Atlas Focus Report: Heavy Menstrual Bleeding

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-term¹ and long-term complications⁷ and unplanned readmission.⁸

Our Heavy Menstrual Bleeding Clinical Care Standard, describes the clinical care that women should be offered for heavy menstrual bleeding and 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, should be 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 local areas with the lowest and highest rates of hysterectomy 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}

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 also examines hospitalisations for endometrial ablation 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 and visualisations for:

• Australia and its states and territories
• Remoteness and socioeconomic status levels

Primary Health Networks (PHNs)

• Local areas (SA3s)
• 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.

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 was in inner regional Western Australia and one was 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).

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% fall 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.

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’ preferences¹⁵
• 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^{16, 17}
• MBS rebates for hysterectomy compared with insertion of LNG-IUDs
• Cost barriers for GPs to insert LNG-IUDs.¹⁷

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 cities¹⁸, 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. 

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 fall 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.

The Heavy Menstrual Bleeding Clinical Care Standard 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.²

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.³

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.⁴ 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.

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.

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 reporting 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 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.^{5, 6}

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.

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 fall 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.

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

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.

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

• Hysterectomy hospitalisations data file
• Endometrial ablation hospitalisations data file

• Hysterectomy hospitalisations data specification
• Endometrial ablation hospitalisations data specification

-

Hysterectomy, for women 15 years and over, between 2014-15 and 2021-22 

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.

Endometrial Ablation hospitalisations for women 15 years and over, between 2013-16 and 2019-22

1. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Endometrial ablation. Melbourne: 2018.
2. Australian Commission on Safety and Quality in Health Care. Heavy Menstrual Bleeding Clinical Care Standard. Sydney: ACSQHC, 2024.
3. 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.
4. 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.
5. 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.
6. 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.

Reducing variation in hysterectomy and endometrial ablation 

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