Please cite this paper as: Cooper K, Lee A, Chien P, Raja E, Timmaraju V, Bhattacharya S. Outcomes following hysterectomy or endometrial ablation for heavy menstrual bleeding: retrospective analysis of hospital episode statistics in Scotland. BJOG 2011; DOI: 10.1111/j.1471‐0528.2011.03011.x Objective  To determine the risk of further gynaecological surgery and gynaecological cancer following hysterectomy and endometrial ablation in women with heavy menstrual bleeding. Design  Population‐based retrospective cohort study. Setting  Scottish hospitals between 1989 and 2006. Population or sample  Scottish women treated with hysterectomy or endometrial ablation for heavy menstrual bleeding between 1989 and 2006. Methods  Anonymised data collected by the Scottish Information Services Division were analysed using appropriate methods across the hysterectomy and endometrial ablation groups. Cox proportional hazards regression analysis was used to examine the survival experience for different surgical outcomes after adjustment for age, year of primary operation and Carstairs quintile. Main outcome measures  Further gynaecological surgery and gynaecological cancer in women. Results  A total of 37 120 women had a hysterectomy, 11 299 women underwent endometrial ablation without a subsequent hysterectomy and 2779 women underwent endometrial ablation followed by a subsequent hysterectomy. The median (interquartile range) duration of follow‐up was 11.6 years (7.9, 14.8) and 6.2 years (2.7, 10.8) in the hysterectomy and endometrial ablation (without hysterectomy) cohorts, respectively. Compared with women who underwent hysterectomy, those who underwent ablation were less likely to need pelvic floor repair adjusted hazards ratio, 0.62; 95% confidence interval (95% CI), 0.50, 0.77 or tension‐free vaginal tape surgery for stress urinary incontinence (adjusted hazards ratio, 0.55; 95% CI, 0.41, 0.74). Abdominal hysterectomy was associated with a lower chance than vaginal hysterectomy of pelvic floor repair surgery (hazards ratio, 0.54; 95% CI, 0.45, 0.64). Overall, the number of women diagnosed with cancer was small, the largest group being breast cancer (n = 584, 1.57% and n = 130, 1.15% in the hysterectomy and endometrial ablation groups respectively; adjusted hazards ratio, 1.14; 95% CI, 0.93–1.39). Conclusions  Hysterectomy is associated with a higher risk than endometrial ablation of surgery for pelvic floor repair and stress urinary incontinence. Surgery for pelvic floor prolapse is more common after vaginal than abdominal hysterectomy.