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Nurse Interviews Cut Hysterectomy Rates

Women with heavy menstrual bleeding opt out of surgery

TUESDAY, Dec. 3, 2002 (HealthDayNews) -- Women with heavy menstrual bleeding are less likely to opt for a hysterectomy if they have a chance to talk it over with a nurse before they see a doctor.

In a study of nearly 900 English women who were referred to a specialist for heavy menstrual bleeding, 38 percent of those who had discussed their treatment preferences with a nurse had a hysterectomy within two years of their initial doctor's visit, compared to 48 percent of the women who saw their doctor without a prior nurse consultation.

"The interviews helped women clarify their preferences for outcomes for different procedures, and it could be that given good evidence-based information on alternate treatments, women will opt for procedures with the least risk," says Andrew Kennedy, a statistician at England's Brunel University and the lead author of the study.

The results of the study, supported by a grant from the United Kingdom's National Health Service (NHS), appear in tomorrow's issue of the Journal of the American Medical Association.

In the study, 894 women who reported heavy menstrual bleeding were divided into three groups: those who received written and video material about their condition and treatment options before their doctor's appointment; those who received the materials and who also had a 20-minute interview with a nurse before their doctor's appointment; and a control group who received no informational materials and who simply went to the specialist.

Interestingly, those in the first group who received the informational materials but who did not have an interview showed no differences in treatment preferences from the women who did not receive additional information.

"The women seemed to need the added structure of an interview to use the information they got in order to come to a firm decision about the treatment they wanted," Kennedy says.

"The information and the interview together may help women validate their preferences. Without them, a woman might be influenced more readily by a doctor who would negate their own values," says Kennedy.

In the highly structured interview, the women were asked questions to elicit how involved they wanted to be in their treatment decisions, what their treatment preferences were and how those treatments related to their lifestyles.

These questions included whether they wanted a hysterectomy, didn't want an operation, wanted drug therapy, and a ranking of what lifestyle issues were important to them, like how important it was to have minimum pain, resume sex, how long they wanted to stay in the hospital and whether they planned a pregnancy.

Kennedy says that you could have this kind of interview intervention and still not see any treatment changes, because women could still be sure of the treatment they wanted. That didn't happen here, though.

"We found that you can change patterns of care," he says.

In the United States, where the rate of hysterectomies is twice that of England, such information could be useful, says Dr. Michel Rivlin, a gynecology professor at the University of Mississippi Medical Center.

"It was news to me that having a nurse interview would drop the surgery rate," he says, adding that other studies have shown that the more information given about procedures, the less likely it is that people will choose the more high-risk option.

Up to one third of menstruating women report heavy bleeding, Kennedy says, and it is a common reason for consulting a doctor. Although not life-threatening, it affects a woman's quality of life. Treatment options include advice and reassurance, addressing possible causes, drug therapy, or surgery.

Further, many of the treatment options depend on a woman's personal situation and lifestyle, Kennedy says. "You can't say which treatment is best because it's value-driven," he says, and the authors hoped to identify how to help women reach decisions with which they were comfortable.

"I think this works very well," he says.

But why aren't doctors asking these questions already?

Not enough time, says Kennedy.

"In England, women get eight minutes with specialists in an outpatient setting," he says, and the appointment includes giving information, getting information, and doing a physical exam. There simply isn't the time for an in-depth interview.

What To Do

For information on heavy menstrual bleeding, you can visit Medline. An interesting discussion on the ethics of informed consent can be found at the University of Washington School of Medicine.

SOURCES: Michel Rivlin, M.D., associate professor of gynecology, University of Mississippi Medical Center, Jackson; Andrew D.M. Kennedy, B.Sc., statistician, Brunel University, Uxbridge, Middlesex, England; Dec. 4, 2002, Journal of the American Medical Association
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