Does medical debulking with gonadotrophin-releasing hormone agonist facilitate vaginal hysterectomy with a moderate enlarged uterus? A randomized control study

Abstract

BackgroundVaginal hysterectomy is considered the method of choice for removal of the uterus but most gynecologists still prefer the abdominal route for removal of benign uteri >14 weeks in size. Conversion of an abdominal to a potential vaginal hysterectomy by uterine size reduction would be advantageous. Gonadotrophin-releasing hormone (GnRH) agonists can reduce uterine bulk by up to 50%. ObjectiveTo evaluate the efficacy of the preoperative administration of a GnRH agonist for women with enlarged non-prolapsing uteri in order to facilitate vaginal hysterectomy, in comparison with patients with enlarged uteri who underwent direct total abdominal hysterectomy (TAH) for the same indication (menorrhagia). Study designRandomized controlled study. Women scheduled for hysterectomy for menorrhagia with a non-prolapsing uterus of ≥14 weeks size (by clinical and sonographic assessments) were offered a trial of vaginal hysterectomy after pre-treatment with a GnRH agonist (goserelin) for 3 months (study group=Group 1=40). A group of women with uteri of comparable size who underwent abdominal hysterectomy for similar indications served as controls (Group 2=40). Pre- and post-operative data such as hemoglobin, myoma size, uterine weight, duration of procedure and complications, pain score and length of hospital stay were collected prospectively. ResultsThe weight of the uterine specimen was significantly lower in Group 1 (511.7±217g) compared to Group 2 (736.8±212g); P<0.001. The mean objective decrease in clinical uterine bulk preoperatively in Group 1 was 20.1%. The duration of surgery was nearly 1.5 times as long in vaginal (119.6±41.7min) compared to abdominal hysterectomy (81.1±34.1min), P<0.001, but analgesia use and the length of inpatient stay were significantly lower in Group 1 (2.6±1.3 days) compared to Group 2 (4.12±1.7 days), P<0.001. There was no significant difference between the two groups as regards the rate of occurrence of surgical complications. ConclusionsIn women with ≥14 week size uteri, treatment with a GnRH agonist reduces uterine size sufficiently to allow safe vaginal hysterectomy. Although duration of surgery was longer, women who underwent vaginal hysterectomy required less analgesia and had a shorter inpatient stay.