In the UK, The National Health Service (The NHS) is a unique system of its kind where taxpayers’ money is utilised to provide a free health system to the public with consideration of reduced waste of that money and setting targets to provide a better service for the patients [9]. The NHS constitution considers six major values to ensure the best possible care for the patients which are: working together for patients, respect and dignity, commitment to quality of care, compassion, improving lives and everyone counts [10].

Over the years, the NHS Bill is growing, and this growth mostly results from the older population growth, together with the increased patients suffering from chronic health illnesses in addition to the high drug bills [6]. The NHS has always planned to improve quality of care together with reducing spent cost on the services provided [7]. A recent report indicated that reviewing past trends in the NHS productivity could provide few lessons for current financial challenged health system, one of which is by providing support to clinical teams to make improvements to the way they deliver services in collaboration with their patients [7]. It has been published before that improving quality reduces costs of treatment and improves value-for-money across the whole health care system [11].

This retrospective study aimed to calculate the cost spent on women referred to hospital with HMB who needed multiple interventions prior to having definitive surgery (hysterectomy). It also aimed to improve the quality of care provided to this group of women especially when suffering was prolonged and definitive surgery was not offered early. Cost saving is proposed to be achieved by avoiding uterine sparing modalities offered to those women if they score >=3 according to a suggested scoring system introduced in this study.

Heavy menstrual bleeding is a common condition affecting 1:4 women during their reproductive life [12]. Around 50000 women are referred annually to the National Health Service (NHS) at secondary care hospitals with HMB in England and Wales [13]. Around 28000 of those women undergo surgical management of HMB, the commonest of which is EA [13]. HMB has several implications on quality of life by affecting the physical and mental health of women as well as their emotional and social wellbeing [13]. It can also be associated with severe pain symptoms, anaemia and fatigue [14,15].

Different pathologies can be associated with HMB including uterine fibroids, adenomyosis and endometriosis which can predispose to additional symptoms including pelvic pain, dysmenorrhoea, dyspareunia and pressure symptoms. Identifying these symptoms during the gynaecological consultation for HMB is important which can highlight the possible association of these pathologies with HMB.

Stevens et al in 2019 published a retrospective review predicting the likelihood of failed EA used to treat HMB. This was based on woman`s age, parity, duration of HMB, associated dysmenorrhoea and previous caesarean section [1].  It suggested that this prediction could aid clinicians in the counselling process for EA in women with HMB by predicting the likelihood of a failed procedure needing further intervention in the following two years post EA [1]. In our study, we identified different factors associated with HMB leading to hysterectomy. These factors were retrieved from symptoms at presentation, uterine cavity length at examination, investigations including USS & haemoglobin level, women`s desire for definitive treatment and histology of the removed uterus.

Associated chronic pelvic pain, dysmenorrhoea, dyspareunia or known endometriosis & adenomyosis were identified as risk factors for failed medical & surgical uterine sparing modalities for HMB in this study, especially these modalities might not improve the pain symptoms completely. EA was reported to be associated with post ablation pelvic pain in 20.8% of women in one series especially in women with pre ablation dysmenorrhoea and endometriosis [16]. It was recommended to properly counsel women regarding the expected surgical outcome post EA in this group [16]. Late-Onset Endometrial Ablation Failure (LOEAF) was lately identified to be associated with hysterectomy in 25% of women undergoing EA regardless of the type of EA used and an unknown number of women who had EA had less than satisfactory results in that series [17]. It has been suggested that understanding factors which lead to LOEAF with good patient selection for the procedure would reduce LOEAF and improve patient`s satisfaction [17]. The commonest cause of post ablation hysterectomy in some series was found to be recurrence of HMB due to inadequate destruction of the endometrium or its regrowth following ablation, chronic pelvic pain, leiomyomas and adenomyosis [17-19]. On the other hand, the Levonorgestrel IUS was found to be associated with failure to control HMB in women with a uterine fibroid>=2.5 cm or a uterine size of>12 cm [20].

In this study, we found that 36.6% of the identified patients had chronic pelvic pain, dysmenorrhoea, dyspareunia or known endometriosis, in addition to 8% had an USS finding of preoperative adenomyosis and 44.6% of uterine fibroid of >=3 cm size. The failure rate of EA in this study was 38.6%, failed Levonorgestrel IUS rate was 39%, whereas both failed in 13.5%. Considering histology, we recognised that several women had fibroids and adenomyosis which were not picked up on USS and were confirmed by histology (Tables 1,4). We appreciate that adenomyosis is more difficult to be picked up on USS compared to uterine fibroids. We recommend further training in gynaecological USS to improve diagnosis. It has been suggested that further training in 3D USS can further pick up adenomyosis [21].  Hanafi M suggested that USS is a valuable non-invasive method to diagnose leiomyoma with or without adenomyosis which can be sensitive but not specific in the diagnosis of adenomyosis [22].

Large uterine cavity >10.5 cm was identified as a risk factor for failed EA and LOEAF and it can also be associated with a failed Levonorgestrel IUS [18,23]. In this study 29.3% of women had a large endometrial cavity >10 cm length which has resulted in failed uterine sparing medical and surgical procedures namely EA and IUS.

We identified that 21.6% of the women in this study were anaemic on oral iron therapy but 10.6% had iron infusions with blood transfusion due to their life-threatening anaemia. We considered this group of women as a potential group benefiting from hysterectomy if other scoring factors existed, giving anaemia needing blood/iron transfusion one score (Table 1). Iron deficiency anaemia can result from chronic and excessive heavy menstrual blood loss and can be life-threatening which should be addressed proactively [24]. A consensus guidance covering screening and diagnosis of iron deficiency anaemia in women with HMB has been suggested to improve health outcomes in those women [25].

Hysterectomy is the most performed major surgical procedure in gynecology [26]. Despite its invasive nature, it represents the most definitive treatment option for HMB in women where future fertility is not a requirement [26].

Due to its invasive nature with longer recovery time and complications, it was suggested that hysterectomy should only be considered when other treatment options have failed or are contraindicated [26].

Women`s desire for definitive treatment was identified as a risk factor leading to hysterectomy in this study. This was especially identified in women aiming for complete amenorrhoea where other uterine sparing modalities such as the Levonorgestrel IUS and EA might not guarantee. Nearly half of the women who had hysterectomy for HMB in this study had a desire for complete amenorrhoea. We recommend that having some additional risk factors to woman`s desire for hysterectomy would aid the clinician to offer definitive treatment for HMB.

A massive financial cost of £ 413,699 was identified by calculating all the medical and surgical cost spent on managing women referred with HMB during the period of the study prior to hysterectomy. This included all medical interventions such as the IUS and surgical management using EA (Table 5). The cost becomes higher when women were offered permanent contraception as recommended by the American College of Obstetricians and gynaecologists offering a long-term reliable contraception for women undergoing endometrial ablation [8].  Due to the fact that hysteroscopic approach for sterilisation is not available anymore, women are offered laparoscopic approach for sterilisation during EA [27]. There is a steady trend towards laparoscopic salpingectomy versus laparoscopic clip sterilisation as shown in our study (Table 5), due to the international recommendation of its large benefits including sterility & decreased lifetime risk of epithelial-cell ovarian cancer [27-30]. It has been suggested that laparoscopic bilateral salpingectomy combined with endometrial ablation could become the most-common surgery performed by gynecologic surgeons [27]. This would include an additional cost (Table 5).

Cost reduction programs in health systems have always been suggested, but most hospitals lack effective cost reduction programs, a recent survey found [31]. This survey recommended that hospitals must identify areas of savings, establish a governance structure and foster collaboration to achieve effective cost reduction programs [31].

A way of introducing a cost reduction process in gynecology clinics, we recommend introducing a scoring system (Table 1), where women who score >=3 would be counselled towards having hysterectomy rather than uterine sparing medical and surgical modalities especially 75% of the women in the study were found to score >=3. This would result in massive cost saving considering the huge cost we calculated on all these modalities utilised prior to hysterectomy in the study group. This study is limited by not including women who were referred with HMB and did not end up having hysterectomy.