Bleeding

Hysterectomy always provides a definitive cure of irregular or excessive menstrual bleeding. The exception is subtotal (supracervical) hysterectomy, after which cyclic bleeding can be seen in 3% to 24% of patients postoperatively. Hysterectomy should be considered a second-line therapy in most cases of abnormal menstrual bleeding because it results in permanent loss of fertility and has greater risk, higher cost, and longer recovery than most alternative treatments. Hormonal therapies (such as oral contraceptive pills and oral or intramuscular medroxyprogesterone acetate), nonsteroidal anti-inflammatory medications (particularly mefenamic acid and naproxen sodium), and medicated intrauterine devices (IUDs) effectively treat abnormal menstrual bleeding in many patients. However, a significant proportion of patients eventually require further treatment, including hysterectomy. The Maine Women’s Health Study prospectively evaluated a cohort of women with abnormal uterine bleeding treated medically over a 1-year period ( ). Overall, they had a significant improvement in symptoms of pain and bleeding and in quality of life. However, 23% still underwent a hysterectomy in the 12-month follow-up period.

Few randomized clinical trials comparing medical therapy to hysterectomy for treatment of abnormal menstrual bleeding exist. One study by Kuppermann and associates (2004) randomized 63 premenopausal women who had failed previous treatment with medroxyprogesterone acetate for excessive menstrual bleeding to receive either hysterectomy or expanded medical therapy, typically oral contraceptive pills with or without nonsteroidal anti-inflammatory drugs (NSAIDs). At 6 months, women in the hysterectomy group had greater improvement in scores of mental health, and greater improvement in symptom resolution, interference with sex, sexual desire, health distress, sleep problems, and satisfaction with health. During the 2 years of follow-up, 53% of those who had received expanded medical treatment eventually requested and received hysterectomy, with resulting improvements in quality of life.

A large randomized trial of 236 women age 35 to 49 with excessive menstrual bleeding compared hysterectomy to a levonorgestrel-releasing intrauterine system (LNG-IUS) ( ). After 5 years of follow-up, both groups reported high (>90%) satisfaction with treatment. In those who received the LNG-IUS, 75% reported amenorrhea or minimal spotting; however, 42% of subjects eventually underwent a hysterectomy during the follow-up period.

Endometrial ablation is an effective alternative to hysterectomy for treatment of excessive menstrual bleeding. To date, there have been seven randomized trials with a total of 1192 participants comparing either abdominal or vaginal hysterectomy to endometrial ablation in women with abnormal uterine bleeding ( ). Compared to hysterectomy, endometrial ablation is associated with a shorter operative time, shorter recovery period, and lower postoperative complication rate. However, although hysterectomy eliminates menstrual bleeding, endometrial ablation results in amenorrhea in only 45% of patients and recurrent excessive bleeding is seen in 15% to 25% of cases. Approximately 9% to 34% of patients who receive endometrial ablation subsequently undergo hysterectomy. A systematic review performed by the Cochrane Collaboration found that hysterectomy had a significant advantage over endometrial ablation for the improvement in anemia as well as overall satisfaction and general health for up to 4 years after surgery ( ). Although many quality-of-life scales reported no differences between surgical groups, there was some evidence of a greater improvement in some health domains (social functioning, energy, pain, and general health) for hysterectomy patients. Most adverse events were significantly more likely to occur after hysterectomy and before discharge from hospital. However, after discharge from hospital, the only difference was a lower rate of infection among those receiving endometrial ablation (odds ratio [OR] = 0.2, confidence interval [CI] 0.1–0.5). The overall cost of endometrial ablation was lower than that of hysterectomy, but the cost differences narrow over time because of the need for eventual hysterectomy in a proportion of those who receive ablation, or re-treatment with other alternatives to hysterectomy including uterine fibroid embolization and myomectomy. The relative advantages and disadvantages of these therapies are discussed in Chapter 12 .

Uterine fibroid embolization (UFE) offers an alternative to hysterectomy in women with symptomatic uterine fibroids, particularly those with uterine fibroids and heavy menstrual bleeding. Women with symptomatic uterine fibroids who are of reproductive age but who are not interested in childbearing are candidates for UFE. Three randomized clinical trials including a total of 391 women have compared UFE to hysterectomy for the treatment of heavy menstrual bleeding in women with uterine fibroids. Overall, hysterectomy offers better control of bleeding than UFE and requires fewer additional treatments but demonstrates no differences in quality of life, sexual health, or frequency of adverse events. The EMMY trial randomized 177 patients with uterine fibroids and menorrhagia to UFE ( n = 88) or hysterectomy ( n = 89) ( ). Of those who received UFE, 62% reported resolution of menorrhagia at 24 months and 4% described their menorrhagia as being unchanged. In both groups hemoglobin levels increased significantly compared to baseline (at 24 months: UFE, +1.37 g/dL; hysterectomy, +2.03 g/dL; p < .001 for each) with the increase in hemoglobin being significantly greater for hysterectomy patients ( p = .037). Two years after treatment, 23.5% of UFE patients had undergone a hysterectomy for inadequate symptom control. This finding is similar to the REST trial, in which 20% of patients receiving UFE required invasive procedure (hysterectomy or repeat UFE) within 2 years after the procedure for continued or recurrent symptoms compared with none in those who received a hysterectomy ( ).

For simple dysfunctional uterine bleeding, a short trial of oral contraceptives followed by second-generation ablation is the most cost-effective strategy. Hysterectomy is more cost-effective for achieving amenorrhea, which likely improves with more follow-up time. Patient preferences of treatment also play an important role ( ).