Minimalism in gynaecology

Abstract

The traditional definitive treatment of endometriosis is total abdominal hysterectomy and bilateral salpingooophorectomy but as R. D. Clayton and colleagues point out (pages 740744), even this radical surgery may fail to alleviate symptoms of the disease. This is because of persistent activation of endometriosis by unopposed oestrogen in hormone replacement therapy taken by the women after removal of their ovaries. The authors describe a case series of five women with persistent endometriosis, in the rectovaginal septum, colon or ureter, who were successfully treated by laparoscopic excision of these endometriotic deposits, with relief of their symptoms. The implication of this study is that it may be preferable to treat endometriosis by a conservative operation such as laparoscopic excision as a primary procedure, rather than by radical surgery such as total abdominal hysterectomy and bilateral salpingooophorectomy. The results of conservative surgery for endometriosis may be disappointing, however, with recurrence of the disorder and its associated symptoms, and this led Paolo Vercellini and his colleagues (pages 672677) to won der whether temporary suppression of ovarian function after conservative surgery may result in fewer recurrences of pelvic pain. The authors performed a randomised trial of goserelin given for six months after conservative surgery, compared with no treatment, in 269 women attending nineteen centres in Italy which specialise in reparative and reconstructive surgery. The trial was conducted rigorously, and used objective scales to measure the women's discomfort in the months following their surgery. After two years about onethird of the women experienced recurrence of their symptoms, and there was no significant difference in the risk of recurrence in the two groups of women; however the time to develop recurrence of symptoms was significantly longer in the women receiving goserelin. In women wishing to conceive treatment with goserelin did not reduce the chance of pregnancy. In a similar way to endometriosis the traditional definitive treatment of submucous fibroids of the uterus is total hysterectomy, but Roger Hart and his colleagues (pages 700705) challenge that view. The authors carried out hysteroscopic myomectomy in 122 women with submucous fibroids and followed them for one to seven years. Menstruation improved in fourfifths of the women and dysmenorrhoea in threequarters, but one in seven women required further surgery, usually repeated hysteroscopic myomectomy. Cox's proportional hazards model showed that uterine size less than a six week pregnancy and the situation of the submucous fibroid mainly inside the uterine cavity were associated with a reduced risk of further surgery, which was not associated with the age of the woman, the number and size of the fibroids or pharmacological preparation of the endometrium before the procedure. Where the outcome is avoidance of further surgery the survival curve is almost identical to that of endometrial ablation for excessive menstruation in the absence of uterine fibroids. There are now many ways of undertaking endometrial ablation, and David Hodgson and his colleagues (pages 684694) describe another, microwave endometrial ablation. The authors describe technical details of the equipment, initial studies to measure the temperature generated at the tip of the applicator and the depth of its sue necrosis, and a case series of 43 women treated by this technique who were followed for at least three years. Six out of seven women were satisfied by the treatment as regards their excessive menstruation, and one bonus was that in most women their periods were much less painful. Hodgson and colleagues recommend a ran domisedtrial to compare microwave endometrial ablation with other techniques of endometrial destruction. In a different sense gynaecology is changing to minimalism, for while in obstetric practice we are coming to terms with the shortcomings of our standard tests and are beginning to abandon them, in gynaecology we are developing newer, effective and less invasive treatments, and are beginning to adopt them. The traditional definitive treatment for endometrosis, uterine fibroids and dysfunctional uterine bleeding is hysterectomy, but all practising gynaecologists should now learn minimally invasive techniques; information is gathering that they are effective and safe, and that women prefer them.