Hysterectomy is a frequent surgica...

Hysterectomy is a frequent surgical procedure that provides definitive treatment for menorrhagia. However, many women count more desirable to continue medical therapy for several years because hysterectomy is irreversible and associated with surgical risks. No randomized controll trials have compared medical and surgical treatment of menorrhagia in women who did not have a vigorous preference or medical indications for either strategy. Learman and colleagues compared the issue of these two treatment strategies in 63 premenopausal women referr to four teaching hospitals in the United States because of symptomatic menorrhagia.

application of mind participants were 30 to 50 years of age and reported abnormal menstrual pour lasting more than seven days each month or sufficient melt to cause anemia for at least sum of two units months. Women who were older than 45 years were exampleed for menopause by measuring follicle-stimulating hormone flush and also were tested for endometrial hyperplasia or carcinoma before being recorded in the study. Exclusion criteria included coagulopathies, other causes of anemia, endocrine conditions, pelvic pathology, desire for pregnancy, and modern use of oral contraceptives or long-acting hormonal therapies.

A total of 413 women initially began the trial and were given cyclic medroxyprogesterone acetate for 10 to 14 days by means of month. Patients who were dissatisfied with this regimen were invited to participate in the comparison trial of hysterectomy and enlargeed medical therapy. Patients assigned to medical therapy received a combined oral contraceptive plus a prostaglandin inhibitor, nevertheless variations in the actual regimen were permitted. Patients were followed each three months for two years to assess health status, beliefs and attitudes, gynecologic and urinary symptoms, and other relevant symptoms, in the same state [i]or[/i] condition as back pain and sexual function.

onward entry to the study, one as well as the other groups reported multiple pelvic symptoms and gentle satisfaction with their current health status and symptom management. The median duration of abnormal bleeding symptoms was three to four years. Initially, 29 of the 32 women assigned to medical treatment received hormonal therapy, still only 17 of these women also received a prostaglandin inhibitor. Within sum of two units years, 17 of these women had undergone a hysterectomy.

Of the 31 women assigned to hysterectomy, 28 had the surgery greatest in quantity of these women (86 percent) required a one- to two-day hospitalization. pair patients had perioperative complications and three required readmission because of late complications. After six month women in the hysterectomy cluster reported significantly greater improvements in pelvic pain, breast pain, urinary press and sensation of incomplete bladder emptying than women receiving medical treatment. They also reported nonstatistically significant improvements in pelvic or bladder hurry and lower back pain compared with women treated medically.

by way of two years, the most significant differences recorded between the collections were hot flushes and incomplete bladder emptying. Women who remained onward medical treatment showed significant improvements from baseline in pelvic pain, pelvic or bladder crushing and stress incontinence symptoms. Women who troubleed over to hysterectomy reported significant improvements in bleeding; pelvic, back, or breast pain; and urinary commonness and urgency. Conversely, women who christian doctrineed over from medicine to hysterectomy had more days misspent from usual activities and more days in bed than women who remained in succession medical therapy.

The authors bring to an end that hysterectomy may be the better treatment option for women who court relief of symptoms such as bleeding, pelvic pain, breast pain, lower back pain, and bladder symptoms. reciprocally medical therapy can provide substantial improvements in symptoms with fewer overall days of restricted activities in the short terminus for women who do not want to have a hysterectomy.

ANNE D WALLING, MD

Learman LA, et al. Hysterectomy versus expanded medical treatment for abnormal uterine bleeding: clinical consequences in the medicine or surgery trial. Obstet Gynecol May 2004;103:824-33

EDITOR'S NOTE: Deciding onward the optimal treatment strategy for an individual woman with menorrhagia can be challenging for several reasons. Although the medical literature is difficult to assess objectively, about the same third of patients are reported to have vigorous personal preferences for a specific therapy. The options are abundant wider than suggested in this article. A review (1) in the BMJ Best Treatments series (http://www.besttreatments.org) conclud that nonsteroidal anti-inflammatory put drugs intos (NSAIDs), tranexamic acid, hysterectomy (after failure of medical therapy), and endometrial thinning before hysteroscopic surgery are "treatments that work," and that endometrial destruction (after failure of medical therapy) is a "treatment likely to work."

"Treatments that ne further study" include ethamsylate, oral contraceptives, intrauterine progesterone gonadotropin-releasing hormone (GnRH) and myomectomy. individual of the more interesting facts raise in this review is that women adequately treated with NSAIDs reported a 25 to 50 per-cent reduction in bleeding, still in the above study, merely a small proportion of the women assigned to treatments including NSAIDs actually took them. Although hysterectomy is the definitive therapy for menorrhagia (and the leading indication for the more than 600000 hysterectomies performed in the United States by year), studies that followed patients for more than brace years after hysterectomy or endometrial ablation build no significant difference between the collections in satisfaction at longer follow-up Women treated according to endometrial ablation were calculated to have a mean reduction in operating time of 23 minutes and reverted to work 4.5 weeks sooner than women undergoing hysterectomy.--A.D.W.