Patient Preferences for Treatment of Dysfunctional Bleeding

Abstract & Commentary

Synopsis: A majority of patients scheduled for endometrial ablation or a levonorgestrel-releasing IUD were willing to accept a 50% likelihood of treatment failure to avoid hysterectomy.

Source: Bourdez, et al. Fertil Steril. 2004;82:160-166.

These dutch investigators conducted structured interviews with patients who were scheduled to undergo endometrial ablation (n = 96), insertion of a levonorgesterel-containing IUD (n = 23), or hysterectomy (n = 25). All patients were suffering from dysfunctional uterine bleeding defined as menorrhagia in the absence of intracavitary abnormalities unresponsive to medical management. Patients were asked to describe both their most significant medical problem as well as the reasons for selecting their respective treatment option. After the advantages and disadvantages of all 3 treatments were explained, subjects were given various hypothetical success rates of the treatments to determine at what level of failure the patient would select it. In this interview, the hypothetical success rate for endometrial ablation was initially quoted as 10%. If the patient opted for hysterectomy (given a hypothetical success of 100%), the success of ablation was then increased to 20%. The patient was asked to choose again at that level. This process was repeated until the patient identified a success level at which she would select ablation. A similar process was done with regard to IUD.

The main reasons that patients chose IUD were: did not want hospital admission (9/23), did not want anesthesia (6/23), desired fast recovery (5/23), and did not want hysterectomy (5/23). Among those choosing an ablation, primary motivations included: did not want IUD (21/96), did not want hysterectomy (18/96), and desire for short admission (14/96). Among those choosing hysterectomy, the vast majority, 20 out of 25, desired a definitive solution to their problem.

Among patients scheduled for endometrial ablation, 70% would opt for either ablation or IUD insertion if the presumed success rate of the treatment were 50%. For women choosing the IUD, this would be preferred over hysterectomy by 95% if the proposed success exceeded 50%. Bourdez and colleagues conclude that gynecologists should recognize that fully informed patients might be willing to accept a particular rate of failure if they can undergo a noninvasive technique.

Comment by Frank W. Ling, MD

If you have read this up to this point and are thinking that this article is a no-brainer, then my response is, "Great!" You are likely a physician who tries to address the wide array of potential issues that patients want discussed prior to choosing a treatment for dysfunctional bleeding/menorrhagia. How patients ultimately make decisions is an absolutely critical aspect of what we do every day and the better that we appreciate the individual patient’s needs, the better that we will be able to cope with them. In the long run, this results in greater patient satisfaction irrespective of success and failure rates.

As a starting point, the importance of complete and accurate information for each patient is a given. Ideally, the data on success/failure rates, complications, implications for sexual functioning, costs, resumption of normal lifestyle, etc, are presented in a fair and balanced fashion. Each of us who advises patients needs to separate ourselves from our favorite technique or hobby horse so that the patient can hear things objectively. Admittedly, patients commonly look to us for advice and guidance, but we should acknowledge that our best efforts to provide truly informed consent are always being filtered.

Access to Internet web sites, consultations from other physicians, advice from well-meaning friends and relatives: these are all factors whether we like it or not. Even before we even see the patient, she may well already have decided on what she wants. Rather than only telling the patient what she needs, it is our responsibility to also listen to what she thinks she needs. By no means am I endorsing just doing what the patient wants, but I am adamant that those of us who have the privilege to care for the health of women should take care of the whole patient. Let’s make sure that the patient is allowed to express her own opinions, explain why she is inclined the way she is, and truly participate in the ultimate decision.

Knowing that each patient is willing to accept a certain risk of failure for this or any procedure is a critical part of the informed consent process. The challenge is to make sure that the good medicine that you practice takes into account the scientific data as well as her idiosyncratic needs. I think that's called the Art of Medicine.

Frank W. Ling, MD, Women’s Health Specialists, PLLC, Memphis, Tennessee, is Associate Editor of OB/GYN Clinical Alert.