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• Idiopathic heavy menstrual bleeding negatively affects women's quality of life. • The stepped care approach shows practice variation between Dutch hospitals. • Women underwent 0.63 treatments (range, 0.36–1.00) before endometrial ablation. • Women underwent 0.96 treatments (range, 0.56–1.45) before hysterectomy. • Scope exists to reduce hysterectomy rates by implementing less invasive therapies. Heavy menstrual bleeding (HMB) affects a quarter of all women, with half having no structural cause. Dutch guidelines recommend a stepped care approach to the management of such idiopathic HMB, starting with medication or a levonorgestrel-releasing intrauterine device (LNG-IUD), before progressing to endometrial ablation, and ultimately, hysterectomy. However, practice variation between hospitals could lead to suboptimal health outcomes and increased healthcare costs for some women. To evaluate adherence to stepped care for women with idiopathic HMB and to identify practice variation among Dutch hospitals. This population-based cross-sectional study used Dutch insurance claims data from primary and secondary care for all women with idiopathic HMB referred to a gynecologist between January 2019 and December 2020. We calculated the average number of treatments in the 3 years before each treatment step at each hospital, making adjustments for age, socioeconomic status, and ethnicity. Variation in medical practice was measured by the coefficient of variation (CV). We studied 20,715 women treated with LNG-IUDs (56%), endometrial ablation (36%), laparoscopic hysterectomy (13%), or vaginal hysterectomy (4%) in 93 hospitals. Before endometrial ablation, on average 47% used medication (hospital range 27%–71%; CV 0.17) and 16% used an LNG-IUD (hospital range 8%–29%, CV 0.32). Before hysterectomy, 52% (hospital range 28%–65%, CV 0.16) used medication, 21% (hospital range 6%–38%, CV 0.35) used an LNG-IUD, and 23% underwent endometrial ablation (hospital range 0%–59%, CV 0.55). On average, women underwent 0.63 (hospital range 0.36–1.00, adjusted rate 0.40–0.98, CV 0.17) and 0.96 (hospital range 0.56–1.45, adjusted rate 0.56–1.44, CV 0.18) treatments before endometrial ablation and hysterectomy, respectively. Considerable practice variation exists among Dutch hospitals in the stepped care approach to idiopathic HMB. Improving adherence to this approach could improve quality of care and reduce costs. [ABSTRACT FROM AUTHOR]

Background: It is estimated that between 12 to 25% of women who undergo an endometrial ablation for heavy menstrual bleeding (HMB) are dissatisfied after two years because of recurrent menstrual bleeding and/or cyclical pelvic pain, with around 15% of these women ultimately having a hysterectomy. The insertion of a levonorgestrel-releasing intrauterine system (LNG-IUS) immediately after endometrial ablation may inactivate residual untreated endometrium and/or inhibit the regeneration of endometrial tissue. Furthermore, the LNG-IUS may prevent agglutination of the uterine walls preventing intrauterine adhesion formation associated with endometrial ablation. In these ways, insertion of an LNG-IUS immediately after endometrial ablation might prevent subsequent hysterectomies because of persisting uterine bleeding and cyclical pelvic pain or pain that arises de novo. Hence, we evaluate if the combination of endometrial ablation and an LNG-IUS is superior to endometrial ablation alone in terms of reducing subsequent rates of hysterectomy at two years following the initial ablative procedure.Methods/design: We perform a multicentre randomised controlled trial in 35 hospitals in the Netherlands. Women with heavy menstrual bleeding, who opt for treatment with endometrial ablation and without contraindication for an LNG-IUS are eligible. After informed consent, participants are randomly allocated to either endometrial ablation plus LNG-IUS or endometrial ablation alone. The primary outcome is the hysterectomy rate at 24 months following endometrial ablation. Secondary outcomes include women's satisfaction, reinterventions, complications, side effects, menstrual bleeding patterns, quality of life, societal costs.Discussion: The results of this study will help clinicians inform women with HMB who opt for treatment with endometrial ablation about whether concomitant use of the LNG-IUS is beneficial for reducing the need for hysterectomy due to ongoing bleeding and/or pain symptoms. Trial registration Dutch Trial registration: NL7817. Registered 20 June 2019, https://www.trialregister.nl/trial/7817 . [ABSTRACT FROM AUTHOR]

Introduction: Despite endometrial ablation/resection being a very successful treatment for women with heavy menstrual bleeding, re‐intervention with additional surgery is needed in 12%–25% of cases. Introducing a levonorgestrel‐intrauterine system (LNG‐IUS) immediately after ablation could preserve the integrity of the uterine cavity and suppress the regenerated or non‐ablated endometrial tissue. Therefore, this combined treatment can perhaps lower the re‐intervention rate. The aim of this systematic review was to assess the impact of the combined treatment. Material and methods: The MEDLINE, EMBASE, and Cochrane library were systematically searched. No language restrictions were applied. All types of studies were included reporting on the results of endometrial ablation or resection combined with immediate insertion of LNG‐IUS for treatment of heavy menstrual bleeding. The primary outcome was the number of hysterectomies after the ablation procedure. Secondary outcomes included re‐intervention rates, removals of LNG‐IUS, bleeding pattern, patient satisfaction, adverse effects, and complications. Our protocol was registered in PROSPERO, an international prospective register of systematic reviews under registration number CRD42020151384. Results: Six studies with a retrospective design and one case series with a follow‐up duration varying from 6 to 55 months were included. In total, 427 women were treated with the combined treatment. The studies described a lower hysterectomy and re‐intervention rate after combined treatment compared with treatment with endometrial ablation/resection alone. Hysterectomy rate varied from 0% to 11% after combined treatment compared with 9.4% to 24% after endometrial ablation/resection alone. Bleeding patterns and patient satisfaction appeared to be in favor of the combined treatment group. No intra‐ or post‐operative complications or complications in the removal of LNG‐IUS were described. The most reported adverse effects after combined treatment were weight gain, mood changes, and headaches. An additional 11 studies with only an abstract available substantiated these findings. All the included studies had poor methodological quality. Conclusions: Based on the available literature, inserting an LNG‐IUS immediately after endometrial ablation/resection seems to lower the hysterectomy and re‐intervention rates compared with ablation/resection alone. However, as only limited observational studies of low methodological quality are available, high‐quality research is necessary to confirm the findings of this systematic review. [ABSTRACT FROM AUTHOR]