Treatment of menorrhagia

Abstract

In Ritva Hurskainen and colleagues’ (Jan 27, p 273)1Hurskainen R Teperi J Rissanen P et al.Quality of life and cost-effectiveness of evonorgestrel-releasing intrauterine system versus hysterectomy for treatment of menorrhagia: a randomised trial.Lancet. 2001; 357: 273-277Summary Full Text Full Text PDF PubMed Scopus (268) Google Scholar comparison of levonorgestrel-releasing intrauterine system (IUS) with hysterectomy for treatment of menorrhagia, they report a significant improvement in heath-related quality of life after both treatments, but no differences in other variables between the two groups. During the first year, the costs of treatment with an IUS are lower than the cost of treatment with hysterectomy. In the hysterectomy group, Hurskainen and colleagues report a mean waiting time between randomisation and surgery of 6·7 months, with a maximum of 21 months. Followup visits after treatment are 6 and 12 months after treatment. If the waiting time to surgery is taken into account, the follow-up visits in the hysterectomy group are on average 1 and 1·5 years after randomisation, whereas the follow-up visits in the IUS group are actually at 6 and 12 months. Consequently, the groups are not as equal as the baseline characteristics suggest. Furthermore, whether the hysterectomy group's cumulative costs were calculated from randomisation or from time of surgery is unclear. The mean waiting time for surgery of more than 6 months is also of concern in the interpretation of the hysterectomy rate in the IUS group, which is 20% in the first year. Could the investigators provide information about the number of patients who were scheduled for hysterectomy, but who were waiting for the procedure in the first year? Hurskainen and colleagues report on quality of life 12 months after treatment, whereas nothing is stated about the measurements at 6 months. In our opinion, repeated-measures analysis of variance to establish changes in healthrelated quality of life over time (time effect), differences in quality of life between the two treatment groups (treatment effect), and interaction between changes in quality of life over time by treatment group (time by treatment effect), would be more appropriate.2Zwinderman AH Statistical analysis of longitudinal quality of life data with missing measurements.Qual Life Res. 1992; 1: 219-224Crossref PubMed Scopus (52) Google Scholar This approach would also take into account the quality-of-life data from follow-up measurements after 1 year for patients who were included from the beginning of the study. Half the included patients had subserous or intramural fibroids detected at transvaginal ultrasonography. The accuracy of this imaging method in the diagnosis of intracavitary abnormalities is low compared with that for saline-infused sonography and hysteroscopy.3Dijkhuizen FPHLJ De Vries LID Mol BWJ et al.Comparison of transvaginal ultrasonography and saline infusion sonography for the detection of intracavitary abnormalities.Ultrasound Obstet Gynecol. 2000; 15: 372-376Crossref PubMed Scopus (84) Google Scholar Unfortunately, salineinfused sonography was not done, but hysteroscopy was done on clinical indication. Nothing was stated on the number of patients that underwent hysteroscopy. Finally, Hurskainen and colleagues report nothing about differences in effectiveness of treatment in patients with different baseline characteristics. How many patients were treated with oral contraceptives before they were referred by their family physician? Did the amount of blood loss or the presence of fibroids affect the success of treatment? Treatment of menorrhagiaAuthors' reply Full-Text PDF