Medical Management of Endometriosis, Uterine
Fibroids and Dysfunctional Uterine Bleeding: Does
Hysterectomy Still Have a Place in Modern
Management?
D. Olive, J. Donnez* and E. Thomas**
Department of Obstetrics and Gynaecology
Yale University School of Medicine, Connecticut, USA
*Department of Gynaecology, University Hospital Saint-Luc
Universit ‫י‬Catholique de Louvain, Brussels, Belgium
**University of Southampton, Princess Anne Hospital, Southampton, United Kingdom
Summary
Hysterectomy is one of the most common abdominal surgical procedures performed in
women today with 600,000 hysterectomies in the USA annually, one in three women
undergoing hysterectomy, and 6–20% in European countries. Despite the availability of other
conservative medical and surgical options, hysterectomy continues to be used frequently in
the treatment of benign gynaecological conditions such as endometriosis, dysfunctional
uterine bleeding (DUB) and fibroids. Hysterectomy procedures (abdominal, vaginal ,
laparoscopic) for benign gynaecological disease are not without risk, with death occurring in 1
of 1000 cases. Other complications of postoperative fever (unexplained 1.4–20%, operative
site infections 4–42%; urinary tract infection <1–5%), haemorrhage (intraoperative 0.2–4%;
postoperative 0.2–6%; transfusions 2–12%) and injury to adjacent organs (bladder 0.5–2%;
bowel 0.1–0.5%; urethra 0.1–0.3%) also occur.1
The reasons for choosing hysterectomy include patient age, extent of disease and fertility
aspirations but remuneration, gender of the gynaecologist and social class of the patient may
also play a part.2,3 Fibroids
Better use of medical treatment alone or in combination with more conservative surgical
approaches should be considered if the needs of the patient are to be fulfilled. For example,
in patients with uterine fibroids, the preoperative use of a gonadatrophin-releasing hormone
analogue (GnRHa) such as Zoladex (goserelin) has been shown to induce amenorrhoea in
the majority of patients. This is particularly useful in those who have heavy menorrhagia or
who are anaemic, where an improvement in haemoglobin concentration has been reported.
Preoperative use of GnRHas may also limit blood transfusions and reduce both uterine and
fibroid volumes enabling a more conservative surgical approach, or a vaginal or laparoscopic
myomectomy with the potential avoidance of hysterectomy.4 Some gynaecologists worry
about missing a leiomyosarcoma and would use this as a reason for hysterectomy. However,
such tumours occur in 1 in 10,000 cases.
DUB
In patients with DUB, antifibrinolytic agents, coils impregnated with a progestogenic agent and
the use of a GnRHa together with addback therapy provide alternative approaches to the
long-term treatment of DUB.5 For those not wishing to retain their fertility, prethinning the
endometrium with a GnRHa followed by endometrial ablation has resulted in avoidance of
further surgical intervention in the majority of cases.6,7
Endometriosis
In the treatment of endometriosis, the following options need to be considered in the earlier
stages of the disease to have a greater chance of success with delayed disease recurrence
following the end of treatment.8–11
•A combination of conservative surgery with pre- and/or postoperative GnRHa alone or in
combination with addback.
•GnRHa alone or with addback.
In addition, some gynaecologists are using GnRHas as a diagnostic tool in symptomatic
patients. With the addition of addback, repeat treatments may now be possible making these
drugs more useful in the management of this chronic recurring disease.
Conclusion
In the coming years, the gynaecologist will be faced with more younger women presenting
with endometriosis or DUB requiring long-term treatment. Many of these women will wish to
retain their fertility and for them a hysterectomy will not be an option. It beholds the
gynaecologist to consider now, more thoroughly, the other available medical and surgical
options. Hysterectomy will still have a place but let us hope it will be used more wisely in the
future.
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