Levonorgestrel‐IUD should be offered before hysterectomy for abnormal uterine bleeding without uterine structural abnormalities: there are no more excuses!

Abstract

In this issue, data from a randomized controlled trial of the levonorgestrel-releasing intrauterine system (LNG-IUS) versus hysterectomy in the treatment of 228 women with menorrhagia is published (1). Surprisingly, these data on a five years follow-up, in contrast to the findings at one year of follow-up, show the LNG-IUS to be more beneficial than hysterectomy on lower back pain. In a one year follow-up published before, data on the decision to treat menorrhagia with hysterectomy rather than LNG-IUS showed that this was three times more expensive after one year of follow-up (2). There was improvement in both the hysterectomy and LNG-IUS groups in quality of life, sexual function and social well-being, and there was no difference in the improvement achieved between hysterectomy and the LNG-IUS. However, there was a benefit of hysterectomy, which showed lesser pelvic pain. These short-term data of better pain scores provided some excuse for performing hysterectomy before the effect of a LNG-IUS had been tried. The new long-term data published now do not offer any good excuse for treating abnormal uterine bleeding without structural uterine abnormalities (i.e. dysfunctional uterine bleeding, DUB) with hysterectomy before the LNG-IUS has been tried. Other data from this study of long-term follow-up on quality of life and psychosocial well-being did not reveal any substantial difference between the two groups. Although 42% of the women assigned to the LNG-IUS group eventually had a hysterectomy, the direct and indirect costs in the LNG-IUS group was almost half (60%) of the price for a hysterectomy (3). The potential risks associated with hysterectomy include immediate operative complications such as bleeding and infection, and a 1% risk of damage of the internal organs (4). Despite several efforts during the last years, the risk of complications at hysterectomy has been rather high and has not decreased considerably. Data from the Scandinavian databases (5, 6) have shown significant complications for one in every 8–12 benign hysterectomies. Thus, there is a substantial morbidity and even mortality with expense to both the individual and society. Short-term consequences of hysterectomy are well-known with an overall benefit in quality of life, sexuality and reduced numbers of patients with pain. However, it is recognized that some of the patients experience more pain after the treatment and develop chronic pain caused by the surgery itself. This can probably be explained by nerve injury or inflammatory response to surgery, or by aggravation of preoperative causes (7). Moreover, estrogen-dependent age-related change in vertebra position could cause back pain, as discussed in (1). Long-term costs of hysterectomy are not very well described and there is still accumulating evidence on some of the long-term expenses of hysterectomies. Concerns have been raised on the possible impact of hysterectomy on ovarian function. Premature loss of ovarian function is associated with long-term health risks, and an overall increased mortality. Although there is a beneficial effect of premature loss of ovarian function on the risk of breast cancer, the increased risk of cardiac disease, stroke and overall cancer risk induce an overall worse effect on health (8). Although some of the information is contradictory, several data indicate that abdominal hysterectomy with ovarian conservation has an impact on ovarian function, inhibin-B levels, ovarian blood-flow, follicle stimulating hormone levels and hot flushes (9–11). In a prospective five year case control study, hysterectomy with ovarian conservation was associated with a 3.7 years earlier menopause compared to the control group, and women who had a unilateral oophorectomy reached the menopause 4.4 years earlier than controls without a hysterectomy (12). Women with a prior hysterectomy might have an increased risk of development of urinary incontinence late in life (13). In a systematic review on women who had a hysterectomy and were 60 years or older, the summary odds ratio for urinary incontinence was increased by 60%, but odds were not increased for women younger than 60 years (14). The risk with operations for stress incontinence is 2.4 times as high in women who have had a hysterectomy compared to women without that operation (15). Moreover, hysterectomy increases the risk for bothersome urge incontinence and other types of incontinence (16, 17). Although this issue is controversial, and some older studies with short-time follow-up have shown conflicting results, the increasing number of data sets which indicate that hysterectomy has a negative effect on continence and ovarian function should at least raise some concern. Are women in Scandinavia then offered minimal invasive therapy such as LNG-IUS for dysfunctional uterine bleeding before hysterectomy? Among women in Sweden who had a hysterectomy based on heavy menstrual bleeding without uterine enlargement, only 53% had tried an LNG-IUS before hysterectomy (5), and this constitutes fewer patients than reported from a University Clinic in the Netherlands (69%) (18). In Denmark, there are no data on the use of LNG-IUS before hysterectomy, but data on surgical intervention indicate some high surgical treatment preferences. Despite the introduction of alternatives, the number of surgical interventions has increased during the last 10 years. According to the national Danish register, more than 6,000 hysterectomies are performed annually in Denmark mostly on benign indications. The proportion of hysterectomy performed on main benign indications such as abnormal bleeding, myomas and pain, has not changed substantially during the last 10 years, although numbers of hysterectomies performed for abnormal bleeding have increased from 1 in 5 to 1 in 3 for benign hysterectomy. Moreover, the number of hysteroscopic procedures has doubled during the last 10 years to more than 2,000 procedures and embolization of uterine myomas has been introduced. The only explanation for this rise is that patients' and doctors acceptance for abnormal bleeding has been lowered during the years and more women are treated. The increase in minimally invasive interventions is accompanied by a failure rate and thereby more re-interventions. With the shifting threshold for intervention and the accompanying re-interventions, the numbers of hysterectomies are at present stable. With a lowered threshold for intervention, it is questionable whether the severity of symptoms actually indicated hysterectomy, but several studies during the last years have indicated that quality of life is improved with the present threshold for intervention. Nevertheless, these studies of surgical interventions are seldom done with the needed long-term follow-up in mind. At the present threshold for intervention, the effect on the older female pelvis of a premenopausal hysterectomy for pelvic pain, back pain, urinary incontinence and prior menopause might have some consequences, and the impact of these consequences might come to more light in the next years. Although more women are offered minimally invasive alternatives before hysterectomy, there seems to be plenty of room for progress. Primarily, it is important to offer and motivate patients for LNG-IUS as a first choice for DUB. Moreover, correct selection of patients for the different treatment alternatives could reduce failure rates, and concentrated efforts might avoid premature removal of the LNG-IUS. A combination of LNG-IUS and hysteroscopic surgery seems to be beneficial in several situations and should more often be tried before hysterectomy (19).