Do British women undergo too many or too few hysterectomies?

Hysterectomy is performed much less frequently in Britain than in North America, Australia and some European countries. Various theories have been advanced to explain this lower rate of surgery. These include: fewer health care resources (hospital beds, surgeons); much less fee-for-service medicine; differences in the attitudes of surgeons; differences in health care organisation, in particular the gatekeeping role of general practitioners; and differences in patients' expectations. This paper reviews the evidence on sources of variation and examines the extent to which hysterectomy rates vary between countries, and between small areas and social groups within Britain. Following an examination of national trends, evidence is presented from studies carried out in the Oxford region to illustrate the extent of variation in the rate at which hysterectomy is carried out and to explore the possible reasons for the differences. The article considers the health policy implications of an apparent increase in demand for hysterectomy and argues the case for a thorough evaluation of the impact of this operation on quality of life.