Hysterectomy For Dysfunctional Uterine Bleeding Research Articles

Incidence of Hysterectomy for Dysfunctional Uterine Bleeding with Post Tubal Ligation

Background: Post tubal ligation syndrome has been a topic of debate and the association of Dysfunctional uterine bleeding (DUB) has been identified as a long-term complication. In refractory cases, hysterectomy can be considered a treatment option for managing the post-ligation syndrome due to prolonged menstrual complaints. But very few studies summarize the fact in our country's context. Considering of epidemiological data, the study was designed to assess the incidence of hysterectomy for DUB with post-tubal ligation. Methods: The hospital-based cross-sectional type of descriptive study was conducted in the inpatient Department of Gynae & Obst in Rajshahi Medical College Hospital (RMCH), From January 2019 to July 2019. Women suffering from DUB and having a history of post tubal ligation were included in the study. After selecting the patients, informed written consent was taken from the subjects. All patients were subjected to a detailed history, clinical examination, and relevant investigation. In necessary cases, hysterectomy was done as a treatment option. Data were collected using a semi-structured questionnaire designed for the study by the researcher. Data analysis and presentation were made by statistical software SPSS 23. Results: Total 100 patients with DUB were included in this study. The mean age was 40.9±6.28 SD (years), range: 25-54 years. The majority of patients (52%) belonged to the age group (41 – 50 years). About 59% came from rural areas. The mean parity was 3.43±1.34. The incidence of hysterectomy among DUB patients with a previous history of tubal ligation was 25%. The mean duration of tubal ligation was 13.4±6.3 years. The usual presentation per vaginal bleeding pattern at presentation was menorrhagia (47%), followed in second and third by metrorrhagia (20%) and postmenopausal bleeding (17%). Besides, 78% of patients also complained of tiredness, and 12% complained of pelvic pain. And Mean duration of symptoms was 13.44 months. Conclusion: About one-fourth of the tubal ligation patients underwent a hysterectomy in their subsequent life, and usually presented with menorrhagia. However, further studies are needed to finalize the incidence rate.

Massive panniculectomy: a novel method of treatment of postlaparotomy wound dehiscence in morbid obesity

It was with interest that we read the article “High-concentration oxygen and surgical site infections in abdominal surgery: a meta-analysis.”1 Massive liposuction and body contouring procedures are no longer primary therapeutic options for the treatment of morbid obesity owing to their complications and suboptimal results. The obvious paradigm shift has been noted to favour bariatric procedures since the advent of laparoscopic approaches over last 2 decades. Panniculectomy is a cosmetic procedure that involves the removal of excess skin and fat from the affected organ. We performed massive panniculectomy for the treatment of postlaparotomy wound dehiscence in a morbidly obese patient. A 60-year-old woman with body mass index (BMI) of 41.7 underwent a total abdominal hysterectomy for dysfunctional uterine bleeding. A surgical site infection and dehiscence involving skin and subcutaneous layers across the complete length of incision developed in the immediate postoperative period. The initial treatment at the primary centre involved drainage, debridement and regular dressings. The patient was referred to our centre for further management in postoperative week 4. Upon clinical examination, we observed that the abdomen skin fold was thick and large, and it was difficult to examine the dehiscence suture line in the recumbent position (Fig. 1A). The bacteriological study of culture and sensitivity from the abdominal wound was unremarkable; blood work was essentially normal. After counselling the patient and her relatives, a decision was made to repair the wound with massive panniculectomy to remove excessive skin and subcutaneous tissue from the abdomen. The excessive abdominal skin complex incorporating the suture line and the umbilicus was removed (weighing 8.5 kg) and the procedure was completed. The duration of the surgery was 180 minutes; blood loss was minimal (100 mL). The postoperative period was uneventful and the wound healed well, with no excessive abdominal fold. The patient was able to resume her normal activities 14 days after the procedure (Fig. 1B). Fig. 1 (A) Clinical picture showing laparotomy wound dehiscence. (B) Postoperative picture of the suture line shows good healing after massive panniculectomy surgery. Management of morbid obesity involves a trial of strict diet and exercise, followed, if unsuccessful, by one of the various bariatric surgical procedures. Plastic surgical intervention usually comprises massive liposuction and body contouring with or without lumpectomies after achieving weight loss. Panniculectomy is a procedure that involves the removal of excess skin and fat from any part of the body. This procedure is different from abdominoplasty, which involves tightening of the muscles. Panniculectomy is done routinely after massive weight loss (e.g., after bariatric surgeries), where excessive skin and subcutaneous fat are removed to enhance appearance and improve confidence. When more than 10 lbs of tissue is removed, the procedure is known as massive panniculectomy.2,3 Abdominal wall hernia repair is treated with mesh repairs, component separation technique and pedicled fascia lata flap. In our case, excess bulk of the abdominal wall mass was dragging in multiple directions, thereby stretching the operative wound and preventing it from closing. During the procedure, the previous vertical wound was excised en masse with the excess abdominal apron and umbilicus using a supra pubic Pfannensteil incision; the postexcision wound was closed transversely corresponding to the relaxed skin tension lines. Therefore, a reduced abdominal wall mass and a new suture line along the relaxed skin tension lines enabled us to have good wound healing and increased patient satisfaction. We conclude that panniculectomy, which is primarily a cosmetic method of excess skin and fatty tissue removal, can be used to treat postsurgical wound dehiscence in morbidly obese patients.

English

Trichosporon asahii is a basidiomycetous yeast which causes white piedra and onychomycosis in immunocompetent hosts. In immunocompromised hosts this species may cause a number of localized and disseminated infections. Urinary tract infection by Trichosporon asahii is a rare occurrence .Few cases have been reported from India. We present a microbiologically confirmed urinary tract infection with T. asahii in a 52 year old diabetic, female patient who had undergone hysterectomy for dysfunctional uterine bleeding. Her urine sample was subjected to culture and sensitivity for postoperative rigor. Gram stain examination of the centrifuged urine revealed septate hyphae with arthroconidia and pus cells. Yeast like fungus was isolated in pure culture in three consecutive samples which was confirmed as Trichosporon asahii by standard tests. The response to antifungal therapy was dramatic. Trichosporon species though occasionally a part of normal flora, may be involved in causing nosocomial opportunistic infection more so in immunocompromised hosts. Very few cases of microbiologically confirmed urinary tract infection have been reported so far. Its diagnosis is likely to be missed or misinterpreted because of lack of awareness. Therefore T. asahii deserves recognition as a pathogen.

Histerectomía en la perimenopausia. Adenomiosis

Objective To review the indications for the hysterectomies performed in Donostia Hospital in perimenopausal women in 2002, especially uterine dys-functional bleeding, and evaluate the presence of adenomyosis in the surgical specimens. Patients and methods We performed a prospective, observational study in women aged 40-55 years old who underwent hysterectomy in 2002. Hysterectomies for malignant disease were excluded. The patients included were classified into distinct groups according to indication, following the Swiss consensus guidelines for hysterectomy. Results We performed 130 hysterectomies, of which 78-79% were appropriate. The principal indication was symptomatic uterine myoma. In 14% of the hysterectomies, histopathologic analysis of the surgical specimen revealed adenomyosis. The most significant group of indications was hysterectomy for dysfunctional uterine bleeding; 80% of the surgical specimens presented adenomyosis. Transvaginal ultrasonography performed prior to surgery did not lead to suspicion of adenomyosis in any of the cases reviewed. Conclusion In our study, the most frequent indication for non-oncological hysterectomy in perimenopausal women was uterine myoma. Within the group of hysterectomies for menometrorrhagia that did not respond to medical treatment and was classified as dysfunctional uterine bleeding, 80% of the surgical specimens from hysterectomy showed adenomyosis, explaining the lack of treatment response. In view of these results, endometrial resection is likely to be unsuccessful in these patients. Currently, hysterectomy is the most effective therapeutic option.

Changing the route of hysterectomy: The results of a policy of attempting the vaginal approach in all cases of dysfunctional uterine bleeding

Objective To assess the effectiveness of a policy of performing a vaginal hysterectomy for as many cases of dysfunctional uterine bleeding without uterine prolapse as possible between 1997 and 2003. Study design The study was prospective, with retrospective analysis of data. Setting Warwick Hospital. Population Eighty-seven women in a district hospital serving a population of 270,000 in South Warwickshire. Methods During 1997 and 2003, an effort was made to perform as many hysterectomies vaginally as possible, with oophorectomy where necessary, in women with dysfunctional uterine bleeding in the absence of prolapse. The trends of the three different operations, total abdominal hysterectomy, sub-total abdominal hysterectomy and vaginal hysterectomy over the 7-year period were analysed. Main outcome measures The ability to undertake surgery successfully, complications rates, length of hospital stay and changes in surgical practice. Results Over this 7-year period, it has proved possible to change the emphasis from abdominal to vaginal hysterectomy for dysfunctional uterine bleeding. In 1997, the most common operation for dysfunctional uterine bleeding (72.7%) was subtotal hysterectomy ± bilateral salpingo-oophorectomy, followed by (27.3%) total abdominal hysterectomy ± bilateral salpingo-oophorectomy. No cases were undertaken vaginally. By 2003, however, the trend had completely reversed, with the only procedure undertaken being vaginal hysterectomy ± bilateral salpingo-oophorectomy. There is no evidence that such an approach increases the complication rate, and the recovery rate from surgery is improved with a tendency towards earlier discharge in the vaginal surgery group. Conclusion The vaginal approach is possible for an average gynaecologist working in a district general hospital, with no additional complications and an improved recovery rate for patients.

Beware: pregnancy and second-generation endometrial ablation

With the promotion of second-generation endometrial ablative techniques—namely thermal balloon endometrial ablation and microwave endometrial ablation—as alternatives to hysterectomy for dysfunctional uterine bleeding, with phrases like “three-minute hysterectomy,” some women become complacent about contraception after ablation. Some even assume that “hysterectomy,” as widely used in the popular press, means “no more children.” Pregnancy after endometrial ablation does not represent a failure of the technique. The failure is due to poor counselling or to women not taking the advice to use appropriate contraception after the procedure.

Economic impact of HydroThermAblator (HTA) endometrial ablation versus hysterectomy for dysfunctional uterine bleeding (DUB)

Economic impact of HydroThermAblator (HTA) endometrial ablation versus hysterectomy for dysfunctional uterine bleeding (DUB)

Photodynamic endometrial ablation: morphological study.

Endometriumablation provides an alternative treatment modality to hysterectomy for dysfunctional uterine bleeding (DUB). Its feasibility was demonstrated in animal studies. The purpose of this study was the evaluation of histological changes following photodynamic endometrial ablation in patients. 5-Aminolevulinic acid (ALA) was topically applied in three premenopausal and one postmenopausal patient 4-6 hours before laser-illumination. ALA-concentration: 100-400 g/ml, NaOH-titration (pH 5.5). Volume applied, 1.5-2.0 ml; intrauterine balloon-lightdiffuser; wavelength, 635 nm; lightdose, 160 J/cm(2). Hysterectomy was performed 3-152 days after photodynamic ablation. Histological examination was carried out on endometrium sections stained with hematoxylin and eosin (H&E). Necrosis including the full thickness of the endometrium was found 3 days after photodynamic endometrial ablation. Specimens collected after 35 and 152 days did not exhibit fibrosis or adhesions. Foci of preserved endometrium were detected in all patients. Photodynamic endometrial ablation is selective and does not cause endometrial fibrosis or adhesions.

Microwave endometrial ablation: does endometrial thickness or the medium for preoperative hysteroscopy affect the depth of ablation?

ABSTRACTObjectives To determine the depth of tissue necrosis following microwave endometrial ablation (MEA) after perioperative saline hysteroscopy, and to determine the effects of varying endometrial thickness on depth and regularity of necrosis after gas hysteroscopy.Subjects 15 premenopausal women undergoing hysterectomy for dysfunctional uterine bleeding at Aberdeen Royal Infirmary.Methods Endometrial thickness was measured by transvaginal ultrasound scanning. After cervical dilation a hysteroscopy was performed with carbon dioxide or saline before proceeding to MEA and then hysterectomy. A vital stain was used to assess the depth and regularity of endomyometrial necrosis in the excised uterus.Results The nitroblue tetrazolium stain was a simple and effective way of demonstrating the depth of necrosis. In this small study, saline hysteroscopy led to cornual sparing in some cases. There was no clear effect of endometrial thickness up to 8 mm with gas hysteroscopy.Conclusions Saline hysteroscopy may affect the clinical outcome of MEA. Aspiration of residual saline may minimize any negative effect. The depth and regularity of necrosis did not seem to be affected by endometrial thicknesses of up to 8 mm after gas hysteroscopy. It seems reasonable to proceed to a clinical trial to assess the outcome of postmenstrual MEA without hormonal endometrial preparation.

Hysterectomy and endometrial ablation in New South Wales, 1981 to 1994-1995.

This study analyses the New South Wales hospital data on hysterectomies from 1981 to 1994-1995, and on endometrial ablations since 1991. The hysterectomy rate declined by about 16% during 1981-1991 and has risen since; the endometrial ablation rate has increased by 28% between 1991 and 1994-1995. Other findings indicate a trend towards older mean age at operation, a swing to vaginal hysterectomy with or without laparoscopy, a shift to private hospitals, and a dramatic decline in length of hospital stay. The majority of endometrial ablations were performed on a day-only basis. Immigrant and Aboriginal women experienced lower hysterectomy rates. Endometrial ablation techniques introduced in the late 1980s, as an alternative to hysterectomy for dysfunctional uterine bleeding, have had a major impact on hysterectomy rates; without these techniques the rates would be much higher.

Trends in endometrial ablation and hysterectomy for dysfunctional uterine bleeding, in Mersey region

The objectives of this study were to describe the trends in National Health Service hysterectomies and endometrial ablations for dysfunctional uterine bleeding (DUB) in Mersey Regional Health Authority residents. Data were extracted from routine hospital statistics. The proportion of patients with DUB treated surgically by endometrial ablation increased from 0 to 30% between 1988/9 and 1992/3. Contrary to expectations of proponents of endometrial ablation, there was little change in the number of hysterectomies performed for DUB. Conversely the life‐chances of a Mersey woman receiving an operation for DUB increased from 6.5 to 11%. While theoretically there are several reasons for the trend of increased operative rates for DUB, a lower threshold for operation with the advent of endometrial ablation was considered most likely to be the strongest factor. It was also noted to be of concern that a novel operation was widely introduced in the UK without there being any obligation for systematic study of medium‐ and long‐term effects.

Randomised Trial of Hysterectomy, Endometrial Laser Ablation, and Transcervical Endometrial Resection for Dysfunctional Uterine Bleeding

Abstract Objective: To evaluate the effectiveness and safety of endometrial laser ablation and transcervical resection of the endometrium compared with hysterectomy in the surgical treatment of women with dysfunctional uterine bleeding. Design: Prospective randomised controlled trial. Setting: Gynaecology department of a large teaching hospital. Subjects: 204 women who would otherwise have been undergoing hysterectomy for menorrhagia were recruited between August 1990 and March 1992 and randomly allocated to hysterectomy (n=99) or conservative (hysteroscopic) surgery (transcervical resection (n=52) and laser ablation (n=53)). Main outcome measures: Operative complications, postoperative recovery, relief of menstrual and other symptoms, patient satisfaction with treatment after six and 12 months. Results - Women treated by hysteroscopic surgery had less early morbidity and a significantly shorter recovery period than those treated by hysterectomy (median time to full recovery 2-4 weeks v 2-3 months, P Conclusions: Hysteroscopic endometrial ablation was superior to hysterectomy in terms of operative complications and postoperative recovery. Satisfaction after hysterectomy was significantly higher, but between 70% and 90% of the women were satisfied with the outcome of hysteroscopic surgery. Hysteroscopic surgery can be recommended as an alternative to hysterectomy for dysfunctional uterine bleeding.

Vaginal hysterectomy is a certain cure

EDITOR,—S B Pinion and colleagues' study comparing endometrial resection and hysterectomy largely ignores the benefits of vaginal hysterectomy.1 The authors conclude that “hysteroscopic surgery can be recommended as an alternative to hysterectomy for dysfunctional uterine bleeding” despite the finding that 28 of 105 patients required a second operation and that the proportion of patients who were “less than very satisfied” in the hysteroscopic group (22%) was double that in the hysterectomy group (11%). In a retrospective audit in our hospital (1989-92) …

Randomised trial of hysterectomy, endometrial laser ablation, and transcervical endometrial resection for dysfunctional uterine bleeding

To evaluate the effectiveness and safety of endometrial laser ablation and transcervical resection of the endometrium compared with hysterectomy in the surgical treatment of women with dysfunctional uterine bleeding. Prospective randomised controlled trial. Gynaecology department of a large teaching hospital. 204 women who would otherwise have been undergoing hysterectomy for menorrhagia were recruited between August 1990 and March 1992 and randomly allocated to hysterectomy (n = 99) or conservative (hysteroscopic) surgery (transcervical resection (n = 52) and laser ablation (n = 53)). Operative complications, postoperative recovery, relief of menstrual and other symptoms, patient satisfaction with treatment after six and 12 months. Women treated by hysteroscopic surgery had less early morbidity and a significantly shorter recovery period than those treated by hysterectomy (median time to full recovery 2-4 weeks v 2-3 months, P < 0.001). Twelve months later 17 women in the hysteroscopy group had had a hysterectomy, 11 for continuing symptoms; 11 women had had a repeat hysteroscopic procedure; 45 were amenorrhoeic or had only a brown discharge; and 35 had light periods. Dysmenorrhoea and premenstrual symptoms improved in most women in both groups. After 12 months 89% (79/89) in the hysterectomy group and 78% (75/96) in the hysteroscopy group were very satisfied with the effect of surgery (P < 0.05); 95% (85/89) and 90% (86/96) thought that there had been an acceptable improvement in symptoms, and 72% (64/89) and 71% (68/96) would recommend the same operation to others. Hysteroscopic endometrial ablation was superior to hysterectomy in terms of operative complications and postoperative recovery. Satisfaction after hysterectomy was significantly higher, but between 70% and 90% of the women were satisfied with the outcome of hysteroscopic surgery. Hysteroscopic surgery can be recommended as an alternative to hysterectomy for dysfunctional uterine bleeding.

A Controlled Trial of Posthysterectomy Abdominal Colic

ABSTRACT The two most common drugs prescribed to relieve postoperative abdominal colic are peppermint oil (a relaxant) and glycerin suppositories (a stimulant), but their efficacy is uncertain. We compared the two agents with placebo in a randomized controlled trial. Sixty-nine women developed abdominal colic after a hysterectomy for dysfunctional uterine bleeding. The duration of postoperative colic was 5 times less for women allocated glycerin suppositories compared to women initially allocated peppermint oil or placebo (median duration of pain: 8 h compared with 39 h for placebo and 47 h for peppermint oil; Kruksal-Wallis H score = 24.5, p < 0.0001). Glycerin is an effective treatment for postoperative abdominal colic, but peppermint oil is no better than placebo. (J GYNECOL SURG 9:201, 1993)

Menstrual Symptoms in Women With Pelvic Endometriosis

Objective— To investigate menstrual symptoms in relation to pelvic pathology. Design— A prospective questionnaire-based study. Setting— Aberdeen Royal Infirmary, Scotland. Subjects— 1250 questionnaires were sent out prior to planned admission and 1200 women (96%) brought the completed questionnaires. They comprised 598 women undergoing laparoscopic sterilization, 312 having laparoscopy because of infertility, 156 having laparoscopy because of chronic pelvic pain and 134 women undergoing abdominal hysterectomy for dysfunctional uterine bleeding. Main outcome measures— The occurrence of dysmenorrhoea, menorrhagia, menstrual regularity, premenstrual spotting, deep dyspareunia and pelvic pain in women with either endometriosis and post infective pelvic adhesions or a normal pelvis. Results— Menorrhagia, menstrual irregularity and premenstrual spotting occurred with equal frequency in all groups. Deep dyspareunia, pain after intercourse and recurrent pain unrelated to menstruation or coitus was more common in women with endometriosis and those with post infective pelvic adhesions than in those with a normal pelvis. Dysmenorrhoea appears to be more prevalent among women having endometriosis. Conclusions— Menstrual symptoms, while raising a high index of suspicion for endometriosis, are not entirely reliable as indicators of disease. Dysmenorrhoea is the most common reported symptom in endometriosis sufferers. Diagnostic laparoscopy should be considered before institution of treatment in women complaining of pelvic pain and menstrual symptoms.

Menstrual symptoms in women with pelvic endometriosis

To investigate menstrual symptoms in relation to pelvic pathology. A prospective questionnaire-based study. Aberdeen Royal Infirmary, Scotland. 1250 questionnaires were sent out prior to planned admission and 1200 women (96%) brought the completed questionnaires. They comprised 598 women undergoing laparoscopic sterilization, 312 having laparoscopy because of infertility, 156 having laparoscopy because of chronic pelvic pain and 134 women undergoing abdominal hysterectomy for dysfunctional uterine bleeding. The occurrence of dysmenorrhoea, menorrhagia, menstrual regularity, premenstrual spotting, deep dyspareunia and pelvic pain in women with either endometriosis and post infective pelvic adhesions or a normal pelvis. Menorrhagia, menstrual irregularity and premenstrual spotting occurred with equal frequency in all groups. Deep dyspareunia, pain after intercourse and recurrent pain unrelated to menstruation or coitus was more common in women with endometriosis and those with post infective pelvic adhesions than in those with a normal pelvis. Dysmenorrhoea appears to be more prevalent among women having endometriosis. Menstrual symptoms, while raising a high index of suspicion for endometriosis, are not entirely reliable as indicators of disease. Dysmenorrhoea is the most common reported symptom in endometriosis sufferers. Diagnostic laparoscopy should be considered before institution of treatment in women complaining of pelvic pain and menstrual symptoms.

Prevalence and genesis of endometriosis

A group of 1542 pre-menopausal Caucasian women were assessed prospectively to investigate the prevalence of endometriosis. The women were either having laparoscopy because of infertility (n = 654), undergoing laparoscopic sterilization (n = 598), having laparoscopy because of chronic abdominal and pelvic pain (n = 156) or undergoing abdominal hysterectomy for dysfunctional uterine bleeding (n = 134). Endometriosis was noted more frequently among women being investigated for infertility (21%) than among those undergoing sterilization (6%). Among those being investigated for chronic abdominal pain, the incidence of endometriosis was 15%, while among those undergoing abdominal hysterectomy, it was 25%. In all groups the total duration of combined pill usage was significantly higher in patients who had a normal pelvis compared to those with endometriosis. It is suggested that among susceptible women, both fertile and infertile, a prolonged period of regular spontaneous menstruation may play a causative role in the genesis of endometriosis.