Surgical Treatment Of Menorrhagia Research Articles

LNG-IUS and Endometrial Ablation Control Menorrhagia Equally Well

Surgical treatment for menorrhagia — traditionally with hysterectomy but, more recently, with endometrial ablation — generally is offered when medical

Menorrhagia

A four-part presentation covering the causes, investigations and medical and surgical treatment of menorrhagia.

Microwave endometrial ablation: a new surgical treatment for menorrhagia

Hysterectomy is an effective treatment for refractory menorrhagia resistant to conservative methods and the commonest major gynecologic operation. However, hysterectomy is associated with substantial post-operative morbidity. As an alternative to hysterectomy, it has become possible to destroy the endometrium in situ with minimal access techniques. Unfortunately, hysteroscopic ablation techniques require considerable surgical skill and long learning curve. Second generation ablative devices have been developed for an effective, safe, quick and easy treatment of mennorrhagia. Microwave endometrial ablation (MEA) at a frequency of 9.2 GHz was first described in 1995 and its effectiveness has been confirmed in randomized trials. Recently a new curved microwave applicator was developed for MEA at 2.45 GHz for uteri with an enlarged distorted uterine cavity. Using the applicator, menorrhagia caused by submucosal myoma nodes was successfully treated. A large number of hysterectomies could be avoided by MEA.

The surgical management of menorrhagia.

Surgical treatment of menorrhagia is likely to be both successful and satisfactory to the patient. Correct diagnosis of the cause of menorrhagia is essential, and management should be directed to the specific cause of the problem. The question of which treatment is best is a complex one and involves balancing patient wishes, expected outcomes, complications, cost-effectiveness and quality of life issues. For the subset of women in whom dysfunctional uterine bleeding is diagnosed, the literature suggests that there is a hierarchy of treatments that, in descending order for both efficacy and patient acceptability, are: (i) hysterectomy; (ii) endometrial ablation (either first- or second-generation); (iii) the levonorgestrel intrauterine system; and (iv) medical treatments. All four of these options should be discussed with the patient and the relative advantages and disadvantages considered before a treatment decision is made. For patients in whom a pathological cause is diagnosed, specific treatments should be aimed at removal of the lesion and observation of the effect on menstrual status. In addition to the treatment options above, specific treatments such as hysteroscopic, laparoscopic or open excision of the lesion need to be considered. For interventional radiological procedures such as uterine artery embolization, further study is recommended before it can be considered as a safe and effective treatment for menorrhagia.

Randomized controlled study comparing the efficacy of Levonova® with surgical treatment of menorrhagia by transcervical endometrial resection

Randomized controlled study comparing the efficacy of Levonova® with surgical treatment of menorrhagia by transcervical endometrial resection

Microwave endometrial ablation for menorrhagia

Sixteen women requesting surgical treatment of menorrhagia were recruited for a study on microwave endometrial ablation. The mean age at treatment was 41.4 years and all patients had completed their family and were pre-menopausal. Average treatment time was 2 minutes 6 seconds. All patients reported a reduction in their menstrual loss and 87.5% were satisfied with their treatment after 1 year follow-up. One patient required overnight admission for analgesia while 15 patients were treated on a day case basis using light general anaesthesia. Sixty-seven per cent of patients reported a reduction in dysmenorrhoea scores at 1 year, two patients reported no change in symptoms and one patient reported a modest increase. One patient had a hysterectomy 10 months after treatment despite being amenorrhoeic. The indication for hysterectomy was pelvic pain (which was present before endometrial ablation). There were few minor complications but no uterine perforation or emergency hysterectomies.

Comparison of Hysteroscopic Endometrial Resection and Laparoscopic Assisted Vaginal Hysterectomy for the Treatment of Menorrhagia

Background. To compare the advantages and disadvantages of the two endoscopic procedures, hysteroscopic endometrial resection and laparoscopic assisted vaginal hysterectomy (LAVH), in the treatment of menorrhagia.Methods. Forty women requiring surgical treatment for menorrhagia underwent LAVH. These women were compared retrospectively with forty women having had endometrial resection for menorrhagia. The operations were performed between November 1991 and February 1995.Results. Operating time, hospitalization and postoperative recovery were significantly shorter with endometrial resection than with LAVH. In the hysteroscopy group amenorrhea or hypomenorrhea was achieved in 80% of cases. Hysterectomy was performed in two cases (5%). In the hysteroscopy group all but three women (92%) were satisfied with the procedure, in the LAVH group all but one (97%).Conclusions. In the surgical treatment of menorrhagia both procedures are effective. LAVH is associated with a longer recovery period, but it offers a perm...

Endometrial resection versus vaginal hysterectomy for the surgical treatment of menorrhagia

To evaluate the efficacy of treatment with endometrial resection versus vaginal hysterectomy in patients with established menorrhagia, 85 women under age 50 years were recruited in an open-label, randomized, clinical trial. Eligible subjects had a mobile uterus with a volume less than a 12-week pregnancy, and no adnexal tumors or submucous myomas with a diameter greater than 3 cm. The patients were asked to grade the degree of satisfaction with their treatment and any modifications in sexual activity 1 year after surgery. Median (interquartile range, IR) operating time was, respectively, 13 minutes (10-15 min) in the endometrial resection group (group 1,41 women) and 71 minutes (66-78 min) in the hysterectomy group (group 2, 44 women). No important complications occurred. Median number of days to return to normal activities and to work were, respectively, 8 (IR 6-8) and 14 (]R 11-16) days in group 1 versus 13 (IR 13-15) and 30 (IR 26-34) in group 2. Four women in group 1 subsequently underwent vaginal hysterectomy, two for recurrent menorrhagia, one for dysmenorrhea, one for atypical hyperplasia. Among the 82 women attending the 1-year follow-up visit, 34 (87%) of those in group 1 were very satisfied or satisfied with their treatment compared with 41 (95%) of those in group 2 (NS). Sexual activity was unchanged in 32 (84%) subjects in the former versus 33 (85%) women in the latter group. Endometrial resection and vaginal hysterectomy seem to be equally effective at 1 year after surgery for menorrhagia.

Endometrial resection increases demand for surgical treatment of menorrhagia

Endometrial resection increases demand for surgical treatment of menorrhagia

An economic evaluation of transcervical endometrial resection versus abdominal hysterectomy for the treatment of menorrhagia

OBJECTIVE To evaluate the relative health service cost of endometrial resection versus abdominal hysterectomy for the treatment of menorrhagia and the value women attach to their health state before and after surgery. DESIGN A prospective economic evaluation running alongside a randomised controlled trial. SETTING The gynaecology department of a teaching hospital. SUBJECTS 200 women requiring surgical treatment of menorrhagia between January 1990 and May 1991; after withdrawals, 97 women underwent hysterectomy and 99 underwent endometrial resection. MAIN OUTCOME MEASURES The total health service cost of managing women in the two arms of the trial until 4 months after their operation. The change in women's valuation of their health state a fortnight after and a minimum of 4 months after surgery relative to that 1 month prior to their operation. RESULTS Total health service costs are significantly higher amongst abdominal hysterectomy patients (mean 1059.73 pounds) than amongst endometrial resection patients with a mean difference of 499.68 pounds (95% CI 432 pounds-567 pounds). This significant difference exists under alternative assumptions about the difference in lengths of stay in hospital between the two treatment groups and the hotel cost per in-patient day. On a scale of 0 to 100, relative to a month before surgery, there is a statistically significant difference in favour of endometrial resection between the two groups in the increase in value women attach to their health state at a fortnight after surgery (mean difference 11.2; 95% CI 0.6-21.7), but not at a minimum of 4 months after surgery (mean difference 7; 95% CI -17.4 to 3.4). CONCLUSIONS On the basis of health service resource cost up to 4 months after surgery, endometrial resection has a cost advantage over abdominal hysterectomy. However, given the fact that a subgroup of women requires retreatment due to resection failure and that this study considers a relatively short period of follow up, the long term costs and benefits of endometrial resection need to be evaluated before widespread diffusion is justified.

Randomised Controlled Trial Comparing Endometrial Resection With Abdominal Hysterectomy for the Surgical Treatment of Menorrhagia

Objective To evaluate the effectiveness of endometrial resection as a surgical treatment for menorrhagia. Design Randomised controlled trial. Setting Gynaecology department at a teaching hospital. Subjects Two hundred women needing surgical treatment for menorrhagia between January 1990 and May 1991. After withdrawal of four women 97 underwent hysterectomy and 99 underwent endometrial resection. Main outcome measures Patient satisfaction 4 months after surgery; post-operative complications; length of hospital stay; duration of time before return to work, normal daily activities and sexual intercourse; change in premenstrual symptoms. Results The difference in patient satisfaction between endometrial resection (84 out of 99) and abdominal hysterectomy (89 out of 95) just reached statistical significance in favour of abdominal hysterectomy at 4 months after surgery (difference = 9%, 95% confidence intervals (CI) 1.1%–17.5%). Post-operative morbidity, length of hospital stay and time taken to return to work, normal daily activities and sexual intercourse were significantly less in the endometrial resection group. However, the premenstrual symptoms of dysmenorrhoea, bloating and breast tenderness were less frequent after hysterectomy. Conclusion In the short term, endometrial resection was almost as satisfactory as abdominal hysterectomy for the surgical treatment of menorrhagia, and was associated with less morbidity. However, even at 4 months after surgery, there was a failure rate of at least 10% in those in whom endometrial resection appeared complete. Longer term comparative studies are necessary before the widespread introduction of endometrial resection as an alternative to abdominal hysterectomy for the surgical treatment of menorrhagia.

Randomised controlled trial comparing endometrial resection with abdominal hysterectomy for the surgical treatment of menorrhagia

To evaluate the effectiveness of endometrial resection as a surgical treatment for menorrhagia. Randomised controlled trial. Gynaecology department at a teaching hospital. Two hundred women needing surgical treatment for menorrhagia between January 1990 and May 1991. After withdrawal of four women 97 underwent hysterectomy and 99 underwent endometrial resection. Patient satisfaction 4 months after surgery; post-operative complications; length of hospital stay; duration of time before return to work, normal daily activities and sexual intercourse; change in premenstrual symptoms. The difference in patient satisfaction between endometrial resection (84 out of 99) and abdominal hysterectomy (89 out of 95) just reached statistical significance in favour of abdominal hysterectomy at 4 months after surgery (difference = 9%, 95% confidence intervals (CI) 1.1%-17.5%). Post-operative morbidity, length of hospital stay and time taken to return to work, normal daily activities and sexual intercourse were significantly less in the endometrial resection group. However, the premenstrual symptoms of dysmenorrhoea, bloating and breast tenderness were less frequent after hysterectomy. In the short term, endometrial resection was almost as satisfactory as abdominal hysterectomy for the surgical treatment of menorrhagia, and was associated with less morbidity. However, even at 4 months after surgery, there was a failure rate of at least 10% in those in whom endometrial resection appeared complete. Longer term comparative studies are necessary before the widespread introduction of endometrial resection as an alternative to abdominal hysterectomy for the surgical treatment of menorrhagia.

10 Psychological problems and uterine bleeding

Gynaecological complaints are often associated with psychiatric disorder. Women with psychiatric disorder are more likely to complain of excessive uterine bleeding than women without psychiatric disorder. When a woman complains of menorrhagia, yet also has a psychiatric disorder, it is important to establish which is the primary problem. If menorrhagia is primary, then any associated psychiatric disorder may be secondary to distress and fear caused by excessive menstruation. If the psychiatric disorder is primary, then psychological distress may lead a women to complain about her usual menstrual pattern or minor changes in it. If the complaint of excessive menstruation is secondary to psychiatric disorder, surgical or medical treatment of this complaint may not be justified. If the gynaecologist is to make the important distinction between complaints of menorrhagia which are primary and those which are secondary to psychiatric disorder, then he/she needs to be able to detect and assess psychiatric disorder in women who present with complaints of excessive uterine bleeding. Recent research has provided information about the relationship between the surgical treatment of menorrhagia and psychiatric disorder. Hysterectomy for menorrhagia seems to alleviate psychiatric disorder in many women who had psychiatric disorder before operation. The operation rarely induces psychiatric disorder in women who are psychiatrically well before surgery. There is no association between psychiatric disorder either before or after hysterectomy for menorrhagia and the presence of absence of demonstrable pelvic pathology. There is no evidence that those women who overestimate their menstrual blood loss have an increased likelihood of being psychiatrically disturbed after hysterectomy. However, an important determinant of psychiatric outcome after hysterectomy for menorrhagia is preoperative psychiatric status--for example, mental state before surgery, previous psychiatric history and neuroticism.