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\begin{document}

\title{SURGICAL TREATMENT OF ABNORMAL UTERINE BLEEDING (AUB-O,E,N): A
COST-EFFECTIVENESS STUDY USING THE FRENCH HOSPITAL CLAIMS DATABASE}



\author[1]{Isabelle Borget}%
\author[2]{Lucie De Leotoing}%
\author[3]{Gwendoline Chaize}%
\author[4]{Jérôme Fernandes}%
\author[5]{Dusan Toth}%
\author[6]{Philippe Descamps}%
\author[7]{Gil Dubernard}%
\author[3]{Thomas Lafon}%
\author[3]{Ludovic Lamarsalle}%
\author[8]{Herve Fernandez}%
\affil[1]{Gustave Roussy}%
\affil[2]{HEVA}%
\affil[3]{Heva}%
\affil[4]{OC Santé}%
\affil[5]{Clinique Saint-Germain}%
\affil[6]{CHU}%
\affil[7]{Hôpital de la Croix Rousse}%
\affil[8]{CHU Bicetre}%


\vspace{-1em}



  
  \date{May 24, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Objective: AUB-O,E,N is treated first with medical management, followed
by surgery, which failure or complications have significant burden. The
objective was to perform a cost-effectiveness analysis of four surgical
strategies, comparing cost and avoided failure rate, using the French
PMSI database. Design: Retrospective analysis performed using the French
exhaustive national hospital discharge database (PMSI). Population: All
incident 35-55 year-old women operated on for four types of AUB-O,E,N
surgery (2nd generation, 1st generation, curettage or hysterectomy)
between 2009 and 2014 were included. Methods : They were followed to
collect rehospitalizations related to failure or complication and their
cost, during at least 18 months. Hospital costs were estimated using the
French tariffs in 2017\textbackslash{}euro. Main Outcome measures : A
cost-effectiveness analysis was performed comparing each surgical
procedure to 2G, in hospitalization costs and rate of patients without
failure. Results : The study included 88,154 patients. At 18 months,
mean cost per patient was \textbackslash{}euro2,448 for 2G,
\textbackslash{}euro2,100 for 1G, \textbackslash{}euro2,275 for
curettage and \textbackslash{}euro4,157 for hysterectomy. Hysterectomy
was the most effective strategy in terms of absence of failure, but also
the most expensive, with an incremental cost of
\textbackslash{}euro24,008 per additional \% of patient without failure.
Even with a mean cost similar to 2G, curettage was the least effective
strategy with a failure rate reaching 20.6\% at 18 months. 1G was less
expensive but also less effective than 2G, with an economy of
\textbackslash{}euro13,078 per \% of patient without failure loss.
Conclusion: 1G and 2G techniques are the most efficient strategie%
\end{abstract}%



\sloppy


\textbf{Introduction}

Heavy menstrual bleeding is defined as excessive menstrual blood loss of
80 mL per cycle, for more than 7 days which interferes with a woman's
physical, social, emotional and/or quality of
life\textsuperscript{1,2}and affects approximately 10\%--30\% of all
women worldwide once in their lifetime\textsuperscript{3,4}. FIGO
defined a new terminology for normal and abnormal uterine bleeding (AUB)
in the reproductive years and for classification cases with
PALM-COEIN\textsuperscript{5}. The causes of dysfunctional uterine
bleeding are now defined by O,E,N (Ovulatory dysfunctional, Endometrial,
Not otherwise classified). The causes defined by C (Coagulopathology)
and I (Iatrogenic) have no indication for surgical treatment. Medical
treatment is usually the first intent treatment. Except for curettage,
surgical interventions are recommended for women with severe AUB-O,E,N
who do not wish to become pregnant\textsuperscript{6,7}. In this case,
different surgical interventions are routinely performed for treatment,
the choices include second-generation (2G) endometrial ablation
techniques (thermal balloon, microwave, cryoablation, radiofrequency)
and first-generation (1G) techniques (endometrectomy, roller-ball and
laser ablation), whereas a first-line curettage or hysterectomy is no
longer recommended in France\textsuperscript{7}. Hysterectomy is
effective but has more complications than endometrial ablation;
endometrial ablation techniques are less invasive but could ultimately
lead to hysterectomy in 20\% of cases within 5 years
\textsuperscript{8}. 2G procedures seem to be as effective as 1G
procedures and present with fewer complications, like operating time
decrease, and can be used more often with local anesthesia
\textsuperscript{9--11}. In 2019, the HEALTH randomized controlled trial
\textsuperscript{12} compared laparoscopic supracervical hysterectomy
\emph{versus} endometrial ablation (2G or 1G) for surgical treatment of
heavy menstrual bleeding for 660 patients. Hysterectomy showed to be
superior in terms of clinical effectiveness, with similar rate of
complications but takes longer time in operating room, a longer hospital
stay and longer recovery time, then increasing the cost of the radical
procedure.

Regarding the economic evidence of surgical procedures, a French
retrospective study showed that hysterectomy was the most effective but
also the most expensive strategy in 2003, as compared to 2G
techniques\textsuperscript{13}. The recent economic analysis of the
HEALTH trial in UK confirmed that hysterectomy expenses is higher of
\selectlanguage{ngerman}£1604 at 15 months\textsuperscript{14}. Two trial-based cost-utility
analyses demonstrated that 2G endometrial ablation were more
cost-effective than 1G devices\textsuperscript{15,16}, but their
external validities was questionable regarding limitations in available
data to build the model. In real conditions, an economic analysis based
on the German health claims database showed that a 2G technique
(radiofrequency ablation) was associated with fewer recurrences, lower
rates of subsequent surgical treatments and lower costs than other
ablation techniques \textsuperscript{17}. The replicability of this
study was however questionable, as it only concerned 88 patients. The
most complete economic study was done by Miller \emph{et al} in 2015 in
the US context \textsuperscript{18}, who performed a semi-Markov model
at 1, 3 and 5-years using the data of 63,482 patients from three large
medical claims databases in real-conditions to compare
Novasure\emph{versus} other ablation modalities and hysterectomy. To
date, there is no similar cost-effectiveness analysis comparing surgical
strategies of AUB, that used only data from a hospital claim database,
reflecting real-life practice in the European context.

Since the introduction of a DRG-based prospective payment system in
France in 2005, the PMSI-MCO database has been used as the basis for the
funding of services in all hospitals. Indeed, its high exhaustiveness
and the quality of its information allow using this database for
epidemiologic, burden of disease, or economic analyses in real-life
conditions. As individual patients can be tracked across multiple
hospitalizations over time through a unique anonymous patient identifier
(with the patient's social security number, date of birth and gender)
which is kept unchanged until the patient dies, a patient can be
followed-up during many years. Several years after the implementation of
recommendations for the management of menorrhagia in
France\textsuperscript{7}, there is a need to compare the different
surgical techniques in real life conditions, by comparing both their
respective efficacy (expressed in terms of the absence of failure and/or
complication) and their associated hospitalizations costs along time. In
the present study, the French PMSI-MCO database was used to perform a
cost-effectiveness analysis, comparing 2G endometrial ablative
techniques to 1G techniques, curettage and hysterectomy for treating
AUB-O,E,N.

\textbf{Methods}

\emph{Data sources}

Data were retrospectively extracted from the French Hospital Medical
Information database (Programme de Médicalisation des Systèmes
d'Information -- PMSI). The French PMSI-MCO database covers all
overnight or day hospitalizations in the public and private French
hospitals\textsuperscript{19}. Each hospital stay results in a
production of a standard discharge summary (``Résumé de Sortie
Standardisé'' RSS) following inpatient conventional stays, day-hospital
stays or sessions. The RSS is then anonymized to become the RSA
(``Résumé de Sortie Anonyme''). The RSA contains information's on the
patient characteristics (gender, age, residence code), on the main
diagnosis that led to hospital admission, on the nature of the treatment
and work-up (examinations) carried out, on comorbidities and on
complications. Diagnoses are coded using the International
Classification of Diseases, 10\textsuperscript{th} revision
(ICD-10)\textsuperscript{20} either as primary- (PD: the condition for
which the patient was hospitalized), related- (RD: any underlying
condition which may have been related to the PD), or significant
associated-diagnoses (SAD: comorbidities or complications which may
affect the course or cost of hospitalization). For each DRG produced,
the hospital receives a payment which amount corresponds to the national
tariff of DRG, intending to cover all hospital expenses.

Since a patient may have several hospital stays during a year, it is
possible to count the number of stays or the total cost of
hospitalization per year, by linking all his hospital stays based on his
patient's identification number.

\emph{Identification of patients operated on for menorrhagia}

The first step consisted in identifying within the PMSI-MCO database all
the hospitalizations of 35-55 year-old women who had a first surgical
management of menorrhagia in France from 1\textsuperscript{st} January
2009 until 30\textsuperscript{th} June 2014. Detailed information's
regarding the algorithm used has already been
described\textsuperscript{21}. Briefly, stays for surgical treatment
(with a CCAM code figuring in the Sup. Table 1) as PD or RD in patients
with menorrhagia (with an ICD-10 code figuring in the Sup. Table 2) were
selected. Patients already operated on for menorrhagia surgery were
excluded, to include incident patients only. Any patient identified as
presenting comorbidities, concomitant conditions (breast or colorectal
cancer), treatments potentially causes of bleeding (Willebrand disease,
myoma respectively, C and L of new terminology\textsuperscript{5}), as
well as patients with gynecological cancers, alcoholic liver,
gynecological and pelvic infections and inflammation, endometriosis,
uro-gynaecological prolapse, fistulas, polyps and dysplasia,
infertility, pregnancy, spina bifida, iatrogenic causes (I of new
terminology\textsuperscript{5}) or blood diseases were excluded as they
would introduce bias.

Stays were classified into one of four categories of surgical techniques
to treat AUB-O,E,N according to the CCAM code (Online supporting
material 1): \emph{(i)} second-generation (2G) endometrial ablation
techniques such as radiofrequency ablation or balloon
thermodestruction,\emph{(ii)} first-generation (1G) endometrial ablation
and/or resection techniques, such as loop resection and/or roller ball,
\emph{(iii)}curettage and \emph{(iv)} hysterectomy. Thanks to their
unique anonymous identifier, all patients were followed from their
initial surgery for at least 18 months and up to date point (31/12/2015)
or death, in order to detect any severe complications or failure.

\emph{Effectiveness criteria: rate of patients without failure or
complication}

In this cost-effectiveness analysis, the main criterion used to express
the effectiveness of the initial menorrhagia surgery was the rate of
patients without failure over time, for each surgical category. Using
a\emph{time-to-event} variable allowed considering both the proportion
of failures that occurred in each surgical group and their time of
occurrence. Failure \emph{(considered as the event)} was defined as the
first re-hospitalization that occurred either as \emph{i)} stay for new
bleeding surgery (\emph{Online supporting material 2} ), \emph{ii)} stay
containing a menorrhagia CIM-10 code stated as main- or
related-diagnosis or \emph{iii)} stay containing any CIM-10 codes for
pregnancy .

As a secondary endpoint, effectiveness of the initial AUB surgery was
also compared between strategies using the rate of patients without
severe complications over time. Severe complication was defined as the
first event that occurred either as \emph{1)} re-hospitalization during
the 30 days following the surgery due to anemia, shock, any complication
directly linked to the surgical intervention, pain, infection, blood
supply, inflammatory disorders or hemoperitoneum within urologic,
genital, abdominal or pelvic location or \emph{2)} re-hospitalization at
any time after the initial surgery due to adhesions, foreign body, pain,
ventral hernia, renal failure, intestinal obstruction or other digestive
disorders, urologic/genital disorders within urologic, genital,
abdominal or pelvic location.

\emph{Cost during and after menorrhagia surgery}

We compared the economic impact during and after the surgical management
of menorrhagia between strategies over time, by tracking all
re-hospitalizations. To do this, we calculated, for each patient, the
total cost of hospitalizations, by linking all stays that occurred from
the surgery and during a given period of time. For the base-case
analysis, the time horizon was fixed at 18 months, as all the included
patients had at least 18 months of follow-up, meaning that the total
cost can be considered as complete during the period (no cost
censoring). Sensitivity analyses were performed with a horizon time of
60 months, only for patients having a follow-up at least equal to 60
months.

Costs were restricted to hospital costs and were determined from the
French social security perspective. Hospital costs were calculated using
the national DRG tariffs for each year considered, and were expressed in
2017 Euros. Tariffs included nursing care, treatments, drugs, food and
accommodation, and investment costs. For public hospitals, tariffs also
covered medical and technical procedures. For private hospitals, costs
were estimated using the official DRG tariffs for private hospitals to
which physician's fees were added (as they are not included in DRG
tariffs and are reimbursed on a fee-for-service basis). Whatever the
sector, costs also included additional cost per day of hospitalisation
in an intensive care unit, if needed. Medications and devices prescribed
or delivered during outpatient visits were not considered, as well as
ambulatory costs and indirect costs related to productivity loss. Costs
are presented as mean cost per patient per strategy.

\emph{Statistical analyses and cost-effectiveness study}

Categorical data were expressed as proportions, whereas continuous data
were expressed as means and standard-deviations (SD).

Both time without failure and time without complications were considered
as censored data and were analyzed using a Kaplan-Meier survival method
and compared with a log-rank test. For each patient, occurrence of a
failure and its delay since the initial menorrhagia surgery were tracked
from the initial surgery date until death or last follow-up date
(31\textsuperscript{th}December 2015). If no failure occurred, the
patient was considered as having no failure (censored) at last follow-up
date. The occurrence of severe complication was tracked from the initial
surgery date until failure, death or last follow-up date
(31\textsuperscript{th} December 2015).

The cost-effectiveness analysis was performed comparing each surgical
strategy to the 2G one. Groups were both compared in terms of
incremental cost \emph{(\textbackslash{}euro)} and of incremental
effectiveness\emph{(rate of patients without failure)} of the different
surgical strategies, as compared to the 2G one, during the 18 months
following the initial surgery. Sensitivity analyses were performed by
varying the horizon time at 60 months, but the analysis was restricted
to the patients with at least this follow-up in the study (as patients
with a follow-up less than 60 months may have an underestimation of
costs). Secondary analyses were also performed by varying the
effectiveness criteria, using the complication rate alone. Analyses were
performed by using the R statistical software (version 3.2.3).

\textbf{Results}

\emph{Study population}

Between 1\textsuperscript{st} January 2009 and
30\textsuperscript{th}June 2014, 152,531 women, 35-55 years old,
hospitalized for AUB-O,E,N surgery were identified in the PMSI database,
of whom 42,658 presenting at least one exclusion criterion were
excluded. The cohort of patients available for analysis thus consisted
of 109,873 patients. Of these, 88,154 could be followed for 18 months
(Figure 1). In the study population, 5,730 women underwent a 2G surgical
procedure (6.5\%), 31,437 a 1G procedure (35.7\%), 32,304 curettage
(36.6\%) and 18,647 hysterectomy (21.2\%). Mean age of the patients was
46 ± 5.0 years, with no difference between groups.

\emph{Effectiveness: patients without failure or complications over
time}

The rate of patients without failure over time according to each
surgical strategy is presented in Figure 2. Hysterectomy was the most
effective strategy, as the rate of patients without failure was the
highest over time, attaining 97.2\% at 18 months and remaining stable
until 60 months (Table 2). Conversely, the rate of patients without
failure for 2G, 1G and curettage, being 90.1\%, 87.3\% and 79.4\% at 18
months (p\textless{}0.0001), showed decrease over time.

The rate of patients without complication over time according to each
surgical group is presented in Figure 3. Women undergoing hysterectomy
were at significantly higher risk for complications after surgery than
women undergoing 2G procedures (p\textless{}0.0001), whereas those
undergoing 1G procedures or curettage were at significantly lower risk
than patients treated by 2G procedure (p\textless{}0.0001).

\emph{Economic burden during and after menorrhagia surgery}

Table 1 gives the hospitalization costs for initial surgery and during
the following 18 months, for the different strategies. Costs were the
highest for women having undergone hysterectomy
(\textbackslash{}euro4,157 per patient on average), almost two-fold
higher than for the 2G and curettage (\textbackslash{}euro2,448 and
\textbackslash{}euro2,275 per patient, on average). 1G surgery procedure
was the least expensive surgical technique (\textbackslash{}euro2,100
per patient), allowing to reduce the hospitalization cost of
\textbackslash{}euro352 per patient, as compared to 2G.

\emph{Cost-effectiveness analysis}

The figures 4 and 5 illustrate cost-effectiveness plans, representing
the differences both in hospitalization costs and in effectiveness of
each surgical procedure at 18 months, compared to the 2G procedure.
Effectiveness is expressed as additional percent of patients without
failure in figure 4A, and as additional percent of patients without
complication in figure 4B.

Hysterectomy is the most effective procedure, as it has the lowest
failure rate, but also the most expensive one, with an incremental
cost-effectiveness ratio (ICER) estimated at \textbackslash{}euro24,008
± per additional \% of patients without failure at 18 months. It means
that, at 18 months following hysterectomy, it is necessary to pay on
average patients without failure, as compared to 2G. Hysterectomy was
conversely the strategy with the highest complication rate.

Curettage was the least effective procedure, as it was responsible for
20.6\% of failure at 18 months, even if it was slightly less expensive
than 2G (\textbackslash{}euro-177/patient). 1G procedure was also
slightly less effective than 2G procedure (-2.8\% of patients without
failure at 18 months) but was less costly (\textbackslash{}euro-352
/patient), leading to an ICER estimated at \textbackslash{}euro13,078
per additional \% of patients without failure at 18 months. It means
that it is possible to gain \textbackslash{}euro13,078/patient on
average, if we accept to lose one \% of success.

Regarding complications at 18 months, hysterectomy was dominated, as
this is the strategy with the lowest rate of patients without
complication and the more expensive (Figure 5). As compared to 2G, 1G
and curettage are both slightly more effective (+ 0.4\% and +0.5\%
patients without complication, respectively) and less expensive
(\textbackslash{}euro-352 and \textbackslash{}euro-177 per patient, on
average respectively), meaning that these strategies were both dominant.

\textbf{Discussion}

The present study was designed to compare, using a cost-effectiveness
analysis, the cost and the effectiveness of four surgical strategies
used for the treatment of AUB-O,E,N in France. It showed that
mini-invasive 2G and 1G procedures, which are recommended as preferred
solutions for the surgical treatment can also be considered as
cost-effective procedures, as they are associated with lower severe
complication rates and lower costs, when compared to curettage and
hysterectomy. Conversely, hysterectomy is the most expensive procedure,
because of the high cost of the initial surgery and the higher rate of
hospitalization for complications over time; curettage is the least
effective one with the highest rate of failures over time.

Our results are in accordance with previous cost-effectiveness studies,
confirming that 2G and 1G are cost-effective. Our study is the first and
the only one for which cost and effectiveness data are entirely
extracted from a unique source of data, \emph{i.e.} the PMSI database.
Roberts\textsuperscript{15} and Garside\textsuperscript{16} both point
out that theirs models included hypothetical patients and they built
them with multiple sources and limited available data.
Miller\textsuperscript{18} also regrets the incorporation in his model
of data from older studies, some of which predate the advent 2G
endometrial ablation technologies. Only Fernandez\textsuperscript{13},
Bischoff-Everding\textsuperscript{17} and
Cooper\textsuperscript{14}performed their cost analysis using economic
data collected on individual patients. These studies are however based
on small sample of patients (147, 88 and 660 patients, respectively),
which may not be representative of AUB surgical management. Our study
has the advantage of being based on observed cost and efficiency data
from patients in real-life conditions, in the largest and exhaustive
cohort of French patients, over a long observation period. The analysis
with KM curves allows considering the time of occurrence of events since
the initial surgery in patients with heterogeneous follow-up time.
Indeed, the sensitivity analysis based on patients with 60 months of
follow-up confirmed the conclusions at 18 months, demonstrating the
robustness of our results.

The use of the PMSI database for performing a cost-effectiveness
analysis presents other advantages. Since it is the basis of prospective
hospital funding, hospitals have to produce standardized reports for
each stay performed. Data extracted from the PMSI then presented a high
exhaustiveness (all public and private hospitals are included and no
sampling is done) and a high level of quality, with limited coding
errors. The large number of cases documented allowed the study outcomes
to be determined with high precision. Bias due to sampling errors and to
loss to follow-up should be minimal. The economic burden of AUB is also
expected to be well documented, as the management of the initial surgery
and of severe complications occurred in hospital setting. At the time of
study completion, hospital external activity was not available in the
PMSI database: activity such as consultations or some procedures could
not be tracked. Therefore, failure and complications that would have
occurred out of hospital and that would not have led to hospitalization
shall not have been tracked as they are not reported in the PMSI
database. We might have an overestimation of failure/complications
avoided. A linkage is currently available between the PMSI and SNIIRAM
(French sick funds comprehensive reimbursement database). However,
SNIIRAM could not be used in this study, as its access was not possible
within the study delay. Other costs could therefore not be tracked, such
as sick leaves, leading to potential underestimation of associated
costs. However, the overestimation of effectiveness as well as the
underestimation of costs might not be different between the 4 groups.

1G and 2G appear to be the preferred techniques. The cost of the device
could be offset by its greater use with a logical reduction in the
purchase cost and by the economy of occupying operating theaters because
performing 2G surgery is twice as fast as for 1G.

In conclusion, this study based on the largest cohort of patients
surgically treated for AUB-O,E,N confirms that 1G and 2G techniques are
the most efficient strategies in real-life conditions. Despite the fact
that hysterectomy and curettage are not recommended as first line
strategies, that curettage is the least effective strategy and
hysterectomy the most expensive one, both strategies are still used in
more than half patients as first line surgical treatment. Switching to
2G techniques would not require a specific training for surgeons, when
compared to curettage or hysterectomy, and it would decrease the annual
AUB budget impact of about 65 millions \textbackslash{}euro (as the
extra-cost of hysterectomy compared to 2G is 24,008 \textbackslash{}euro
and 3000 annual hysterectomies are done in France with 90\% of which are
not justified for this indication). Improving the 2G French tariffs
could foster this switch, allowing a more adapted treatment to these
patients, with a limited expected increase of costs for the National
Health Insurance. Moreover, most second-generation endometrial ablation
are still performed under general or epidural anaesthetic in an
operating theatre. However, the new small diameter devices should
encourage movement of minimal invasive surgery out of the traditional
operating theatre and this next development will accentuate the
cost-effectiveness of the treatment of heavy menstrual bleedings by 2G
techniques.

Finally, we are at a turning point where we have to balance the superior
efficiency of radical surgeries (total or subtotal hysterectomy) and the
lesser efficiency of 2G or 1G techniques, but despite all, that being
significant with less than 20\% reoperations, and their economic impact
for national health insurance.

\textbf{Disclosure of interests :} GD, JF, DT, PD, HF and IB received
personal fees from Hologic for their participation to Steering Committee
during the work. PD, HF and DT reports personal fees from HOLOGIC
France, outside the submitted work. HEVA works with all pharmaceutical
and medical devices industries like JANSSEN, BMS, PFIZER, NOVARTIS,
BSCI. JF reports personal fees from HEVA during the conduct of the study
and personal fees from Astellas Pharma outside the submitted work. IB
received personnel fees from Novartis, Allergan, CSL-Berhing, Merck
outside the submitted work.

\textbf{Contributions of authorship :} This study was~initiated by LdL,
LL, IB and supported by Hologic. IB, LDL and LL elaborated the protocol.
TL and GC performed the PMSI data extraction, their data-management and
their statistical analysis under the control of LL and LDL. IB performed
the cost-effectiveness analysis. GD, HF, DT, PD and JF were members of
the Steering Committee which oversaw the implementation of the study and
contributed to the interpretation of the study. The authors were fully
responsible for all content and editorial decisions. All the authors
made substantial contributions during all the stages of the work,
including the conception and design of the work, acquisition, analysis
and interpretation of data, manuscript development, revision of the
manuscript and have approved its final version.

\textbf{Details of ethics approval} \emph{:} The study was conducted in
accordance with relevant international and French regulatory
requirements. Since this was a retrospective study of an anonymized
database and had no influence on patient care, ethics committee approval
was not required. Use of the PMSI-MCO database for this type of study
has been approved by the French national data protection agency (CNIL;
annual authorization \#1419102 v7 -- 2015-111111-56-18 / order M14N056
and M14L056).

\textbf{Funding} : The study was funded by Hologic (no grant number), a
company that markets NovaSure®, a radiofrequency endometrial ablation
device. The funder had no role in study design, data collection and
analysis, decision to publish, or preparation of the manuscript.

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7 Marret H, Fauconnier A, Chabbert-Buffet N, \emph{et al.} Clinical
practice guidelines on menorrhagia: Management of abnormal uterine
bleeding before menopause. Eur. J. Obstet. Gynecol. Reprod. Biol.
2010;\textbf{152} : 133--7.

8 Cooper K, Lee AJ, Chien P, Raja EA, Timmaraju V, Bhattacharya S.
Outcomes following hysterectomy or endometrial ablation for heavy
menstrual bleeding: Retrospective analysis of hospital episode
statistics in Scotland. \emph{BJOG An Int J Obstet Gynaecol} 2011.
DOI:10.1111/j.1471-0528.2011.03011.x.

9 Kroft J, Liu G. First-Versus Second-Generation Endometrial Ablation
Devices for Treatment of Menorrhagia: A Systematic Review, Meta-Analysis
and Appraisal of Economic Evaluations. \emph{J Obstet Gynaecol
Canada}2013; \textbf{35} : 1010--9.

10 Lethaby A, Penninx J, Hickey M, Garry R, Marjoribanks J. Endometrial
resection and ablation techniques for heavy menstrual bleeding. Cochrane
Database Syst. Rev. 2013; \textbf{2013} .
DOI:10.1002/14651858.CD001501.pub4.

11 Daniels JP, Middleton LJ, Champaneria R, \emph{et al.} Second
generation endometrial ablation techniques for heavy menstrual bleeding:
network meta-analysis. BMJ. 2012; \textbf{344} . DOI:10.1136/bmj.e2564.

12 Cooper K, McCormack K, Breeman S, \emph{et al.} HEALTH: Laparoscopic
supracervical hysterectomy versus second-generation endometrial ablation
for the treatment of heavy menstrual bleeding: Study protocol for a
randomised controlled trial. \emph{Trials} 2018.
DOI:10.1186/s13063-017-2374-9.

13 Fernandez H, Kobelt G, Gervaise A. Economic evaluation of three
surgical interventions for menorrhagia. \emph{Hum Reprod}
2003;\textbf{18} : 583--7.

14 Cooper K, Breeman S, Scott NW, \emph{et al.} Laparoscopic
supracervical hysterectomy compared with second-generation endometrial
ablation for heavy menstrual bleeding: The HEALTH RCT. \emph{Health
Technol Assess (Rockv)} 2019. DOI:10.3310/hta23530.

15 Roberts TE, Tsourapas A, Middleton LJ, \emph{et al.} Hysterectomy,
endometrial ablation, and levonorgestrel releasing intrauterine system
(Mirena) for treatment of heavy menstrual bleeding: Cost effectiveness
analysis. In: BMJ (Online). 2011. DOI:10.1136/bmj.d2202.

16 Garside R, Stein K, Wyatt K, Round A, Pitt M. A cost-utility analysis
of microwave and thermal balloon endometrial ablation techniques for the
treatment of heavy menstrual bleeding. \emph{BJOG An Int J Obstet
Gynaecol} 2004; \textbf{111} : 1103--14.

17 Bischoff-Everding C, Soeder R, Neukirch B. Economic and clinical
benefits of endometrial radiofrequency ablation compared with other
ablation techniques in women with menorrhagia: A retrospective analysis
with German health claims data. \emph{Int J Womens Health}
2016;\textbf{8} : 23--9.

18 Miller JD, Lenhart GM, Bonafede MM, Basinski CM, Lukes AS, Troeger
KA. Cost effectiveness of endometrial ablation with the NovaSure® system
versus other global ablation modalities and hysterectomy for treatment
of abnormal uterine bleeding: US commercial and medicaid payer
perspectives. \emph{Int J Womens Health} 2015; \textbf{7} : 59--73.

19 Bezin J, Duong M, Lassalle R, \emph{et al.} The national healthcare
system claims databases in France, SNIIRAM and EGB: Powerful tools for
pharmacoepidemiology. \emph{Pharmacoepidemiol Drug Saf} 2017;\textbf{26}
: 954--62.

20 WHO. International Statistical Classification of Diseases and Related
Health Problems (International Classification of Diseases)(ICD) 10th
Revision - Version:2010. 2010.

21 de Léotoing L, Chaize G, Fernandes J, \emph{et al.} The surgical
treatment of idiopathic abnormal uterine bleeding: An analysis of 88 000
patients from the French exhaustive national hospital discharge database
from 2009 to 2015. \emph{PLoS One} 2019.
DOI:10.1371/journal.pone.0217579.

\textbf{Table 1: Hospitalization costs and rate of patients without
failure and without complication, over 18 months, for the different
surgical strategies}\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
\textbf{2G surgery} \textbf{N=5~730 pts}\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
\textbf{1G surgery} \textbf{N=31~473 pts}\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
\textbf{Curettage} \textbf{N=32~304 pts}\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
\textbf{Hysterectomy} \textbf{N= 18 647 pts}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Hospitalization costs}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Hospitalization costs}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Hospitalization costs}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Hospitalization costs}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Hospitalization costs}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Mean cost per patient at 18 months\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
2 448 \selectlanguage{ngerman}± 8254 {[}2234; 2661{]}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
2100 \selectlanguage{ngerman}± 3476 {[}2061 ; 2138{]}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
2 275 \selectlanguage{ngerman}± 5 278 {[}2217; 2332{]}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
4 157 \selectlanguage{ngerman}± 3 535 {[}4106; 4208{]}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Difference of cost as compared to 2G strategy\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
-352 \selectlanguage{ngerman}± 115 {[}-359 ; -345{]}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
-177 \selectlanguage{ngerman}± 115 {[}-185 ; -170{]}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
1705 \selectlanguage{ngerman}± 115 {[}1697 ; 1712{]}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Failure}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Failure}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Failure}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Failure}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Failure}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Rate of patients without failure at 18 months\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
90.1\% {[}89.3-90.8{]}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
87.3\% {[}86.9-87.6{]}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
79.4\% {[}79.0-79.9{]}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
97.2\% {[}97.0 ; 97.5{]}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Difference in the proportion of patients without failure at 18 months,
as compared to 2G\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
-2.8\% {[}-2.8 ; -2.8{]}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
-10.6\% {[}-10.7 ; -10.6{]}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
+7.1\% {[}7.1 ; 7.2{]}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Complication}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Complication}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Complication}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Complication}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Complication}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Proportion of patients without complication at 18 months\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
97.9\% {[}97.5-98.3{]}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
98.3\% {[}98.1-98.4{]}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
98.4\% {[}98.3-98.6{]}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
94.2\% {[}93.9 ; 94.6{]}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Difference in the proportion of patients without complication at 18
months, as compared to 2G\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
+0.4\% {[}0.4 ; 0.4{]}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
+0.5\% {[}0.5 ; 0.5{]}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
-3.7\% {[}-3.7 ; -3.7{]}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 2: Hospitalization costs and rate of patients without
failure and without complication, over 60 months, for the different
surgical strategies for the 33~093 patients with at least 60 months of
follow-up}\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
\textbf{2G surgery} \textbf{N=1 676 pts}\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
\textbf{1G surgery} \textbf{N=11~084 pts}\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
\textbf{Curettage} \textbf{N=13~335 pts}\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
\textbf{Hysterectomy} \textbf{N= 6~998 pts}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Hospitalization costs}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Hospitalization costs}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Hospitalization costs}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Hospitalization costs}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Hospitalization costs}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Mean cost per patient at 60 months\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
4 438 \selectlanguage{ngerman}± 7610 {[}3936-4206{]}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
4071 \selectlanguage{ngerman}± 7243 {[}3936 ; 4206{]}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
4~277 \selectlanguage{ngerman}± 8~553 {[}4132; 4422{]}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
6~435 \selectlanguage{ngerman}± 8~530 {[}6235; 6635{]}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Difference of cost as compared to 2G strategy\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
-367 \textbackslash{}euro\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
-161 \textbackslash{}euro\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
+1997 \textbackslash{}euro\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Failure}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Failure}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Failure}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Failure}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Failure}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Rate of patients without failure at 60 months\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
80.3\% {[}78.4-82.2{]}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
77.5\% {[}76.7-78.3{]}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
68.5\% {[}67.7-69.3{]}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
97.2\% {[}96.8 ; 97.6{]}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Difference in the proportion of patients without failure at 18 months,
as compared to 2G\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
-2.8\%\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
-11.8\%\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
+16.9\%\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Complication}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Complication}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Complication}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Complication}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Complication}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Proportion of patients without complication at 60 months\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
94.2\% {[}93.0-95.3{]}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
96.1\% {[}95.8-96.4{]}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
96.3\% {[}95.9-96.6{]}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
89.4\% {[}88.7-90.2{]}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Difference in the proportion of patients without complication at 60
months, as compared to 2G\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
+1.9\%\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
+2.1\%\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
-4.8\%\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\emph{List of figures :}

\textbf{Figure 1: Flow-chart of patients selected for study}

\textbf{Figure 2: Time without failure over time according the initial
surgical groups}

\textbf{Figure 3: Time without complication over time according to the
surgical groups}

\textbf{Figure 4: Cost-effectiveness plan}

\textbf{A - representing the difference of cost and the additional rate
of patients without failure of the surgical procedures at 18 months,
compared to the 2G groupB- representing the difference of cost and the
additional patient without complication of the surgical procedures
compared to the 2G}

Online supporting material 1: CCAM codes for menorrhagia surgery\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
CCAM code & French title\tabularnewline
\midrule
\endhead
2G (2\textsuperscript{nd} generation endometrial ablation techniques
such as radiofrequency, laser\ldots{}) & 2G (2\textsuperscript{nd}
generation endometrial ablation techniques such as radiofrequency,
laser\ldots{})\tabularnewline
JKND001 & Destruction de la muqueuse ut\selectlanguage{ngerman}érine par thermocontact, par voie
vaginale\tabularnewline
1G (1\textsuperscript{st} generation endometrial ablation techniques,
such as loop resection) & 1G (1\textsuperscript{st} generation
endometrial ablation techniques, such as loop resection)\tabularnewline
JKNE001 & Abrasion de la muqueuse de l'ut\selectlanguage{ngerman}érus {[}Endométrectomie{]}, par
hystéroscopie\tabularnewline
Curettage & Curettage\tabularnewline
JKGD002 & Curetage de la cavit\selectlanguage{ngerman}é de l'utérus à visée
thérapeutique\tabularnewline
JKQE001 & Hyst\selectlanguage{ngerman}éroscopie avec curetage de la cavité de l'utérus (without
JKND001)\tabularnewline
JKGD003 & Curetage de la cavit\selectlanguage{ngerman}é de l'utérus à visée diagnostique (with
anesthesia)\tabularnewline
Hysterectomy & Hysterectomy\tabularnewline
JKFC002 & Hyst\selectlanguage{ngerman}érectomie subtotale, par c\selectlanguage{polish}œ\selectlanguage{english}lioscopie\tabularnewline
JKFC006 & Hyst\selectlanguage{ngerman}érectomie subtotale avec annexectomie unilatérale ou
bilatérale, par c\selectlanguage{polish}œ\selectlanguage{english}lioscopie\tabularnewline
JKFC005 & Hyst\selectlanguage{ngerman}érectomie totale, par c\selectlanguage{polish}œ\selectlanguage{english}lioscopie\tabularnewline
JKFA018 & Hyst\selectlanguage{ngerman}érectomie totale, par c\selectlanguage{polish}œ\selectlanguage{english}lioscopie et par abord
vaginal\tabularnewline
JKFA026 & Hyst\selectlanguage{ngerman}érectomie totale, par abord vaginal\tabularnewline
JKFC003 & Hyst\selectlanguage{ngerman}érectomie totale avec annexectomie unilatérale ou
bilatérale, par c\selectlanguage{polish}œ\selectlanguage{english}lioscopie\tabularnewline
JKFA006 & Hyst\selectlanguage{ngerman}érectomie totale avec annexectomie unilatérale ou
bilatérale, par c\selectlanguage{polish}œ\selectlanguage{english}lioscopie et par abord vaginal\tabularnewline
JKFA005 & Hyst\selectlanguage{ngerman}érectomie totale avec annexectomie unilatérale ou
bilatérale, par abord vaginal\tabularnewline
JKFA024 & Hyst\selectlanguage{ngerman}érectomie subtotale, par laparotomie\tabularnewline
JKFA032 & Hyst\selectlanguage{ngerman}érectomie subtotale avec annexectomie unilatérale ou
bilatérale, par laparotomie\tabularnewline
JKFA015 & Hyst\selectlanguage{ngerman}érectomie totale, par laparotomie\tabularnewline
JKFA028 & Hyst\selectlanguage{ngerman}érectomie totale avec annexectomie unilatérale ou
bilatérale, par laparotomie\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{ngerman}

Online supporting material 2: ICD-10 codes for menorraghia\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
ICD-10 code\strut
\end{minipage} & \begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
Wording\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
N800\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Endom\selectlanguage{ngerman}étriose de l'utérus (Adénomyose) Endometriosis of uterus\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
N850\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Hyperplasie glandulaire de l'endom\selectlanguage{ngerman}ètre Endometrial glandular
hyperplasia\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
N920\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Menstruation trop abondante et trop fr\selectlanguage{ngerman}équente avec cycle menstruel
régulier Excessive and frequent menstruation with regular cycle\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
N921\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Menstruation trop abondante et trop fr\selectlanguage{ngerman}équente avec cycle menstruel
irrégulier Excessive and frequent menstruation with irregular
cycle\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
N924\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Saignements abondants de la pr\selectlanguage{ngerman}éménopause Excessive bleeding in the
premenopausal period\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
N925\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Autres irr\selectlanguage{ngerman}égularités menstruelles précisées Other specified irregular
menstruation\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
N926\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Irr\selectlanguage{ngerman}égularités menstruelles, sans precision Irregular menstruation,
unspecified\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
N938\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Autres saignements anormaux pr\selectlanguage{ngerman}écisés de l'utérus et du vagin Other
specified abnormal uterine and vaginal bleeding\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
N939\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Saignement anormal de l'ut\selectlanguage{ngerman}érus et du vagin, sans précision Abnormal
uterine and vaginal bleeding, unspecified\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{ngerman}

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\selectlanguage{english}
\FloatBarrier
\end{document}

