Women's Health Focus Report

Why is this important?

Hysterectomy is an operation to remove the uterus (womb) through abdominal, vaginal or laparoscopic (keyhole) surgery. Sometimes the ovaries and fallopian tubes are removed when hysterectomy is performed. 

Most hysterectomies are performed for benign (non-cancer) gynaecological conditions, of which heavy menstrual bleeding is one of the most common, followed by genital prolapse and fibroids.^{1, 2}

Heavy menstrual bleeding is excessive loss of menstrual blood that interferes with a woman’s physical, emotional, social and material quality of life. It can occur alone or in combination with other symptoms, such as pain², and affects about 1 in 4 women of reproductive age.³ It is one of the most common gynaecological reasons for consultations with GPs.⁴

Although hysterectomy stops menstrual bleeding, it is a major surgical procedure and generally not recommended unless less-invasive options fail or are inappropriate, or if the woman chooses it.^{5, 6} 

Hysterectomy usually requires admission to hospital and 4–6 weeks’ recovery time. In some cases, it can be followed by short-term² and long-term complications⁷ and unplanned readmission.⁸

The Heavy Menstrual Bleeding Clinical Care Standard first released in 2017 and updated in 2024, describes the clinical care that women should be offered for heavy menstrual bleeding. It advises that, where appropriate, treatments that leave the uterus in place, such as oral medicines, the 52mg levonorgestrel-releasing intrauterine device (LNG-IUD), endometrial ablation, or other uterine-preserving procedures appropriate to the woman’s condition, are considered before hysterectomy.⁵ 

Despite these recommendations, hysterectomy rates in Australia are higher than in comparable Organisation for Economic Co-operation and Development (OECD) countries. In 2019, there were 215 hysterectomies per 100,000 women in Australia, compared with 126 in New Zealand and 132 in the United Kingdom (for cancer and non‑cancer diagnoses).⁹ Comparisons using more recent data are complicated by the varying impacts of COVID-19 on elective surgery rates in other countries.

Mapping variation in hysterectomy is a tool to investigate the appropriateness of care for heavy menstrual bleeding. In 2017, the Second Australian Atlas of Healthcare Variation (Second Atlas) identified a seven-fold difference between the lowest and highest rates of hysterectomy in local areas across Australia. Rates were much higher in regional areas than in major cities and remote areas¹⁰, suggesting that alternatives to hysterectomy for women with heavy menstrual bleeding were not being consistently used across Australia.

It is important to revisit hysterectomy rates because of the geographical variation reported in the Second Atlas, Australia’s high rate compared to other countries and continuing concerns about potential harm when there may be more appropriate options. Reducing inappropriate use of hysterectomy would also have benefits in terms of health system and environmental sustainability, as surgery is resource intensive and generates significant waste.^{11, 12} 

What this report examines

This report examines hospitalisations for hysterectomy for benign (non-cancer) gynaecological conditions from 2014–15 to 2021–22. Rates are based on the number of hospitalisations for hysterectomy per 100,000 women aged 15 years and over.

The report presents data and visualisations over eight years for:

• National, state and territory trends
• Primary Health Network (PHN) trends
• Local area (SA3) trends
• Remoteness and socioeconomic status
• Indigenous status (national, state and territory)
• Private and public funding status (national, state and territory).

Data are reported according to where patients live, not where the procedure was carried out. 

The data are sourced from the National Hospital Morbidity Database and include both public and private hospitals. 

Data are age standardised to allow comparisons between geographic areas with different age structures. Data quality issues – for example, the accuracy of Indigenous status in datasets – could influence the variation seen.

For more information about the data, see the data resources. 

What did we find?

Hospitalisation rates for hysterectomy decreased nationally and in all states and territories between 2014–15 and 2021–22.

National trends 

• There was a 20% decrease in the rate of hospitalisations for hysterectomy. In 2014–15, there were 27,552 hospitalisations (290 per 100,000 women) compared to 24,030 hospitalisations in 2021–22 (231 per 100,000 women)
• The rate decreased throughout the analysis period, except for 2020–21, when there was an increase on the previous year
• In 2021–22, there was a five-fold difference between the local area with the highest rate and the local area with the lowest rate. This was 31% lower than in 2014–15, when there was a seven-fold difference.

State and territory trends 

• Rates fell in all states and territories
• The largest decrease (31%) was in the Northern Territory and the smallest decrease (12%) was in Queensland
• Queensland had the highest rate of any state or territory in both 2014–15 (326 per 100,000 women) and 2021–22 (286 per 100,000 women)
• The Australian Capital Territory had the lowest rate of any state or territory in 2014–15 (223 per 100,000 women) and the Northern Territory had the lowest rate in 2021–22 (163 per 100,000 women)
• In all states and territories, other than South Australia, rates increased in 2020–21 and decreased in 2021–22
• Rates in Tasmania and Western Australia increased from 2014–15 to 2016–17 and then trended down
• Although still comparatively high, regional Victoria recorded substantial reductions in rates.

Remoteness

• Rates were consistently higher in regional areas compared to major cities and remote areas. 

Socioeconomic status

• In major cities and regional areas, the least socioeconomically disadvantaged group consistently recorded the lowest rates
• In remote areas, the most socioeconomically disadvantaged group consistently recorded the lowest rates.

Primary Health Networks (PHNs)

• Rates decreased in all PHNs, except Gold Coast PHN, which recorded a 5% increase
• Western Victoria PHN had the highest PHN rate in 2014–15 (432 per 100,000 women) and Darling Downs and West Moreton PHN in Queensland had the highest PHN rate in 2021–22 (353 per 100,000 women)
• Northern Sydney PHN in New South Wales had the lowest PHN rate in 2014–15 (176 per 100,000 women) and Northern Territory PHN had the lowest PHN rate in 2021–22 (156 per 100,000 women).

Indigenous status

• Nationally, in 2021–22, the rate for First Nations women (251 per 100,000 women) was about 9% higher than the rate for other Australian women (231 per 100,000 women)
• Between 2014–15 and 2021–22, the rate for First Nations women increased in Western Australia and New South Wales compared to other Australian women in these states.

Patient funding status

• Around 60% of hospitalisations were for privately funded patients (in private and public hospitals) throughout the analysis period
• The highest proportion of hospitalisations for publicly funded patients was 84% in 2020–21, in the Australian Capital Territory. 

Consistently high and low local areas 

The data identified local areas (SA3s) that had consistently high or low rates of hysterectomy:

• Four of the 340 SA3s in Australia had consistently high rates (that is, rates in the top 10% for the five most recent reporting years). Two of these SA3s were in inner regional Victoria; one in inner regional Western Australia and one in Perth, Western Australia
• Nine SA3s had consistently low rates (that is, rates in the bottom 10% for the five most recent reporting years). All of these SA3s were in major cities: one in New South Wales and eight in Victoria. Six of these SA3s were in areas of least socioeconomic disadvantage (highest SES quintile).

Interpretation

Effect of COVID-19

Elective surgery cancellations and postponements related to the COVID-19 pandemic are likely to have affected rates of hysterectomy hospitalisations from early 2020; the timing and extent of restrictions varied between states and territories.^{13, 14} All states and territories other than South Australia had an increase in the rate of hysterectomy hospitalisations in 2020–21. This is likely due to health services catching up on elective surgeries after COVID-19 restrictions eased. 

Trends over time

The 20% decrease nationally in the rate of hysterectomy hospitalisations reversed the trend reported in the Second Atlas, which found that the rate increased between 2012–13 and 2014–15. There was a downward trend in the rate of hospitalisations for hysterectomy between 2014–15 and 2018-19 before the COVID-19 pandemic.

While the latest data show a reduction in the geographical variation, there is still a five-fold difference between the local area with the highest rate compared to the area with the lowest rate. This could reflect variation in access to the procedure. 

Continuing trends seen in the Second Atlas, regional areas had higher rates compared to major cities and remote areas, and rates were lower in areas of least socioeconomic disadvantage.

The 31% reduction in the rate of hysterectomy in the Northern Territory might be due to improvements in access to women’s health and gynaecological services. Rates for First Nations women in the Northern Territory were consistently around half that of other Australian women during the analysis period.

Reasons for variation

Lower rates of hysterectomy in some areas could be partly due to the use of other treatments for heavy menstrual bleeding. Factors that may have contributed to variation in hysterectomy rates include the following.

Consumer factors

Differences in:

• Awareness of the significance of heavy menstrual bleeding and treatment options
• Knowledge of hysterectomy alternatives
• Cultural factors, such as family views, which may influence decision-making
• Socioeconomic factors, for example, ability to pay out-of-pocket expenses for other treatment and ability to travel for specialist appointments
• Private health insurance coverage
• Access to trusted gynaecologists, GPs and other primary care practitioners.

Clinician factors

Differences in:

• Clinicians’ preferences¹⁶
• Knowledge of recommended management of heavy menstrual bleeding and the risks and benefits of treatment options
• Access to training in hysterectomy procedures
• Clinicians’ skills, experience and confidence in providing alternatives to hysterectomy for heavy menstrual bleeding, such as inserting LNG-IUDs^{17, 18}
• MBS rebates for hysterectomy compared with insertion of LNG-IUDs
• Cost barriers for GPs to insert LNG-IUDs.¹⁸

Health service organisation factors

Differences in:

• Availability and accessibility of appropriate services to treat heavy menstrual bleeding including primary care, hysterectomy alternatives and specialist care
• Availability and accessibility of ancillary services, such as physiotherapy, for the conservative management of genital prolapse (hysterectomy may be used to treat this condition where conservative measures have failed)
• Referral pathways – availability or accessibility of hysterectomy alternatives
• Access to good quality consumer resources and support
• Ability to offer culturally safe care, such as access to an Aboriginal and Torres Strait Islander health worker or practitioner
• Access to hysterectomy alternatives in the public system and training in those procedures
• Opportunities, training and funding for more nurses or other health practitioners to insert LNG-IUDs
• Evidence gaps, such as lack of understanding of women’s experiences of care and limited capacity to monitor the quality of care at a system level. 

What is driving higher rates of hysterectomy in regional areas?

Regional areas continue to record the highest rates of hysterectomy hospitalisations compared to inner-city areas, which have the lowest rates.

These data may reflect differences in access to healthcare services that provide less-invasive treatment options, such as to GPs who insert LNG-IUDs.

The higher rates may also reflect women’s needs and preferences. For example, women in regional areas may be more likely than women in inner-city areas to opt for hysterectomy to achieve a permanent solution for heavy menstrual bleeding, although there is no evidence for this. Women may be less willing to trial therapies if they have to travel long distances to access specialist care. 

Also, on average, women in regional areas give birth at an earlier age than those in major cities¹⁵, and may finish having children at a younger age (in their 20s and early 30s). Faced with a menstrual problem for 20 years or more, these women may be more likely to choose a definitive solution if they are not planning more pregnancies. 

What has changed?

Factors that may have contributed to the lower rate of hysterectomy in 2021-22 include the following.

Heavy Menstrual Bleeding Clinical Care Standard

In 2017, in response to high rates of variation in hysterectomy found in the Second Atlas, the Australian Commission on Safety and Quality in Heath Care (the Commission) published the first national clinical care standard on the management of heavy menstrual bleeding.¹⁹

The Heavy Menstrual Bleeding Clinical Care Standard (the Standard) recommended that less invasive treatments, such as the LNG-IUD and endometrial ablation, should be considered before hysterectomy. The Standard has been included as a key resource in many PHNs’ HealthPathways for heavy menstrual bleeding management.

The Standard was reviewed and updated and the second version released in 2024. 

Consumer education and awareness

As well as the clinical care standard, which includes information for consumers, new resources and media attention have helped to focus attention on heavy menstrual bleeding and treatment options including alternatives to hysterectomy: 

• The Commission produced a factsheet to explain what the Heavy Menstrual Bleeding Clinical Care Standard means for women exploring treatment options²⁰
• The Royal Australian and New Zealand College of Obstetricians and Gynaecologists updated its patient information about heavy menstrual bleeding.²¹

Health service models of care

Safer Care Victoria provided resources to support consumers and healthcare providers to develop a shared understanding of opportunities and barriers to improve the management of heavy menstrual bleeding.²² 

In New South Wales, menopause clinics may have contributed to the lower rate of hysterectomy in some areas of the state by increasing awareness of, and access to, alternative treatments for heavy menstrual bleeding. Two well-established clinics are in areas of Sydney that have had consistently low rates of hysterectomy. 

Increased use of other treatments

The national rate of hospitalisations for endometrial ablation increased by 10% over the analysis period. This increase in an alternative procedure may have contributed to the reduction in the rate of hysterectomy hospitalisations.

The use of other treatments for heavy menstrual bleeding and other benign gynaecological conditions may also have increased, but data are not available. For example, increased use of LNG-IUDs may have contributed to the decrease in hysterectomy rates. However, this is not known because Pharmaceutical Benefits Scheme data do not differentiate between the use of LNG-IUDs for contraception and the treatment of heavy menstrual bleeding.

Resources

Australian Commission on Safety and Quality in Health Care

• Heavy Menstrual Bleeding Clinical Care Standard 2024
• Heavy Menstrual Bleeding Clinical Care Standard – Consumer guide
• Heavy Menstrual Bleeding Clinical Care Standard – Clinician fact sheet
• Heavy Menstrual Bleeding Clinical Care Standard – Healthcare services information sheet

Royal Australian and New Zealand College of Obstetricians and Gynaecologists

• Hysterectomy
• Endometrial Ablation
• Heavy Menstrual Bleeding

References

1. Yusuf F, Leeder S, Wilson A. Recent estimates of the incidence of hysterectomy in New South Wales and trends over the past 30 years. Aust N Z J Obstet Gynaecol. 2016;56(4):420-425.
2. Spilsbury K, Hammond I, Bulsara M, Semmens JB. Morbidity outcomes of 78,577 hysterectomies for benign reasons over 23 years. BJOG. 2008 Nov;115(12):1473-1483.
3. Shapley M, Jordan K, Croft PR. An epidemiological survey of symptoms of menstrual loss in the community. Br J Gen Pract. 2004 May;54(502):359-363.
4. Britt H, Miller GC, Henderson J, Bayram C, Harrison C, Valenti L, et al. General practice activity in Australia 2015-16. Sydney: Sydney University Press, 2016.
5. Australian Commission on Safety and Quality in Health Care. Heavy Menstrual Bleeding Clinical Care Standard. Sydney: ACSQHC, 2024.
6. National Institute for Health and Care Excellence. Heavy menstrual bleeding: assessment and management (NG88). London: NICE, 2018 [updated May 2021].
7. Madueke-Laveaux OS, Elsharoud A, Al-Hendy A. What we know about the long-term risks of hysterectomy for benign indication - a systematic review. J Clin Med. 2021;10(22).
8. Australian Institute of Health and Welfare. Admitted patient care: 2017-18. Australian hospital statistics. Canberra: AIHW; 2019.
9. Organisation for Economic Co-operation and Development. Healthcare utilisation: surgical procedures – hysterectomy [Internet]. OECD, data extracted 7 Mar 2024. Available from: stats.oecd.org/index.aspx?queryid=30167#.
10. Australian Commission on Safety and Quality in Health Care and Australian Institute of Health and Welfare. The Second Australian Atlas of Healthcare Variation. Sydney: ACSQHC, 2017.
11. Rizan C, Steinbach I, Nicholson R, Lillywhite R, Reed M, Bhutta MF. The carbon footprint of surgical operations: a systematic review. Ann Surg. 2020;272(6):986-995.
12. Ramani S, Hartnett J, Karki S, Gallousis SM, Clark M, Andikyan V. Carbon dioxide emissions and environmental impact of different surgical modalities of hysterectomies. JSLS. 2023;27(3):e2023.00021.
13. Australian Institute of Health and Welfare. Elective surgery activity. Canberra: AIHW, 2020 [cited 12 Mar 2024]. Available from: https://www.aihw.gov.au/reports-data/myhospitals/intersection/activity/eswt.
14. Australian Institute of Health and Welfare. Australia's hospitals at a glance - web report. Canberra: AIHW, 2023 [cited 7 Mar 2024]. Available from: https://www.aihw.gov.au/getmedia/8c50762e-f614-438d-86d5-713d19203686/aihw-hse-253-hospitals-at-a-glance-dec23.pdf.
15. Australian Bureau of Statistics. Births, Australia 2022. Table 4.1 Births, summary, remoteness areas (ASGS 2021)-2012 to 2022. Canberra: ABS, 2023 [cited 12 Mar 2024]. Available from: https://www.abs.gov.au/statistics/people/population/births-australia/latest-release.
16. Higgins C, McDonald R, Mol BW. Indications and surgical route for hysterectomy for benign disorders: a retrospective analysis in a large Australian tertiary hospital network. Arch Gynecol Obstet. 2022 Dec;306(6):2027-2033.
17. Mazza D, Watson CJ, Taft A, Lucke J, McGeechan K, Haas M, et al. Pathways to IUD and implant insertion in general practice: a secondary analysis of the ACCORd study. Aust J Prim Health. 2023;29(3):222-228.
18. Stewart M, Digiusto E, Bateson D, South R, Black KI. Outcomes of intrauterine device insertion training for doctors working in primary care. Aust Fam Physician. 2016;45(11):837–41.
19. Australian Commission on Safety and Quality in Health Care. Heavy Menstrual Bleeding Clinical Care Standard. Sydney: ACSQHC, 2017.
20. Australian Commission on Safety and Quality in Health Care. Heavy Menstrual Bleeding: Clinical Care Standard - Consumer fact sheet. Sydney: ACSQHC, 2017.
21. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Heavy Menstrual Bleeding. Melbourne: RANZCOG, 2018.
22. Safer Care Victoria. Best Care for Heavy Menstrual Bleeding [Internet]. Melbourne: SCV, 2022 [cited 10 Dec 2023]. Available from: https://www.safercare.vic.gov.au/100000lives/projects/best-care-for-heavy-menstrual-bleeding.

Why is this important?

Endometrial ablation is an operation that uses heat to destroy the inner lining (endometrium) of the uterus (womb) but leaves the uterus in place. Generally, the procedure requires a light general anaesthetic and is performed in a day-stay surgery unit or hospital.¹

Endometrial ablation is used to treat heavy menstrual bleeding, which is excessive loss of menstrual blood that interferes with a woman’s physical, emotional, social and material quality of life. It can occur alone or in combination with other symptoms, such as pain², and affects about 1 in 4 women of reproductive age.³ Heavy menstrual bleeding is one of the most common reasons for gynaecological consultations with GPs.⁴

The Heavy Menstrual Bleeding Clinical Care Standard, first released in 2017 and updated in 2024, describes the clinical care that women should be offered for heavy menstrual bleeding. It advises that, where appropriate, treatments that leave the uterus in place, such as oral medicines, the 52 mg levonorgestrel-releasing intrauterine device (LNG-IUD), endometrial ablation or other uterine-preserving procedures appropriate to the woman’s condition, should be considered before hysterectomy.⁵ 

Endometrial ablation is generally not as effective as hysterectomy in managing heavy menstrual bleeding, but recovery is likely to be shorter and the risk of short-term adverse events is lower than with hysterectomy.⁶ 

Mapping variation in endometrial ablation is a tool to investigate the appropriateness of care for heavy menstrual bleeding. In 2017, the Second Australian Atlas of Healthcare Variation (Second Atlas) found a 21-fold difference between the lowest and highest rates of endometrial ablation in local areas across Australia.⁷ These data suggested that endometrial ablation was not being consistently used for women with heavy menstrual bleeding. 

It is important to revisit endometrial ablation rates because of the high geographical variation shown in the Second Atlas and its place as a less invasive and safer alternative to hysterectomy for women who do not wish to retain fertility.

What this report examines

This report examines hospitalisations for endometrial ablation for women aged 15 years and over from 2013–16 to 2019–22. Rates are based on the number of hospitalisations for endometrial ablation per 100,000 women aged 15 years and over.

The report presents data over nine years for:

• National, state and territory trends
• PHN trends
• Local area (SA3) trends
• Remoteness and socioeconomic status
• Indigenous status (national, state and territory)
• Private and public funding status (national, state and territory).

Data are reported according to where patients live, not where the procedure was carried out. 

The data are sourced from the National Hospital Morbidity Database and include both public and private hospitals. 

Data are age standardised to allow comparisons between geographic areas with different age structures. Data quality issues – for example, the accuracy of Indigenous status in datasets – could influence the variation seen.

For more information about the data, see the data resources.

What did we find?

Endometrial ablation rates increased nationally and in most states and territories between 2013–16 and 2019–22.

National trends 

• There was a 10% increase in the rate of hospitalisations between 2013–16 and 2019–22. In 2013–16, there were 31,857 hospitalisations (119 per 100,000 women) compared to 37,239 hospitalisations in 2019–22 (131 per 100,000 women)
• After an initial increase, the rate of hospitalisations plateaued from 2016–19 to 
  2019–22
• In 2019–22, there was a 20-fold difference between the local area with the highest rate and the area with the lowest rate. This variation was 9% higher than in 2013–16, when there was an 18-fold difference. 

State and territory trends 

• Rates increased in most states and territories
• Western Australia had the highest rate of any state and territory in both 2013–16 (164 per 100,000 women) and 2019–22 (181 per 100,000)
• The Northern Territory had the lowest rate of any state and territory in both 2013–16 (70 per 100,000 women) and 2019–22 (91 per 100,000 women)
• Tasmania and Victoria were the only states to show a downward trend.

Remoteness

• Rates were generally higher in regional areas than in major cities and remote areas.

Socioeconomic status

• Rates were consistently higher in regional areas with most socioeconomic disadvantage.

Primary Health Networks (PHNs)

• Country WA PHN in Western Australia had the highest PHN rate in 2013–16 (206 per 100,000 women). It was also one of two PHNs to have the highest rate in 2019–22 (215 per 100,000 women), along with the Central Queensland, Wide Bay and Sunshine Coast PHN
• Western Sydney PHN in New South Wales had the lowest PHN rate in 2013–16 
  (46 per 100,000 women) and Central and Eastern Sydney PHN had the lowest rate in 2019–22 (43 per 100,000 women).

Indigenous status 

• Nationally, in 2013–16, the rate for First Nations women (81 per 100,000 women) was about 32% lower than the rate for other Australian women (120 per 100,000 women) 
• In 2019–22, the rate for First Nations women was 129 per 100,000 women, which was around 2% lower than for other Australian women (131 per 100,000 women). This represents a 59% increase for First Nations women over the analysis period, compared to a 9% increase for other Australian women
• Queensland, South Australia, Northern Territory and New South Wales had the largest increases over the reporting period for First Nations women, while the Australian Capital Territory and Tasmania recorded decreases in rates. 

Patient funding status

• Around 60% of hospitalisations were for privately funded patients (in private and public hospitals) throughout the analysis period 
• In 2019–22, the proportion of hospitalisations for privately funded patients varied from 34% in the Australian Capital Territory to 63% in Queensland. 

Consistently high and low local areas 

The data identified local areas (SA3s) that had consistently high or low rates of endometrial ablation:

• Fifteen of the 340 SA3s had consistently high rates (that is, rates in the top 10% for the three reporting periods). Around half (seven) of these were in major cities, including four SA3s in the Hunter New England and Central Coast Primary Health Network in New South Wales
• Twenty SA3s had consistently low rates (that is, rates in the bottom 10% for the three reporting periods). All of these SA3s were in major cities – 13 were in New South Wales and seven were in Victoria.

Interpretation

While there was a 10% increase in the national rate of hospitalisations for endometrial ablation between 2013–16 and 2019–22, the rate at the end of the analysis period (131 per 100,000 women) was still 76% lower than for hysterectomy (231 per 100,000 women).

Geographical variation in endometrial ablation rates increased over the analysis period. In 2019–22, there was a 20-fold difference between the local area with the highest rate and the area with the lowest rate, compared to an 18-fold difference in 2013–16. This magnitude of geographical variation was four times higher than for hysterectomy, suggesting less consistent use across Australia.

Factors influencing the variation in rates of endometrial ablation may include:

• Access and acceptability of other treatments for heavy menstrual bleeding, including hysterectomy and the LNG-IUD
• Availability of required equipment
• Training of clinical staff.

Elective surgery cancellations and postponements related to the COVID-19 pandemic are likely to have affected rates of endometrial ablation from early 2020; the timing and extent of restrictions varied between states and territories.^{8, 9} 

Continuing the trend seen in the Second Atlas, rates were higher in regional areas compared to major cities and remote areas. Rates were higher in areas of most socioeconomic disadvantage, whereas the Second Atlas found no clear pattern according to socioeconomic status.

What has changed?

Possible reasons for the increase in endometrial ablation rates include:

• The Heavy Menstrual Bleeding Clinical Care Standard released in 2017 recommended that uterine-preserving treatments, such as endometrial ablation, should be considered before hysterectomy 
• New resources and media attention have helped to focus attention on heavy menstrual bleeding and treatment options including alternatives to hysterectomy
• There was a decrease in the use of hysterectomy for benign gynaecological conditions
• The technique has advanced, requires less direct supervision than hysterectomy and can be done as a day procedure
• More recently qualified obstetricians/gynaecologists are skilled in the procedure
• Financial incentives for clinicians to perform the procedure, due to the combination of the level of Medicare rebate and relative speed and lower complexity compared to hysterectomy.

Resources

Australian Commission on Safety and Quality in Health Care

• Heavy Menstrual Bleeding Clinical Care Standard 2024
• Heavy Menstrual Bleeding Clinical Care Standard – Consumer guide
• Heavy Menstrual Bleeding Clinical Care Standard – Clinician fact sheet
• Heavy Menstrual Bleeding Clinical Care Standard – Healthcare services information sheet

Royal Australian and New Zealand College of Obstetricians and Gynaecologists

• Endometrial Ablation
• Hysterectomy
• Heavy Menstrual Bleeding

References

1. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Endometrial ablation. Melbourne: 2018.
2. Spilsbury K, Hammond I, Bulsara M, Semmens JB. Morbidity outcomes of 78,577 hysterectomies for benign reasons over 23 years. BJOG. 2008 Nov;115(12):1473-1483.
3. Shapley M, Jordan K, Croft PR. An epidemiological survey of symptoms of menstrual loss in the community. Br J Gen Pract. 2004 May;54(502):359-363.
4. Britt H, Miller GC, Henderson J, Bayram C, Harrison C, Valenti L, et al. General practice activity in Australia 2015-16. General practice series no. 40. Sydney: Sydney University Press, 2016.
5. Australian Commission on Safety and Quality in Health Care. Heavy Menstrual Bleeding Clinical Care Standard. Sydney: ACSQHC, 2024.
6. Bofill Rodriguez M, Lethaby A, Fergusson RJ. Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding. Cochrane Database Syst Rev. 2021 Feb 23;2(2):CD000329.
7. Australian Commission on Safety and Quality in Health Care and Australian Institute of Health and Welfare. The Second Australian Atlas of Healthcare Variation. Sydney: ACSQHC, 2017.
8. Australian Institute of Health and Welfare. Elective surgery activity. Canberra: AIHW, 2020 [cited 12 Mar 2024]. Available from: https://www.aihw.gov.au/reports-data/myhospitals/intersection/activity/eswt.
9. Australian Institute of Health and Welfare. Australia's hospitals at a glance - web report. Canberra: AIHW, 2023 [cited 7 Mar 2024]. Available from: https://www.aihw.gov.au/getmedia/8c50762e-f614-438d-86d5-713d19203686/aihw-hse-253-hospitals-at-a-glance-dec23.pdf.

The reduction in the rate of hospitalisations for hysterectomy in Australia is encouraging, but the rate is still high when compared to similar countries OECD.¹

The increase in the rate of endometrial ablation hospitalisations is also a positive sign and may indicate a reason for the reduced hysterectomy hospitalisations. 

However, geographical variation in endometrial ablation remains high. In 2019–22, the number of hospitalisations for endometrial ablation was 20 times higher in the local area with the highest rate than in the local area with the lowest rate, suggesting that the procedure was not being consistently used for women with heavy menstrual bleeding.

More equitable access to hysterectomy alternatives, such as oral treatments, the LNG-IUD and endometrial ablation, may help to address the variation in hysterectomy rates.

Options to reduce variation in hysterectomy and endometrial ablation for the management of benign gynaecological conditions and to increase the use of less invasive treatments are discussed below.

Consumer awareness

Increase consumer awareness that heavy menstrual bleeding is not normal and reduce stigma and increase knowledge about treatment choices. Strategies include:

• Culturally appropriate consumer information about treatment options such as decision-support tools about heavy menstrual bleeding, and education through women’s health nurses, GPs and private health insurers
• The use of media, social media, high-profile spokespeople and consumer stories to drive awareness of choices women can make.

Clinician awareness

Drive clinician awareness of the prevalence and impact of heavy menstrual bleeding, the risks and benefits of treatment options, and increase skills to deliver appropriate diagnosis and treatments. Strategies include:

• Resources to support clinicians’ awareness of alternatives to hysterectomy for heavy menstrual bleeding and use of the revised Heavy Menstrual Bleeding Clinical Care Standard²
• Feedback to clinicians about their practice, using audit and feedback interventions comparing clinicians’ intervention rates to their peers
• Education for clinicians, including:
  • online learning programs for the management of heavy menstrual bleeding, such as the Project ECHO (Extension for Community Healthcare Outcomes) platform – for example, New South Wales launched MenoECHO in September 2023 to provide free online education about menopause
  • use of HealthPathways to ensure local pathways reflect best practice and incorporate appropriate resources for consumers and clinicians, including resources from the Australian Commission on Safety and Quality in Health Care 
  • case studies told from the consumer’s viewpoint
• Supporting LNG-IUD insertion in primary care, including with training and education.

Overcoming barriers to LNG-IUD insertion in primary care

The Heavy Menstrual Bleeding Clinical Care Standard advises that, when medical options are being considered, a women is offered the LNG-IUD if clinically appropriate, as it is the most effective medical option for managing heavy menstrual bleeding.²

Relatively few primary care practitioners, such as GPs, are able to insert the LNG-IUD. Of those who have been trained, some do not have the opportunity to maintain their skills and confidence in the procedure.^{3, 4}

Factors hindering GPs from inserting the LNG-IUD include provider issues, such as lack of knowledge and skills, and system barriers, including poor remuneration, difficulty in maintaining skills after training, and the need for additional resources such as equipment and nursing assistance.^{3, 4}

Options to overcome these barriers include:

• Education and training to increase GPs’ skills and confidence to insert the LNG-IUD⁵
• Rapid referral pathways within primary care networks for GPs to refer to clinicians in primary care or family planning clinics who are qualified to insert the LNG-IUD^{4, 6}
• Rapid access clinics
• Mobile services 
• Training nurses or other health practitioners to insert the LNG-IUD³
• Remuneration models that adequately cover costs of LNG-IUD insertion in primary care.

Health service organisation and Primary Health Network options

Health services and PHNs can:

• Enable new models of care that improve continuity of care for heavy menstrual bleeding, update or expand guidelines and referral pathways (including HealthPathways), and improve access to hysterectomy alternatives. An example of improved referral pathways is the network of menopause clinics being implemented across New South Wales
• Support collaboration between PHNs and Local Health Networks to provide clear pathways for the management of heavy menstrual bleeding in their areas
• Ensure consistency in clinical guidance, for example alignment between HealthPathways and the Heavy Menstrual Bleeding Clinical Care Standard
• Monitor clinical indicators for the Heavy Menstrual Bleeding Clinical Care Standard
• Improve the cultural appropriateness of services and provide more culturally appropriate models specific to local circumstances. Examples include a working group in New South Wales to support enhanced menopause care for First Nations women and in-reach models of specialist gynaecological care in Aboriginal Community Controlled Health Organisations that use attendance rates as a marker of cultural safety 
• Increase use of telehealth to manage heavy menstrual bleeding in women in rural and regional areas
• Increase consumer education about the benefits of less invasive treatment of heavy menstrual bleeding
• Identify opportunities to align with other current health initiatives designed to improve access for women to diagnostic, treatment and referral services
• Conduct research to cover evidence gaps, such as factors affecting women’s choices, including cultural taboos.

Government options

• Incorporate appropriate use of hysterectomy in state-wide and national initiatives on 
  reducing low-value care
• Increase access to linked data to allow reporting on the use of LNG-IUDs to treat heavy menstrual bleeding
• Review remuneration for MBS-funded LNG-IUD insertion
• Investigate the influence of workforce and the availability of investigations (particularly pelvic ultrasound) on patterns of treatment for heavy menstrual bleeding
• Increase access to the LNG-IUD.

Reducing inappropriate use of hysterectomy

Many state and territory health departments have programs of work to reduce rates of inappropriate surgery that could further reduce the rate of elective hysterectomies for benign conditions.

Safer Care Victoria developed Best Care guidance, which provides evidence-based information for health professionals about elective surgical procedures that can only be performed under certain circumstances or at certain time intervals.⁷ Hysterectomy for heavy menstrual bleeding is included in that list of procedures. 

More recently in New South Wales, the Agency for Clinical Innovation published the Value-based surgery: Clinical practice guide, which includes hysterectomy in a proposed list of discretionary procedures to be assessed by a local review panel for approval. The guide outlines the rationale and proposed change mechanisms to ensure appropriate performance of hysterectomy for heavy menstrual bleeding.⁸

References

1. Organisation for Economic Co-operation and Development. Healthcare utilisation: surgical procedures - hysterectomy [Internet] 2023 [cited 12 March 2024]. Available from: https://stats.oecd.org/index.aspx?queryid=30167#.
2. Australian Commission on Safety and Quality in Health Care. Heavy Menstrual Bleeding Clinical Care Standard. Sydney: ACSQHC, 2024.
3. Mazza D, Watson CJ, Taft A, Lucke J, McGeechan K, Haas M, et al. Pathways to IUD and implant insertion in general practice: a secondary analysis of the ACCORd study. Aust J Prim Health. 2023;29(3):222-228.
4. Stewart M, Digiusto E, Bateson D, South R, Black KI. Outcomes of intrauterine device insertion training for doctors working in primary care. Aust Fam Physician. 2016 Nov;45(11):837-841.
5. Ashworth G, Bateson D, Britt H, McGeechan K, Harrison C. Management of heavy menstrual bleeding in Australian general practice: An analysis of BEACH data. Aust J Gen Pract. 2021 Aug;50(8):573-579.
6. Taft A, Watson CJ, McCarthy E, Black KI, Lucke J, McGeechan K, et al. Sustainable and effective methods to increase long-acting reversible contraception uptake from the ACCORd general practice trial. Aust N Z J Public Health. 2022 Aug;46(4):540-544.
7. Safer Care Victoria. Best care: Guidance for non-urgent elective surgery. [Internet] Melbourne: SCV; 2021 [cited December 2023]. Available from https://www.safercare.vic.gov.au/clinical-guidance/non-urgent-elective-surgery.
8. Agency for Clinical Innovation. Value-based surgery: Clinical practice guide. Sydney: ACI, 2023.

Derbarl Yerrigan Health Service in Perth has improved care for Aboriginal women with gynaecological conditions such as heavy menstrual bleeding by establishing a gynaecology clinic that ensures culturally safe care.

Derbarl, an Aboriginal community-controlled health organisation (ACCHO) in Perth, established the gynaecology clinic in its East Perth Clinic in 2021. 

Visiting gynaecologists from local tertiary hospitals, partly funded by health workforce agency Rural Health West, work in the clinic alongside GPs and Aboriginal health practitioners and nurses to build trust and ensure cultural safety.

The clinic aims to improve care for Aboriginal women, who have higher incidences of gynaecological cancers and poorer survival rates compared to non-Aboriginal women.

It was established by Derbarl Medical Director Dr Richelle Douglas and registered nurse Gail Yarran, a proud Noongar woman, with the help of gynaecologists Dr Mat Epee and Dr Lauren Megaw. The project had the full support of CEO Tracey Brand, a proud Eastern Arrernte woman.

Dr Douglas said reduced access to care in the hospital system contributed to the poorer outcomes. She said it was important to help Aboriginal women access and engage with the health system by improving cultural safety, supporting them to navigate the system, addressing financial and geographical disadvantages, and improving communication from health professionals.

Bringing specialists to the patient

The gynaecology clinic is based on the ACCHO holistic model of care, in which primary care and specialist services work together under one roof. ACCHO GPs refer patients to visiting female gynaecologists, who have links to a local tertiary hospital and can book patients direct to their operating lists. 

‘We're bringing specialists to the patient rather than the other way around,’ Dr Douglas said.

Heavy menstrual bleeding is one of the most common conditions treated at the gynaecology clinic, which offers medical treatment in line with the Heavy Menstrual Bleeding Clinical Care Standard.

Dr Douglas said sometimes women present with abdominal pain and fatigue but do not say they have heavy menstrual bleeding. 

Culturally safe approach 

The clinic’s culturally safe approach helps to identify and treat women who have heavy menstrual bleeding and are reluctant to disclose it due to stigma, Dr Douglas said.

‘When patients come to our clinic, we have Aboriginal transport officers, Aboriginal receptionists, and Aboriginal liaison officers. Patients are greeted on arrival by an Aboriginal receptionist and screened by an Aboriginal health practitioner who takes the history before the doctor sees them,’ she said. 

A female Aboriginal health practitioner provides care for the patient throughout her journey at the clinic. That care may include coordinating transport and being the interface between the patient and the tertiary hospital if they need specialised treatment, Dr Douglas said.

Since 2021, the gynaecology clinic has seen more than 300 patients. Attendance rates for booked appointments have been over 80% compared to 56% attendance at the tertiary referral centre outpatient clinic.

One hundred per cent of Aboriginal women booked for surgery through the Derbal gynaecology clinic attended hospital for surgery, compared to 73% of patients booked through the tertiary system.

Dr Douglas said the outcomes showed the importance of flexible models of care for all patients, not only Aboriginal people. 

‘I hope embedded clinics and a holistic approach to health care is the future of health care in Australia,’ she said. ‘The Aboriginal community-controlled health organisations do that well. We should be learning from the oldest culture on earth.’

Findings in the Australian Atlas of Healthcare Variation series prompted Ballarat gynaecologist Dr Natasha Frawley to review the use of hysterectomy to treat heavy menstrual bleeding at the local hospital.

The Second Atlas found that women living in Ballarat had the second highest rate of hospitalisations for hysterectomy for benign conditions in Australia in 2014–15.

The release of the Heavy Menstrual Bleeding Clinical Care Standard in 2017, which was developed as a result of Atlas findings, presented an opportunity for Dr Frawley to study whether Ballarat Hospital’s care of women with heavy menstrual bleeding aligned with best practice. 

The Standard, which has recently been revised, sets out eight quality statements that describe the care that should be offered to a woman with heavy menstrual bleeding. 

Dr Frawley, Clinical Director of Women’s and Children’s Services, Grampians Health, and Hospital Medical Officer Dr Madison Phung audited hospital and clinic data to identify patients who had hysterectomies for benign heavy menstrual bleeding at Ballarat Hospital in the 10 months before the release of the Standard and the 10 months after it. They have submitted their findings to a peer-reviewed journal. 

‘Using the Clinical Care Standard was incredibly helpful to assess each patient’s journey to benign hysterectomy,’ Dr Frawley said.

Focus for improvement

Dr Frawley and Dr Phung identified areas for improvement that were specific to the Ballarat hospital context, including offering endometrial ablation and the 52 mg levonorgestrel-releasing intrauterine device (LNG-IUD) to patients with heavy menstrual bleeding considering hysterectomy. 

The latest Atlas data show that the hysterectomy rate in Ballarat dropped by almost one-third (31%) between 2014–15 and 2021–22. However, Ballarat still has the second highest rate of hospitalisations for hysterectomy of any local area in Australia.

Dr Frawley said data from their audit showed more could be done to ensure women were offered alternatives to hysterectomy to treat heavy menstrual bleeding.

She said one way to do that was to increase gynaecologists’ and patients’ awareness of the morbidity associated with hysterectomy, which affects 4–8% of patients having hysterectomy. Complications can include organ injury, infection, prolonged stay and readmission. 

Fast-tracked care

Ballarat Hospital is also working to offer women alternative medical treatments such as non-steroidal anti-inflammatory medications, treatment of iron deficiency, oral hormone treatments and the LNG-IUD, even when they’re referred to the hospital for surgery. In a new project that is part of the surgical reform pathway at the Grampians Health Service, women referred to Ballarat Hospital for heavy menstrual bleeding will be offered a fast-track appointment for medical management. 

Registrar-led care will align with the Standard and include offering early insertion of the LNG-IUD. 

Dr Frawley said the audit showed women were waiting a long time to get to the clinic. ‘These appointments outside the surgical pathway will mean women have quick access to good medical management treatment options. This will mean that patients will access treatment faster, and also in the end they may not need a hysterectomy.’

Data for the Women's Health Focus Report were supplied by the Australian Institute of Health and Welfare. The data files are reported at national, state and territory, Primary Health Network and local area level following the analysis.

Hysterectomy hospitalisations data file

Number of hysterectomy hospitalisations per 100,000 women, 15 years and over, age standardised, 2014-15 to 2021-22.

Endometrial ablation hospitalisations data file

Number of endometrial ablation hospitalisations per 100,000 women, 15 years and over, age standardised, 2013–14 to 2015–16, 2016–17 to 2018–19 and 2019–20 to 2021–22.

The technical note for the Women's Health Focus Report was supplied by the Australian Institute of Health and Welfare and describes the analysis performed on the data to produce the reported rates. 

Women's Health Focus Report - technical note

Hysterectomy and endometrial ablation hospitalisations per 100,000 women, 15 years and over.

The data specifications describe the databases and data codes used to extract the raw data. 

Hysterectomy hospitalisations data specification

Number of hysterectomy hospitalisations per 100,000 women, 15 years and over, age standardised, 2014-15 to 2021-22.

Endometrial ablation hospitalisations data specification

Number of endometrial ablation hospitalisations per 100,000 women, 15 years and over, age standardised, 2013–14 to 2015–16, 2016–17 to 2018–19 and 2019–20 to 2021–22.