Management of menorrhagia in primary care—impact on referral and hysterectomy: data from the Somerset Morbidity Project

• Published in: Journal of epidemiology and community health (1979) Vol. 54; no. 9; pp. 709 - 713
• Main Authors: Grant, Clare, Gallier, Lesley, Fahey, Tom, Pearson, Nicky, Sarangi, Joyshri
• Format: Journal Article
• Language: English
• Published: London BMJ Publishing Group Ltd 01.09.2000; British Medical Association; BMJ; BMJ Publishing Group LTD; BMJ Group
• Subjects: Adult; Biological and medical sciences; Correlation coefficient; England - epidemiology; Female; Female genital diseases; General practice; Gynecology; Gynecology. Andrology. Obstetrics; Humans; Hysterectomy; Hysterectomy - statistics & numerical data; Managed care; Medical referrals; Medical sciences; Medical treatment; Menorrhagia; Menorrhagia - epidemiology; Menorrhagia - therapy; Middle Aged; Morbidity; Non tumoral diseases; Observational studies; Practice Patterns, Physicians; Prescription drugs; Prevalence; Primary care; Primary Health Care; Prospective Studies; Public Health Policy and Practice; Studies; Womens health; United Kingdom; Europe; England; United Kingdom > UK; Human; Menstruation disorders; Correlation; Health staff; Primary health care; Rate; Physician; Hysterectomy; Epidemiology; Hemorrhage; Menorrhagia; Female genital diseases; Clinical management; Treatment; Surgery; Professional practice; Uterine diseases; Female; Public health
• ISSN: 0143-005X; 1470-2738
• DOI: 10.1136/jech.54.9.709

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.