Factors influencing decision-making among rural women with abnormal uterine bleeding: A prospective observational study from central India

Background: Abnormal uterine bleeding (AUB) is a frequent reason for gynecological consultation and, in resource-limited rural settings, may become a pathway toward hysterectomy even when conservative options remain clinically appropriate. Distance from care, limited understanding of the disease, absence of prior documentation, and family-level decision-making can all shape treatment preference in ways that are not captured by diagnosis alone.

To describe the sociodemographic, clinical, access -related, and perception -based factors influencing decision -making about conservative versus operative management among rural women presenting with AUB.

This prospective observational study was conducted in the Department of Obstetrics and Gynecology, R.S.D.K.S. Government Medical College, Ambikapur, from January 2022 to October 2023. A total of 230 consenting women with AUB were interviewed one -to-one after counselling regarding disease nature and available tre atment options. Demographic variables, access constraints, bleeding pattern, prior treatment history, diagnostic category, and reasons favouring hysterectomy were summarized as frequencies and percentages.

AUB accounted for 47% of gynecological out patient attendance during the study period. Most women were aged 36 -40 years (138/230, 60%), had parity 1 -3 (184/230, 80%), belonged to low socioeconomic status (195/230, 85%), and were uneducated (184/230, 80%). Seventy percent (161/230) travelled more th an 100 km to reach the hospital. Prolonged heavy menstrual bleeding was the dominant complaint (161/230, 70%), and 172 women (75%) reported bleeding for more than eight days per cycle. Previous medical treatment for AUB was absent in 184 women (80%), while 207 (90%) had no records of earlier care. Adenomyosis (88/230, 38%) and leiomyoma (80/230, 35%) were the most frequent diagnostic categories. The commonest decision -influencing reasons were lack of awareness of options other than surgery (207/230, 90%), p rolonged suffering (161/230, 70%), distance -related difficulty in returning for follow-up (161/230, 70%), and the husband's belief that surgery would cure the illness (138/230, 60%).

Decision-making for AUB among rural women in this cohort was d riven not only by pathology but also by health literacy, travel burden, missing treatment documentation, chronicity of symptoms, and household influence. Strengthening early counselling, peripheral follow -up linkages, and documentation of medical managemen t may reduce avoidable progression toward hysterectomy while preserving timely surgery for clinically indicated cases.

Abnormal uterine bleeding, hysterectomy, rural women, decision -making, PALM-COEIN, health access, India

Abnormal uterine bleeding is not a single disease label. It is a clinical presentation covering disturbances in menstrual frequency, regularity, duration, or volume, and its causes are now most usefully organized through the FIGO PALM -COEIN system, which s eparates structural causes such as polyp, adenomyosis, leiomyoma, and malignancy/hyperplasia from non - structural causes such as coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not - yet-classified conditions [1]. The diagnostic language matt ers. When AUB is described only as “heavy bleeding” or “menstrual problem,” the underlying cause may be missed, and the woman may move directly into a surgical narrative before medical or uterine -preserving choices have been properly explored [2]. The burde n is also not merely gynecological. A systematic review found that AUB among reproductive-age women is associated with impaired health -related quality of life, work loss, and considerable healthcare utilization [3]. Heavy menstrual bleeding, in particular, can quietly International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 501 ~ narrow a woman's social and economic life. It affects travel, daily labour, sexual life, religious participation, and the ability to attend family or agricultural responsibilities without anxiety about bleeding through clothes. Such consequence s are often under-reported in rural outpatient consultations because women may normalize heavy bleeding after childbirth, sterilization, or the onset of Perimenopause [4]. Indian good clinical practice recommendations emphasize structured evaluation, classi fication according to etiology, and medical or conservative management wherever clinically appropriate. For several AUB categories, first -line approaches include tranexamic acid, non -steroidal anti-inflammatory drugs, combined oral contraceptives, oral pro gestins, or levonorgestrel intrauterine system, while hysterectomy is generally reserved for specific indications, failure or refusal of medical management, contraindications to conservative options, completed fertility with appropriate pathology, or malig nant/premalignant disease [5]. This treatment hierarchy, however, enters a very different reality in rural India. National surveys show that hysterectomy is not evenly distributed across social and geographic groups, and treatment decisions may be shaped by age, parity, residence, private-sector exposure, and reported symptoms such as excessive bleeding or fibroids [6]. Recent Indian analyses have further shown that hysterectomy is more commonly reported among women above 35 years and that excessive menstrual bleeding or pain remains one of the dominant self -reported reasons for undergoing the operation [7]. Earlier NFHS -based work also highlighted rural residence, low schooling, higher parity, and regional variation as relevant determinants [8]. The present stu dy was therefore planned around a practical question seen every day in tertiary gynecology clinics serving remote catchments: why do rural women with AUB lean toward hysterectomy, even when conservative treatment is explained? The objective was to describe the sociodemographic, clinical, access-related, and perception -based factors influencing decision-making regarding conservative versus operative management among rural women presenting with AUB at a tertiary care hospital in Ambikapur.

Study Design and Setting: A prospective observational study was conducted in the Department of Obstetrics and Gynecology, R.S.D.K.S. Government Medical College, Ambikapur , from January 2022 to October 2023. Study Population Women presenting to the gynecology outpatient department with complaints of abnormal uterine bleeding and consenting to participate were included. The final study group consisted of 230 women. Sampling Method: Eligible consenting women attending the outpatient service during the st udy period were enrolled prospectively. Data Collection; Demographic details, parity, socioeconomic status, education, approximate distance from residence to hospital, bleeding pattern, prior treatment history, availability of previous records, diagnostic category, and self -reported reasons influencing treatment choice were recorded. Each woman was interviewed one -to-one after counselling regarding the disease process and available treatment options. Where reasons were expressed in local language, they were grouped into clear operational categories for analysis. Study Variables: The main variables were age group, parity, socioeconomic status, educational status, residence -to-hospital distance, presenting bleeding complaint, duration of bleeding, pads or cloths used per day, prior medical treatment for AUB, availability of previous treatment records, PALM -COEIN diagnostic category, and reported reasons favouring operative management. Operational Definitions: A decision -influencing factor was defined as any reason stated by the woman or her accompanying family member that shaped preference toward hysterectomy or difficulty accepting conservative management. Access difficulty was defined using travel distance and inability to return for repeated visits. Prior treatment documentation referred to written prescriptions, investigations, discharge notes, or other medical records available at the time of consultation. Statistical Analysis: Qualitative variables were summarized as frequencies and percentages. As the study was descriptive and the available variables did not include a comparative outcome group with complete inferential fields, no hypothesis testing was performed. The outpatient proportion of AUB was reported descriptively because the underlying denomina tor for total gynecological outpatient attendance was not available in analyzable form. Ethical Considerations: Informed consent was obtained from all participating women. Institutional Ethical Committee clearance was obtained.

During the study p eriod, 230 women with AUB consented to participate. AUB accounted for 47% of gynecological outpatient attendance during the same period. This figure is presented as an OPD -based proportion rather than a population incidence. The age distribution was concen trated in the late reproductive and perimenopausal years: 138 women (60%) were aged 36 -40 years, 58 (25%) were aged 41 -45 years, and 34 (15%) were aged 31-35 years (Table 1 and Figure 1). Table 1: Sociodemographic and access profile of women with AUB (n=230) Characteristic Category n % Age group (years) 31-35 34 15 36-40 138 60 41-45 58 25 Parity Nullipara 12 5 1-3 184 80 4-6 34 15 Socioeconomic status Lower middle 35 15 Low 195 85 Educational status Uneducated 184 80 Educated up to primary 35 15 Educated up to high school 11 5 Distance from residence Within 50 km 23 10 50-100 km 46 20 >100 km 161 70 International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 502 ~ Fig 1: Age distribution of women presenting with abnormal uterine bleeding Bar chart displays participant counts and corresponding percentages by age group. Parity 1-3 was reported by 184 women (80%), while 34 (15%) had parity 4 -6 and 12 (5%) were nulliparous. Low socioeconomic status was recorded in 195 women (85%), and 184 women (80%) were uneducated. Travel burden wa s a prominent feature of the cohort: 161 women (70%) travelled more than 100 km to attend the outpatient department, while only 23 (10%) lived within 50 km of the facility (Table 1). The dominant presenting complaint was prolonged heavy menstrual bleeding, reported by 161 women (70%). Heavy menstrual bleeding without prolonged duration was reported by 58 (25%), and intermenstrual bleeding by 11 (5%). Bleeding for more than eight days per cycle was reported by 172 women (75%), and the same number reported us ing more than eight pads or cloths per day. Prior medical treatment for AUB was absent in 184 women (80%), while 207 women (90%) had no previous records available at consultation (Table 2 and Figure 2). Table 2: Bleeding pattern, prior care, and documentation status (n=230) Clinical/access variable Category n % Presenting complaint Intermenstrual bleeding 11 5 Heavy menstrual bleeding 58 25 Prolonged heavy menstrual bleeding 161 70 Reported bleeding days per cycle 2-4 days 12 5 4-8 days 46 20 >8 days 172 75 Pads/cloths used per day 4-7 58 25 >8 172 75 Previous medical treatment for AUB Yes 46 20 No 184 80 Previous treatment records available Yes 23 10 No 207 90 AUB: abnormal uterine bleeding Fig 2: Previous medical treatment and availability of treatment records International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 503 ~ Stacked bars show yes/no responses for previous AUB treatment and medical documentation. Diagnostic classification showed a predominance of structural causes. Adenomyosis was diagnosed in 88 women (38%) and leiomyoma in 80 (35%). Malignancy or endometrial hyperplasia accounted for 23 cases (10%). Among non -structural causes, ovulatory dysfunction and endometrial causes were each recorded in 12 women (5%). Smaller proportions were classified as polyp, coagulopathy, iat rogenic, or not yet classified (Table 3 and Figure 3). Table 3: Diagnostic profile according to PALM-COEIN categories (n=230) PALM-COEIN diagnostic category n % Polyp 4 2 Adenomyosis 88 38 Leiomyoma 80 35 Malignancy/hyperplasia 23 10 Coagulopathy 3 1 Ovulatory dysfunction 12 5 Endometrial 12 5 Iatrogenic 4 2 Not yet classified 4 2 Percentages are rounded to the nearest whole number and match the recorded study categories Fig 3: Distribution of diagnostic categories among women with AUB Donut chart shows the proportion of each recorded PALM - COEIN category. When women were asked why they were inclined toward hysterectomy or found repeated conservative management difficult, the most frequent reason was lack of awareness of any treatment op tion other than surgery, stated by 207 women (90%). Prolonged suffering and distance -related inability to return for follow -up were each reported by 161 women (70%). Husband-driven belief that uterine surgery would cure the illness was reported in 138 wome n (60%). Fear of cancer was reported by 57 women (25%). Because more than one reason could be reported by the same woman, these percentages are not mutually exclusive (Table 4 & Figure 4). Table 4: Self-reported factors influencing preference toward operative management (n=230) Decision-influencing factor n % Unaware of treatment options other than surgery 207 90 Troubled by symptoms for a long period 161 70 Perceived lack of benefit from medicines 69 30 Residence too far / difficulty returning for follow-up 161 70 Belief that there is a uterine lump 69 30 Belief that the uterus is swollen 104 45 Husband's belief that surgery will cure the illness 138 60 Fear of cancer 57 25 Multiple responses were allowed; therefore, percentages exceed 100 when summed International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 504 ~ Fig 4: Self-reported factors influencing decision-making toward hysterectomy Horizontal bars show multiple -response frequencies; percentages use n=230 as denominator.

This study shows that decision -making for AUB in rural women is shaped by a cluster of clinical, social, and access -related pressures rather than by diagnosis alone. The most visible finding is the heavy concentration of women in the 36 -40-year age group, with low educational status, low socioeconomic status, substantial travel distance, and prolonged symptoms. In practical terms, these women were not simply choosing between tablet and surgery in an equal clinical space. Many were choosing under fatigue, uncertainty, and the fear that another hospital visit might not be possible. The OPD -based AUB proportion of 47% reinforces how large the symptomatic burden can be in a tertiary gynecology service receiving rural referrals. Since the denominator was not available for independent verification, the value should not be read as community incidence. Even so, it fits the larger observation that menstrual morbidity is a frequent and under - treated reason for gynecological consultation. Indian spatial analyses of hysterectomy have shown clear variation by place of residence and district, and rural women often carry delayed care pathways before reaching surgical services [9]. Adenomyosis and leiomyoma together accounted for nearly three-fourths of the diagnoses in this cohort. That pattern is clinically important because b oth conditions can cause heavy and prolonged bleeding, anaemia, pelvic discomfort, and repeated health visits. National evidence has shown that bleeding complaints and fibroids/cysts are commonly reported reasons for hysterectomy in India [7]. Desai and colleagues, using older women's national survey data, have also drawn attention to the long life -course consequences of early hysterectomy, particularly when surgery occurs before natural menopause .[10] The present study does not evaluate long -term outcomes, but it places the decision point under a sharper lens. The absence of prior medical treatment in 80% of women and the lack of previous records in 90% are among the most actionable findings. When prescriptions, ultrasound reports, endometrial sampling resul ts, or anaemia management details are unavailable, the clinician at a tertiary centre has to reconstruct the entire history from memory. That uncertainty can push both patient and provider toward a definitive solution, especially if the woman has travelled more than 100 km and cannot promise follow -up. Khunte et al. described similar rural constraints in central India, including prior irregular treatment, poor compliance, transport difficulty, wage loss, and refusal to return for follow -up [11]. The overlap with the present cohort is striking. The strongest decision -influencing factor was not pain, bleeding volume, or even a diagnosis. It was lack of awareness that treatment options other than surgery existed. This matters. A woman who knows only hysterectomy will interpret counselling differently from a woman who has previously received a structured explanation of tranexamic acid, hormonal therapy, LNG-IUS, endometrial evaluation, myomectomy, or staged follow-up. Desai's qualitative work from rural Gujarat de scribed hysterectomy as a “permanent solution” for women facing severe gynecological symptoms, insecure work, poor access to care, and household-level pressure [12]. The present findings echo that narrative, particularly in the 60% of women where the husband's belief in surgery as cure was recorded. Distance was not merely a geographic variable. For 70% of women, travelling more than 100 km meant cost, time, dependence on an escort, loss of daily wages, and sometimes social permission to leave home. A conservative plan that requires repeated visits may be scientifically correct but practically fragile unless the woman can be linked to a nearby facility. This is where counselling has to become operational: the woman should leave with a written diagnosis, an explained treatment plan, red -flag symptoms, anaemia management advice, and a realistic follow -up location closer to home. Without that chain, “conservative managemen t” can sound like postponement rather than care. Guidelines also support this measured approach. NICE emphasizes treatment choice based on the woman's symptoms, International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 505 ~ quality-of-life burden, clinical findings, and priorities, not blood loss alone.[13] ACOG guidance for acute AUB states that medical management should be the initial treatment for most clinically appropriate patients after assessment and stabilization .[14] Cochrane evidence similarly supports medical options such as LNG-IUS and antifibrinolytics for heavy menstrual bleeding, while recognizing that invasive procedures may be needed when conservative treatment fails, is unsuitable, or is not acceptable to the woman [15]. None of this means hysterectomy should be denied where it is clearly indicated. Mal ignancy, atypical hyperplasia, large symptomatic fibroids in women who have completed fertility, failed medical treatment, and severe quality -of-life impairment may all justify surgery after adequate evaluation. But the route to hysterectomy should be a de cision, not a default. When hysterectomy is required for benign disease, evidence favours the least invasive safe route, with the decision individualized to pathology, uterine size, surgical expertise, and patient factors.[16] This study has limitations. I t was conducted at a single tertiary care institution and therefore reflects women who reached a referral hospital, not all rural women with AUB in the community. The OPD -based AUB proportion could not be converted into a true incidence measure because the complete denominator was not available for analysis. The study used descriptive statistics only, and the final uptake of conservative versus operative treatment after counselling was not recorded in a way that allowed comparative testing. Reasons for deci sion- making were grouped into operational categories, which may simplify the emotional and household dynamics behind each answer. Even with these constraints, the findings are useful because they identify modifiable points: awareness, written documentation, local follow -up, husband/family counselling, and earlier treatment before symptoms become chronic.

Among rural women presenting with AUB in this tertiary care cohort, preference toward hysterectomy was influenced by limited knowledge of cons ervative options, prolonged heavy bleeding, long travel distance, lack of prior treatment documentation, low educational status, and family -level beliefs about surgery. Adenomyosis and leiomyoma were the leading diagnostic categories, but pathology alone d id not explain the decision-making pattern. Early counselling at peripheral facilities, structured written treatment plans, anaemia and bleeding control protocols, and practical referral -back linkages may help women receive timely conservative care while s till allowing hysterectomy for clear and well-counselled indications.  Source of Funding: Nil  Conflict of Interest: Nil  Conflict of Interest: Not available  Financial Support: Not available

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