Ablation versus Hysterectomy for the Treatment of Mmenorrhagia
Robert S. Neuwirth, M.D,
Babcock Professor of Obstetrics/Gynecology, Emeritus,
Columbia University, Director of Hysteroscopic Surgery, St.
Luke's - Roosevelt Hospital Center, New York City, U.S.A.
Menorrhagia and associated conditions such as uterine f‫ם‬broids are some of
the most common problems seen by gynecologists. It is estimated that 20%
of women suffer from these conditions (l). The diagnostic work-up should
rule out cancer and coagulation problems. Other causes are amenable to
hormonal therapeutic trials or a variety of other more interventional
treatments provided no contraindication exists. Costs and safety are prime
considerations. The interventional options include uterine embolization,
endometrial ablation and various forms of hysterectomy.
Uterine embolization is the most recent interventional treatment introduced.
It clearly has been successful in several reports (2, 3). However it is too
early to define the categories of patients best indicated and contraindicated.
It was introduced primarily as a treatment to reduce myomas but has had
success in control of menorrhagia. The complication rates are unknown at
this time. A registry of cases with follow-up is needed to answer these
questions,
Hysterectomy indisputably cures menorrhagia and uterine f‫ם‬broids. It has
been practiced for one hundred years. Curettage as a therapy has been
ineffective for menorrhagia or fibroids unless a polyp was removed. Its
advantage was low risk and its roots are its effectiveness for control of
bleeding from abortion. Hysterectomy has been and remains the primary
treatment in patients with menorrhagia who did not respond to hormonal
therapy. Although a variety of types of hysterectomy have been introduced
recently, the data on complications, costs and length of stay are relatively
limited. The information suggests that costs and hospital stay are about the
same (4.). Clearly the skills required are less for supracervical hysterectomy
than for laparoscopic or vaginal hysterectomy. As all these procedures are
skill dependent and case selection is also a confounding factor, it is difficult
to sort out complication rates except in narrowly defined circumstances.
However. it is safe to say that for all forms of hysterectomy the
complication rate is higher than for hysteroscopic ablation and certainly
higher than for second generation ablation methods where there has been
sufficient breadth and duration of experience to determine rates. The death
rate for hysterectomy for benign disease is about one per one thousand
cases (5). The death rate from hysteroscopic ablation is about one in five
thousand, and the death rate for Thermochoice balloon ablation in over
100,000 cases is zero (6). Major complications from hysterectomy
including pulmonary embolism, hemorrhage, anesthesia, visceral injury,
urinary retention and peripheral nerve injuries are
about 8 per hundred. The immediate direct costs of hysterectomy are about
double hysteroscopic endometrial ablation, even if repeat procedures for
failure are included (7).
Indirect costs, such as lost work, and assistance during recovery are
difficult to analyze but probably favor ablation. Long term post- treatment
data can modify the analysis but is generally rot available or soft. For
example, the costs of endometrial cancer following ablation have not been
reported as yet, The incidence of endometrial cancer after ablation appears
to be low as there are very few reports in the literature and those cases are
clustered in high risk patients for endometrial cancer (8). A long term
follow-up focused on endometrial cancer is undervay,
The long term sequelae of hysterectomy also require consideration. Tulandi
reported (9) recently a l .6% incidence of bowel obstruction from adhesions
as a late complication of hysterectomy. An incidence as high as 3% has
been reported. Urinary incontinence surgery appears to be more frequent in
women who have undergone hysterectomy. Olsen reported (10) 37% of
women having a primary procedure for urinary incontinence and/or pelvic
organ prolapse had a prior hysterectomy not for prolapse. Serious longterm risks following a procedure must be considered, particularly now that
there are reasonable altematives. Such data may change the cost or health
risk analysis for a patient when comparing hysterectomy to ablation.
The third category of intervention for menorrhagia is endometrial ablation.
Follwing introducticn of the resectoscope to treat submucus fibroids,
Goldrath in 1981 reported (11) on laser ablation of the endometrium under
hysteroscopic control. De Cherney reported (12) using the resectoscope for
the same purpose in 1984. It was soon evident that hysterescopic thermal
ablation of the endometrial was effective in the short run. In 1991 our
group published (13) a ten year follow-up study covering 1978 to 1988
which showed a 91% chance to avoid a second surgery in a cohort study
using a life-table analysis. Magos reported (14) a prospective five year trial
in 1996 confirming the long term effectiveness of endometrial ablation.
These reports created interest in ablation as a treatment for menorrhagia in
lieu of hysterectomy. Comparison of laser and electrosurgical hysteroscopic
ablation showed similar amenorrhea, repeat surgery and patient satisfaction
rates. Pre-treatment with GRnH agonists improved success. Complications
are perforation, visceral burns, and problems related to fluids used to
distend the uterine cavity which can be absorbed.
Pulmonaiy edema from fluid overload and hyponatremia with convulsions
and coma have occurred when non-electrolyte solutions are used and have
been the major problems. Both have resulted in fatalities. Nonetheless,
complication rates have been acceptable. In the U.K. Mistletoe study (15)
there was a 1.26% rate of emergency surgery (half laparoscopy only). There
were two deaths in 10,880 women related to ablation. The complication rate
was inversely proportional to the number of cases performed by the surgeon
emphasizing the technical skills needed for hysteroscopic ablation. There
was about an 85% satisfaction rate, and a low complication and death rate
with a less costly procedure.
However favorable, the data accumulated on hysteroscopic endometrial
ablation has not been followed by general acceptance of ablation as an
alternative for hysterectomy.
O'Connor published (16) a randomized prospective trial comparing
hysterectomy with hysteroscopic endometrial ablation. In a group of
women with menorrhagia 56 were randomized to hysterectomy and 116 to
hysteroscopic ablation. The uterus was 12 weeks or smaller, any submucus
myoma 5 cm or less, and uterine supports were good. The staff were all
experienced in both techniques. Statistical profiles of demographics,
menstrual experience and uterine size were equivalent in both groups. The
results showed general anesthesia in all hysterectomies compared to 86%
in the ablation group. Operating time for ablation was half the time for
hysterectomy. Hemorrhage occurred in 9% of the hysterectomy patients
requiring transfusion in all but one. There was no hemorrhage in the
ablation group but one patient required a pre-op-transfusion. There was a
3% fluid overload rate and one ablation could not be performed. The postop stay averaged 6.3 days for hysterectomy versus 1.3 days for ablation
and return to work was 2.9 weeks against 7.4 weeks for hysterectomy.
In spite of this comparative data and general experience, Bridgeman
reported (17) in 2000 that the hysterectomy rate in the U.K. had not
changed and there is a stable rate of endometrial ablation. The traditional
use of hysterectomy prevails and there is a 25% increase in hysterectomy
plus ablation procedures which can only come from women who refused
hysterectomy and accepted ablation, women who could not be scheduled
for hysterectomy in the Health system, or women who switched from
hormonal therapy to ablation. In addition, it appears that only a small
segment of gynecologists has become sufficiently interested to acquire the
skills and equipment to perform hysteroscopic ablationIn order to reduce
the skill level needed to perform ablation, improve safety, and lower cost, a
second generation ablation device and technique was developed (18),
Thermochoice is a balloon catheter which is inserted into the endometrial
cavity, filled with 5% dextrose in water to 160 mm Hg. Pressure, and
heated to 187 F for 8 minutes. In a prospective randomized trial against
roller ball hysteroscopic ablation it produced comparable results and was
approved by the F.D.A. Safety has been very high with no known deaths
and two visceral injuries in over 100,000 cases in three years. Other second
generation devices have come to the market and show effectiveness. The
safety record for these devices is not available as they have only recently
been released. At this point, ablation technology is becoming less
expensive, more user friendly, requires less anesthesia and analgesia, and
is producing about 85% patient satisfaction.
Hysterectomy remains a skill-dependent procedure with 100%
effectiveness. However, its safety record for death and injury compares
unfavorably with ablation. Its costs are higher and recovery is longer. The
long term problems w‫ם‬th ablation are failure before menopause requiring a
repeat procedure, and the unknown rate of post ablation endometrial
cancer. The long term impact of hysterectomy relate to psychosexual
effects, bowel obstruction, and pelvic door weakness requiring surgical
repair. While the data indicate that ablation has been slow to be practiced,
the method is evolving with new technology to appeal to patients who fail,
cannot use or refuse hormonal therapy and wish to avoid the costs, risks
and the immediate and long term morbidity associated with hysterectomy.
This information and the options are becoming more clear. Patient
counseling must now include the full range of drug and procedure choices.
Hysterectomy will certainly not disappear as a treatment for benign uterine
diseases but its role in the treatment of peri-menopausal menorrhagia will
undoubtedly assume a third line behind drugs and ablative therapy in those
patients without contraindications to the f‫ם‬rst and second line options.
References:
1. Goth, D, Osborn,M, Bungy,G., Psychiatric disorders and gynecological
symptoms in middle aged women: a community survey BMJ 294:213-218,
1987
2. Spies, J., Ashcher, S., Roth, A., Kim, J., Levy, E., Gomez-Jorge, J.,
Uterine artery embolization for leiomyomata Obstet. Gynecol. 98: 29-34,
2001
3. Hutchins, F., Worhington-Kirsch, R., Berkowitz, R., Selective uterine
artery embolization as primary treatment for symptomatic leiomyomata J.
Am. Assoc. Gynecol. Laparosc. 6: 279-84, 1999
4. Farquahr, C., Steiner, C., Hysterectomy rates in the United States 19901997 Obstet.Gynecol. 99: 229-234, 2002
5. Wingo, P.A., Huezo, C., Rubin, G.L., Ory, H., Peterson, H., The
mortality risk associated with hysterectomy Am.J. Obstet.Gynecol. 803:813, 1985
6. Persona. Communication Marketing Dept. Gynecare, Inc, Somerville,
N.J., U.S.A. Dec. 2000
7. Brumstead, J., Blackman, J., Badger, G., Riddick, D., Hysteroscopy
versus hysterectomy for the treatment of abnormal bleeding: a comparison
of cost Fertil. Steril. 65:310-316,1996
8. Brooks-Carter, G., Killackey, M., Neuwirth, R., Adenocarcinoma of the
endometrium after endometrial ablation Obstet. Gynecol. 80: 313-315,
2000
9. Al-Tool, S., Platt, R., Tulandi, T., Adhesion related small bowel
obstruction after gynecological operations Am. J. Obstet. Gynecol.
180:313-315, 1999
l0.Olsen, A., Smith, V., Bergstrom, J., et al., Epidemiology of surgically
managed pelvic organ prolapse and urinary incontipence Obstet. Gynecol.
89: 501-506, 1997
11. Goldrath, M., Fuller, T., Segal, Laser photovaporization of
endometrium for the treatment of menorrhagia Am. J. Obstet. Gynecol.
140; 14-19, 1981
12. DeCherney, A., Polan, M., Hysteroscopic management of intrauterine
lesions and intractable bleeding Obstet. Gynecol. 61:392-397, 1983
13. Derman, S. Blane, J., Neuwirth, R., The long-term effectiveness of
hysteroscopy treatment of menorrhagia and leiomyoma Am. J. Obstet.
Gynecol., 77: 591-594, 1991
14. O'Connor, H., Magos, A., Endometrial resection for the treatment of
menorrhagia New Engl. J. Med. 335:151-156, 1996
15. Overton, C., Hargreaves, J., Maresh, M., A national survey of the
complications of endometrial destruction for menstrual disorders: THE
MIST-LETOE STUDY Brit. J. Obstet. Gynecol. 103: 339-344, 1996
16.O'Connor, H., Broadbent, J., Magos, A., McPherson K., Medical
Research Council randomized trial of endometrial resection versus
hysterectomy in management of menorrhagia The Lancet 389; 897-901,
1997
17. Bridgeman, S., Dunn, K., Has endometrial ablation replaced
hysterectomy for the treatment of dysfunctional uterine bleeding? Brit. J.
Obstet. Gynecol., 107: 531-534, 2000
18. Neuwirth, R., Duran, A., Singer, A., et al., The endometrial ablator: a
new instrument Obstet. Gynecol. 83:792-796,1994