somerset Morbidity Project. SUBJECTS—885 women consulting their general practitioner with menorrhagia over four years. MAIN OUTCOME MEASURES—Proportions of these women investigated and treated with drugs in primary care, referred to a gynaecologist and undergoing operative procedures. The relation between investigation and prescribing in primary care and referral to and surgery in secondary care. RESULTS—Less than half of women had a vaginal examination (42%, 95% CI 39% to 45%), or a full blood count (39%, 95% CI 36% to 43%). Almost a quarter of women, 23% (95% CI 20% to 26%), received no drugs and 37% (95% CI 34% to 40%) received norethisterone. Over a third, 38% (95% CI 34% to 40%), of women were referred, and once referred 43% (95% CI 38% to 48%) of women were operated on. Women referred to a gynaecologist were significantly more likely to have received tranexamic acid and/or mefenamic acid in primary care (χ2=16.4, df=1, p<0.001). There were substantial between practice variations in management, for example in prescribing of tranexamic acid and/or mefenamic acid (range 16% to 72%) and referral to gynaecology (range 24% to 52%). There was a significant association between high referral and high operative rates (Spearman's correlation coefficient=0.86, p=0.001). CONCLUSIONS—Substantial differences in management exist between practices when investigating and prescribing for menorrhagia in primary care. Rates of prescribing of effective medical treatment remain low. The decision to refer a woman impacts markedly on her chances of subsequently being operated on. Effective management in primary care may not reduce referral or hysterectomy rates.
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Selected References
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- Bonnar J., Sheppard B. L. Treatment of menorrhagia during menstruation: randomised controlled trial of ethamsylate, mefenamic acid, and tranexamic acid. BMJ. 1996 Sep 7;313(7057):579–582. doi: 10.1136/bmj.313.7057.579. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 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 records. Br J Obstet Gynaecol. 1991 Aug;98(8):789–796. doi: 10.1111/j.1471-0528.1991.tb13484.x. [DOI] [PubMed] [Google Scholar]
- Coulter A., Kelland J., Peto V., Rees M. C. Treating menorrhagia in primary care. An overview of drug trials and a survey of prescribing practice. Int J Technol Assess Health Care. 1995 Summer;11(3):456–471. doi: 10.1017/s0266462300008679. [DOI] [PubMed] [Google Scholar]
- Coulter A., McPherson K., Vessey M. Do British women undergo too many or too few hysterectomies? Soc Sci Med. 1988;27(9):987–994. doi: 10.1016/0277-9536(88)90289-4. [DOI] [PubMed] [Google Scholar]
- Coulter A., Peto V., Doll H. Patients' preferences and general practitioners' decisions in the treatment of menstrual disorders. Fam Pract. 1994 Mar;11(1):67–74. doi: 10.1093/fampra/11.1.67. [DOI] [PubMed] [Google Scholar]
- Coulter A., Peto V., Jenkinson C. Quality of life and patient satisfaction following treatment for menorrhagia. Fam Pract. 1994 Dec;11(4):394–401. doi: 10.1093/fampra/11.4.394. [DOI] [PubMed] [Google Scholar]
- Eccles M., Ford G. A., Duggan S., Steen N. Are postal questionnaire surveys of reported activity valid? An exploration using general practitioner management of hypertension in older people. Br J Gen Pract. 1999 Jan;49(438):35–38. [PMC free article] [PubMed] [Google Scholar]
- Fender G. R., Prentice A., Gorst T., Nixon R. M., Duffy S. W., Day N. E., Smith S. K. Randomised controlled trial of educational package on management of menorrhagia in primary care: the Anglia menorrhagia education study. BMJ. 1999 May 8;318(7193):1246–1250. doi: 10.1136/bmj.318.7193.1246. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Irvine G. A., Campbell-Brown M. B., Lumsden M. A., Heikkilä A., Walker J. J., Cameron I. T. Randomised comparative trial of the levonorgestrel intrauterine system and norethisterone for treatment of idiopathic menorrhagia. Br J Obstet Gynaecol. 1998 Jun;105(6):592–598. doi: 10.1111/j.1471-0528.1998.tb10172.x. [DOI] [PubMed] [Google Scholar]
- Lilford R. J. Hysterectomy: will it pay the bills in 2007? BMJ. 1997 Jan 18;314(7075):160–161. doi: 10.1136/bmj.314.7075.160. [DOI] [PMC free article] [PubMed] [Google Scholar]
- O'Connell D. L., Henry D., Tomlins R. Randomised controlled trial of effect of feedback on general practitioners' prescribing in Australia. BMJ. 1999 Feb 20;318(7182):507–511. doi: 10.1136/bmj.318.7182.507. [DOI] [PMC free article] [PubMed] [Google Scholar]
- O'Flynn N., Britten N. Menorrhagia in general practice--disease or illness. Soc Sci Med. 2000 Mar;50(5):651–661. doi: 10.1016/s0277-9536(99)00318-4. [DOI] [PubMed] [Google Scholar]
- Oxman A. D., Thomson M. A., Davis D. A., Haynes R. B. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ. 1995 Nov 15;153(10):1423–1431. [PMC free article] [PubMed] [Google Scholar]
- Pearson N., O'Brien J., Thomas H., Ewings P., Gallier L., Bussey A. Collecting morbidity data in general practice: the Somerset morbidity project. BMJ. 1996 Jun 15;312(7045):1517–1520. doi: 10.1136/bmj.312.7045.1517. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Shaw R. W., Brickley M. R., Evans L., Edwards M. J. Perceptions of women on the impact of menorrhagia on their health using multi-attribute utility assessment. Br J Obstet Gynaecol. 1998 Nov;105(11):1155–1159. doi: 10.1111/j.1471-0528.1998.tb09968.x. [DOI] [PubMed] [Google Scholar]