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Oderkerk TJ, Beelen P, Bukkems ALA, Van Kuijk SMJ, Sluijter HMM, van de Kar MRD, Herman MC, Bongers MY, Geomini PMAJ. Risk of Hysterectomy After Endometrial Ablation: A Systematic Review and Meta-analysis. Obstet Gynecol 2023; 142:51-60. [PMID: 37290114 DOI: 10.1097/aog.0000000000005223] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/30/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To assess the risk of hysterectomy after nonresectoscopic endometrial ablation in patients with heavy menstrual bleeding. DATA SOURCES The EMBASE, MEDLINE, ClinicalTrials.gov and Cochrane databases were searched for eligible articles from inception until June 13, 2022. We used combinations of search terms for endometrial ablation and hysterectomy. METHODS OF STUDY SELECTION Articles included in the review described the incidence of hysterectomy at a specific point in time after ablation with a minimum follow-up duration of 12 months. TABULATION, INTEGRATION, AND RESULTS The literature search yielded a total of 3,022 hits. A total of 53 studies met our inclusion and exclusion criteria, including six retrospective studies, 24 randomized controlled trials, and 23 prospective studies. A total of 48,071 patients underwent endometrial ablation between 1992 and 2017. Follow-up duration varied between 12 and 120 months. Analyses per follow-up moment showed 4.3% hysterectomy rate at 12 months of follow-up (n=29 studies), 11.1% at 18 months (n=1 study), 8.0% at 24 months (n=11 studies), 10.2% at 36 months (n=12 studies), 7.6% at 48 months (n=2 studies), and 12.4% at 60 months (n=6 studies). Two studies reported a mean hysterectomy rate at 10 years after ablation of 21.3%. Minimal clinically relevant differences in hysterectomy rates were observed among the different study designs. Furthermore, we found no significant differences in hysterectomy rate among the different nonresectoscopic endometrial ablation devices. CONCLUSION The risk of hysterectomy after endometrial ablation seems to increase from 4.3% after 1 year to 12.4% after 5 years. Clinicians can use the results of this review to counsel patients about the 12% risk of hysterectomy 5 years after endometrial ablation. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42020156281.
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Affiliation(s)
- Tamara J Oderkerk
- Department of Obstetrics and Gynecology, Máxima Medical Centre, Veldhoven, the Department of Obstetrics and Gynecology, Grow-school of Oncology and Reproduction, Maastricht University, and the Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre+, Maastricht, the Community Health Service, GGD Noord Brabant, North Brabant, and the Department of Obstetrics and Gynecology, Jeroen Bosch Hospital's-Hertogenbosch, Hertogenbosch, the Netherlands
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Shan J, Tian H, Zhou C, Wang H, Ma X, Li R, Yu H, Chen G, Zhu J, Cai Z, Lin C, Cheng L, Xu Y, Liu S, Zhang C, Luo Q, Zhang Y, Jin S, Liu C, Zhang Q, Lv L, Yang L, Chen J, Li Q, Liu W, Yue W, Song X, Zhuo C. Prevalence of Heavy Menstrual Bleeding and Its Associated Cognitive Risks and Predictive Factors in Women With Severe Mental Disorders. Front Pharmacol 2022; 13:904908. [PMID: 35910343 PMCID: PMC9326357 DOI: 10.3389/fphar.2022.904908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 06/13/2022] [Indexed: 11/26/2022] Open
Abstract
There has been limited studies examining treatment-induced heavy menstrual bleeding (HMB) in women with severe mental illnesses. The aim of this study was to examine HMB prevalence and HMB-associated factors in young women (18–34 years old) diagnosed with bipolar disorder (BP), major depressive disorder (MDD), or schizophrenia (SCZ) who have full insight and normal intelligence. Eighteen-month menstruation histories were recorded with pictorial blood loss assessment chart assessments of HMB. Multivariate analyses were conducted to obtain odds ratios (ORs) and 95% confidence intervals (CIs). Drug effects on cognition were assessed with the MATRICS Consensus Cognitive Battery (MCCB). HMB prevalence were: BP, 25.85%; MDD, 18.78%; and SCH, 13.7%. High glycosylated hemoglobin (HbA1c) level was a strong risk factor for HMB [BP OR, 19.39 (16.60–23.01); MDD OR, 2.69 (4.59–13.78); and SCZ OR, 9.59 (6.14–12.43)]. Additional risk factors included fasting blood sugar, 2-h postprandial blood glucose, and use of the medication valproate [BP: OR, 16.00 (95%CI 12.74–20.22); MDD: OR, 13.88 (95%CI 11.24–17.03); and SCZ OR, 11.35 (95%CI 8.84–19.20)]. Antipsychotic, antidepressant, and electroconvulsive therapy use were minor risk factors. Pharmacotherapy-induced visual learning impairment was associated with HMB [BP: OR, 9.01 (95%CI 3.15–13.44); MDD: OR, 5.99 (95%CI 3.11–9.00); and SCZ: OR, 7.09 (95%CI 2.99–9.20)]. Lithium emerged as a protective factor against HMB [BP: OR, 0.22 (95%CI 0.14–0.40); MDD: OR, 0.30 (95%CI 0.20–0.62); and SCZ: OR, 0.65 (95%CI 0.33–0.90)]. In SCZ patients, hyperlipidemia and high total cholesterol were HMB-associated factors (ORs, 1.87–2.22). Psychiatrist awareness of HMB risk is concerningly low (12/257, 2.28%). In conclusion, prescription of VPA should be cautioned for women with mental illness, especially BP, and lithium may be protective against HMB.
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Affiliation(s)
- Jianmin Shan
- Department of Psychiatry, Tianjin Fourth Center Hospital, Tianjin, China
- Department of Psychiatry, Wenzhou Seventh Peoples Hospital, Wenzhou, China
| | - Hongjun Tian
- Department of Psychiatry, Wenzhou Seventh Peoples Hospital, Wenzhou, China
| | - Chunhua Zhou
- Department of Pharmacology, The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Haibo Wang
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
| | - Xiaoyan Ma
- MECT Center, Sleep Disorder Center, Tianjin Anding Hospital, Tianjin, China
| | - Ranli Li
- MECT Center, Sleep Disorder Center, Tianjin Anding Hospital, Tianjin, China
| | - Haiping Yu
- Department of Psychiatry, Tianjin Fourth Center Hospital, Tianjin, China
| | - Guangdong Chen
- Department of Psychiatry, Tianjin Fourth Center Hospital, Tianjin, China
| | - Jingjing Zhu
- Department of Psychiatry, Tianjin Fourth Center Hospital, Tianjin, China
| | - Ziyao Cai
- Department of Psychiatry, Tianjin Fourth Center Hospital, Tianjin, China
| | - Chongguang Lin
- Department of Psychiatry, Tianjin Fourth Center Hospital, Tianjin, China
| | - Langlang Cheng
- Department of Psychiatry, Tianjin Fourth Center Hospital, Tianjin, China
| | - Yong Xu
- Department of Psychiatry, First Hospital/First Clinical Medical College of Shanxi Medical University, Taiyuan, China
| | - Sha Liu
- Department of Psychiatry, First Hospital/First Clinical Medical College of Shanxi Medical University, Taiyuan, China
| | - Congpei Zhang
- Inpatient Department of Harbin First Psychiatry Hospital, Harbin, China
| | - Qinghua Luo
- Department of Psychiatry, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yunshu Zhang
- Inpatient Department of Hebei Mental Health Center, Baoding, China
| | - Shili Jin
- Inpatient Department, Shandong Daizhuang Hospital, Jining, China
| | - Chuanxin Liu
- Institute of Psychiatry, Jining Medical University, Jinning, China
| | - Qiuyu Zhang
- Institute of Psychiatry, Jining Medical University, Jinning, China
| | - Luxian Lv
- Department of Psychiatry, Henan Psychiatry Hospital, Xinxiang, China
| | - Lei Yang
- Key Laboratory of Mental Health, Ministry of Health (Peking University) and National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, China
| | - Jiayue Chen
- Department of Psychiatry, The First Hospital Affiliated to Harbin Medical University, Harbin, China
| | - Qianchen Li
- Department of Pharmacology, The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Wei Liu
- Department of Psychiatry, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Wei Liu, ; Weihua Yue, ; Xueqin Song, ; Chuanjun Zhuo,
| | - Weihua Yue
- Department of Psychiatry, The First Hospital Affiliated to Harbin Medical University, Harbin, China
- *Correspondence: Wei Liu, ; Weihua Yue, ; Xueqin Song, ; Chuanjun Zhuo,
| | - Xueqin Song
- Department of Psychiatry, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Wei Liu, ; Weihua Yue, ; Xueqin Song, ; Chuanjun Zhuo,
| | - Chuanjun Zhuo
- Department of Psychiatry, Tianjin Fourth Center Hospital, Tianjin, China
- Department of Psychiatry, Wenzhou Seventh Peoples Hospital, Wenzhou, China
- Department of Psychiatry, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Laboratory of Psychiatric-Neuroimaging-Genetic and Cor-morbidity, Tianjin Mental Health Center of Tianjin Medical University, Tianjin Anding Hospital, Tianjin, China
- *Correspondence: Wei Liu, ; Weihua Yue, ; Xueqin Song, ; Chuanjun Zhuo,
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3
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Zhuo C, Chen G, Lin C, Ping J, Zhu J, Wang L, Jin S, Liu C, Zhang Q, Yang L, Li Q, Zhou C, Cheng L, Tian H, Song X. Risk-to-befit ratios of consecutive antidepressants for heavy menstrual bleeding in young women with bipolar disorder or major depressive disorder. Front Psychiatry 2022; 13:1012644. [PMID: 36386987 PMCID: PMC9650378 DOI: 10.3389/fpsyt.2022.1012644] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 10/06/2022] [Indexed: 11/24/2022] Open
Abstract
The occurrence of heavy menstrual bleeding (HMB) induced by pharmacological agents has been reported in young adult women. This study aimed to investigate a possible association between the occurrence rates of HMB and different treatment methods such as antidepressant agents alone and in combination with other pharmacological agents. The examined cohort included young women (age 18-35 years, n = 1,949) with bipolar disorder (BP) or major depressive disorder (MDD). Menstruation history for 24 months was recorded and evaluated according to pictorial blood loss assessment charts of HMB. Multivariate analyses were conducted to determine odds ratios (ORs) and 95% confidence intervals. The examined antidepressant agents had varying ORs for patients with BP vs. those with MDD. For example, the ORs of venlafaxine-induced HMB were 5.27 and 4.58 for patients with BP and MDD, respectively; duloxetine-induced HMB, 4.72 and 3.98; mirtazapine-induced HMB, 3.26 and 2.39; fluvoxamine-induced HMB, 3.11 and 2.08; fluoxetine-induced HMB, 2.45 and 1.13; citalopram-induced HMB, 2.03 and 1.25; escitalopram-induced HMB, 1.85 and 1.99; agomelatine-induced HMB, 1.45 and 2.97; paroxetine-induced HMB, 1.19 and 1.75; sertraline-induced HMB, 0.88 and 1.13; reboxetine-induced HMB, 0.45 and 0.45; and bupropion-induced HMB, 0.33 and 0.37, in each case. However, when antidepressant agents were combined with valproate, the OR of HMB greatly increased, with distinct profiles observed for patients with BP vs. those with MDD. For example, the ORs of HMB induced by venlafaxine combined with valproate were 8.48 and 6.70 for patients with BP and MDD, respectively; for duloxetine, 5.40 and 4.40; mirtazapine, 5.67 and 3.73; fluvoxamine, 5.27 and 3.37; fluoxetine, 3.69 and 4.30; citalopram, 5.88 and 3.46; escitalopram, 6.00 and 7.55; agomelatine, 4.26 and 5.65; paroxetine, 5.24 and 3.25; sertraline, 4.97 and 5.11; reboxetine, 3.54 and 2.19; and bupropion, 4.85 and 3.46, in each case. In conclusion, some antidepressant agents exhibited potential risks of inducing HMB. Therefore, a combined prescription of antidepressant agents and valproate should be carefully considered for young women with HMB.
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Affiliation(s)
- Chuanjun Zhuo
- Department of Psychiatry, Wenzhou Seventh Peoples Hospital, Wenzhou, China.,Key Laboratory of Multiple Organs Damage in Patients With Metal Disorder, Tianjin Fourth Center Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin, China.,Department of Psychiatry, Tianjin Fourth Center Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin, China.,Department of Psychiatry, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Laboratory of Psychiatric-Neuroimaging-Genetic and Comorbidity, Tianjin Anding Hospital, Tianjin Mental Health Center of Tianjin Medical University, Tianjin, China
| | - Guangdong Chen
- Department of Psychiatry, Wenzhou Seventh Peoples Hospital, Wenzhou, China
| | - Chongguang Lin
- Department of Psychiatry, Wenzhou Seventh Peoples Hospital, Wenzhou, China
| | - Jing Ping
- Department of Psychiatry, Wenzhou Seventh Peoples Hospital, Wenzhou, China
| | - Jingjing Zhu
- Department of Psychiatry, Wenzhou Seventh Peoples Hospital, Wenzhou, China
| | - Lina Wang
- Laboratory of Psychiatric-Neuroimaging-Genetic and Comorbidity, Tianjin Anding Hospital, Tianjin Mental Health Center of Tianjin Medical University, Tianjin, China
| | - Shili Jin
- Inpatient Department, Shandong Daizhuang Hospital, Jining, China
| | - Chuanxin Liu
- College of Mental Disorder, Jining Medical University, Jining, China
| | - Qiuyu Zhang
- Key Laboratory of Multiple Organs Damage in Patients With Metal Disorder, Tianjin Fourth Center Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin, China
| | - Lei Yang
- Key Laboratory of Multiple Organs Damage in Patients With Metal Disorder, Tianjin Fourth Center Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin, China
| | - Qianchen Li
- Key Laboratory of Multiple Organs Damage in Patients With Metal Disorder, Tianjin Fourth Center Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin, China
| | - Chunhua Zhou
- Department of Pharmacology, The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Langlang Cheng
- Department of Psychiatry, Wenzhou Seventh Peoples Hospital, Wenzhou, China
| | - Hongjun Tian
- Key Laboratory of Multiple Organs Damage in Patients With Metal Disorder, Tianjin Fourth Center Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin, China
| | - Xueqin Song
- Department of Psychiatry, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Bergeron C, Laberge PY, Boutin A, Thériault MA, Valcourt F, Lemyre M, Maheux-Lacroix S. Endometrial ablation or resection versus levonorgestrel intra-uterine system for the treatment of women with heavy menstrual bleeding and a normal uterine cavity: a systematic review with meta-analysis. Hum Reprod Update 2020; 26:302-311. [PMID: 31990359 DOI: 10.1093/humupd/dmz051] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 12/02/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Endometrial ablation/resection and the levonorgestrel intra-uterine system (LNG-IUS) are well-established treatment options for heavy menstrual bleeding to avoid more invasive alternatives, such as hysterectomy. OBJECTIVE The aim was to compare the efficacy and safety of endometrial ablation or resection with the LNG-IUS in the treatment of premenopausal women with heavy menstrual bleeding and to investigate sources of heterogeneity between studies. SEARCH METHODS We searched the databases MEDLINE, EMBASE, CENTRAL, Web of Science, Biosis and Google Scholar as well as citations and reference lists published up to August 2019. Two authors independently screened 3701 citations for eligibility. We included randomized controlled trials published in any language, comparing endometrial ablation or resection to the LNG-IUS in the treatment of premenopausal women with heavy menstrual bleeding and a normal uterine cavity. OUTCOMES Thirteen studies (N = 884) were eligible. Two independent authors extracted data and assessed the quality of included studies. Random effect models were used to compare the modalities and evaluate sources of heterogeneity. No significant differences were observed between endometrial ablation/resection and the LNG-IUS in terms of subsequent hysterectomy (primary outcome, risk ratio (RR) = 1.13, 95% CI 0.60 to 2.11, P = 0.71, I2 = 14%, 12 studies, 726 women), satisfaction, quality of life, amenorrhea and treatment failure. However, side effects were less common in women treated with endometrial ablation/resection compared to the LNG-IUS (RR = 0.52, 95% CI 0.37 to 0.71, P < 0.001, I2 = 0%, 10 studies, 580 women). Three complications were reported in the endometrial ablation/resection group and none in the LNG-IUS group (P = 0.25). Mean age of the studied populations was identified as a significant source of heterogeneity between studies in subgroup analysis (P = 0.01). In fact, endometrial ablation/resection was associated with a higher risk of subsequent hysterectomy compared to the LNG-IUS in younger populations (mean age ≤ 42 years old, RR = 5.26, 95% CI 1.21 to 22.91, P = 0.03, I2 = 0%, 3 studies, 189 women). On the contrary, subsequent hysterectomy seemed to be less likely with endometrial ablation/resection compared to the LNG-IUS in older populations (mean age > 42 years old), although the reduction did not reach statistical significance (RR = 0.51, 95% CI 0.21 to 1.24, P = 0.14, I2 = 0%, 5 studies, 297 women). Finally, sensitivity analysis taking into account the risk of bias of included studies and type of surgical devices (first and second generation) did not modify the results. Most of the included studies reported outcomes at up to 3 years, and the relative performance of endometrial ablation/resection and LNG-IUS remains unknown in the longer term. WIDER IMPLICATIONS Endometrial ablation/resection and the LNG-IUS are two excellent treatment options for heavy menstrual bleeding, although women treated with the LNG-IUS are at higher risk of experiencing side effects compared to endometrial ablation/resection. Otherwise, younger women seem to present a lower risk of eventually requiring hysterectomy when treated with the LNG-IUS compared to endometrial ablation/resection.
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Affiliation(s)
- Catherine Bergeron
- Université Laval, 2325 Rue de l'Université, QC, Québec, Canada G1V 0A6.,CHU de Québec, 2705, boul. Laurier, QC, Québec, Canada GIV 4G2
| | - Philippe Y Laberge
- Université Laval, 2325 Rue de l'Université, QC, Québec, Canada G1V 0A6.,CHU de Québec, 2705, boul. Laurier, QC, Québec, Canada GIV 4G2
| | - Amélie Boutin
- University of British Columbia, 2329 West Mall, Vancouver, BC, Canada V6T 1Z4
| | - Marie-Anne Thériault
- Université Laval, 2325 Rue de l'Université, QC, Québec, Canada G1V 0A6.,CHU de Québec, 2705, boul. Laurier, QC, Québec, Canada GIV 4G2
| | - Florence Valcourt
- Université Laval, 2325 Rue de l'Université, QC, Québec, Canada G1V 0A6.,CHU de Québec, 2705, boul. Laurier, QC, Québec, Canada GIV 4G2
| | - Madeleine Lemyre
- Université Laval, 2325 Rue de l'Université, QC, Québec, Canada G1V 0A6.,CHU de Québec, 2705, boul. Laurier, QC, Québec, Canada GIV 4G2
| | - Sarah Maheux-Lacroix
- Université Laval, 2325 Rue de l'Université, QC, Québec, Canada G1V 0A6.,CHU de Québec, 2705, boul. Laurier, QC, Québec, Canada GIV 4G2
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Cooper K, Breeman S, Scott NW, Scotland G, Hernández R, Clark TJ, Hawe J, Hawthorn R, Phillips K, Wileman S, McCormack K, Norrie J, Bhattacharya S. Laparoscopic supracervical hysterectomy compared with second-generation endometrial ablation for heavy menstrual bleeding: the HEALTH RCT. Health Technol Assess 2020; 23:1-108. [PMID: 31577219 DOI: 10.3310/hta23530] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Heavy menstrual bleeding (HMB) is a common problem that affects many British women. When initial medical treatment is unsuccessful, the National Institute for Health and Care Excellence recommends surgical options such as endometrial ablation (EA) or hysterectomy. Although clinically and economically more effective than EA, total hysterectomy necessitates a longer hospital stay and is associated with slower recovery and a higher risk of complications. Improvements in endoscopic equipment and training have made laparoscopic supracervical hysterectomy (LASH) accessible to most gynaecologists. This operation could preserve the advantages of total hysterectomy and reduce the risk of complications. OBJECTIVES To compare the clinical effectiveness and cost-effectiveness of LASH with second-generation EA in women with HMB. DESIGN A parallel-group, multicentre, randomised controlled trial. Allocation was by remote web-based randomisation (1 : 1 ratio). Surgeons and participants were not blinded to the allocated procedure. SETTING Thirty-one UK secondary and tertiary hospitals. PARTICIPANTS Women aged < 50 years with HMB. Exclusion criteria included plans to conceive; endometrial atypia; abnormal cytology; uterine cavity size > 11 cm; any fibroids > 3 cm; contraindications to laparoscopic surgery; previous EA; and inability to give informed consent or complete trial paperwork. INTERVENTIONS LASH compared with second-generation EA. MAIN OUTCOME MEASURES Co-primary clinical outcome measures were (1) patient satisfaction and (2) Menorrhagia Multi-Attribute Quality-of-Life Scale (MMAS) score at 15 months post randomisation. The primary economic outcome was incremental cost (NHS perspective) per quality-adjusted life-year (QALY) gained. RESULTS A total of 330 participants were randomised to each group (total n = 660). Women randomised to LASH were more likely to be satisfied with their treatment than those randomised to EA (97.1% vs. 87.1%) [adjusted difference in proportions 0.10, 95% confidence interval (CI) 0.05 to 0.15; adjusted odds ratio (OR) from ordinal logistic regression (OLR) 2.53, 95% CI 1.83 to 3.48; p < 0.001]. Women randomised to LASH were also more likely to have the best possible MMAS score of 100 (68.7% vs. 54.5%) (adjusted difference in proportions 0.13, 95% CI 0.04 to 0.23; adjusted OR from OLR 1.87, 95% CI 1.31 to 2.67; p = 0.001). Serious adverse event rates were low and similar in both groups (4.5% vs. 3.6%). There was a significant difference in adjusted mean costs between LASH (£2886) and EA (£1282) at 15 months, but no significant difference in QALYs. Based on an extrapolation of expected differences in cost and QALYs out to 10 years, LASH cost an additional £1362 for an average QALY gain of 0.11, equating to an incremental cost-effectiveness ratio of £12,314 per QALY. Probabilities of cost-effectiveness were 53%, 71% and 80% at cost-effectiveness thresholds of £13,000, £20,000 and £30,000 per QALY gained, respectively. LIMITATIONS Follow-up data beyond 15 months post randomisation are not available to inform cost-effectiveness. CONCLUSION LASH is superior to EA in terms of clinical effectiveness. EA is less costly in the short term, but expected higher retreatment rates mean that LASH could be considered cost-effective by 10 years post procedure. FUTURE WORK Retreatment rates, satisfaction and quality-of-life scores at 10-year follow-up will help to inform long-term cost-effectiveness. TRIAI REGISTRATION Current Controlled Trials ISRCTN49013893. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 53. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Kevin Cooper
- NHS Grampian, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Suzanne Breeman
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Neil W Scott
- Medical Statistics Team, University of Aberdeen, Aberdeen, UK
| | - Graham Scotland
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK.,Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Rodolfo Hernández
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - T Justin Clark
- Birmingham Women's NHS Foundation Trust, Birmingham Women's Hospital, Birmingham, UK
| | - Jed Hawe
- Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Robert Hawthorn
- NHS Greater Glasgow and Clyde, Southern General Hospital, Glasgow, UK
| | - Kevin Phillips
- Hull and East Yorkshire Hospitals NHS Trust, Castle Hill Hospital, Cottingham, UK
| | - Samantha Wileman
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Kirsty McCormack
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Usher Institute of Population Health Sciences & Informatics, University of Edinburgh, Edinburgh, UK
| | - Siladitya Bhattacharya
- NHS Grampian, Aberdeen Royal Infirmary, Aberdeen, UK.,Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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de Léotoing L, Chaize G, Fernandes J, Toth D, Descamps P, Dubernard G, Lafon T, Lamarsalle L, Fernandez H. The surgical treatment of idiopathic abnormal uterine bleeding: An analysis of 88 000 patients from the French exhaustive national hospital discharge database from 2009 to 2015. PLoS One 2019; 14:e0217579. [PMID: 31185019 PMCID: PMC6559634 DOI: 10.1371/journal.pone.0217579] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 05/14/2019] [Indexed: 11/19/2022] Open
Abstract
Objective The objective of the study was to compare success rates, complications and management costs of different surgical techniques for abnormal uterine bleeding (AUB). Methods This was a retrospective analysis of the French national hospital discharge database. All hospital stays with a diagnostic code for AUB and an appropriate surgical procedure code between 2009 and 2015 inclusive were identified, concerning 109,884 women overall. Outcomes were compared between second generation procedures (2G surgery), first-generation procedures (1G surgery), curettage and hysterectomy. Clinical outcomes were treatment failure and complications during the follow-up period. Costs were attributed using standard French hospital tariffs. Results 7,863 women underwent a 2G procedure (7.2%), 39,935 a 1G procedure, (36.3%), 38,923 curettage (35.4%) and 23,163 hysterectomy (21.1%). Failure rates at 18 months were 9.9% for 2G surgery, 12.7% for 1G surgery, 20.6% for curettage and 2.8% for hysterectomy. Complication rates at 18 months were 1.9% for 2G surgery, 1.5% for 1G surgery, 1.4% for curettage and 5.3% for hysterectomy. Median 18-month costs were € 1 173 for 2G surgery, € 1 059 for 1G surgery, € 782 for curettage and € 3 090 for hysterectomy. Conclusion Curettage has the highest failure rate. Hysterectomy has the lowest failure rate but the highest complication rate and is also the most expensive. Despite good clinical outcomes and relatively low cost, 1G and 2G procedures are not widely used. Current guidelines for treatment of AUB are not respected, the recommended 2G procedures being only used in <10% of cases.
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Affiliation(s)
| | | | | | - Dusan Toth
- Clinique Saint Germain, Brive La Gaillarde, France
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Abstract
The rapid evolution in ambulatory hysteroscopy (AH) has transformed the approach to diagnose and manage abnormal uterine bleeding (AUB). The medical management in primary care remains the mainstay for initial treatment of this common presentation; however, many women are referred to secondary care for further evaluation. To confirm the diagnosis of suspected intrauterine pathology, the traditional diagnostic tool of day case hysteroscopy and dilatation and curettage in a hospital setting under general anesthesia is now no longer required. The combination of ultrasound diagnostics and modern AH now allows thorough evaluation of uterine cavity in an outpatient setting. Advent of miniature hysteroscopic operative systems has revolutionized the ways in which clinicians can not only diagnose but also treat menstrual disorders such as heavy menstrual bleeding, intermenstrual bleeding and postmenopausal bleeding in most women predominantly in a one-stop clinic. This review discussed the approach to manage women presenting with AUB with a focus on the role of AH in the diagnosis and treatment of this common condition in an outpatient setting.
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Affiliation(s)
- Shilpa Kolhe
- Ambulatory Gynaecology Unit, Royal Derby Hospital, Derby, UK
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8
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Hysteroscopic Endometrial Polypectomy: Clinical and Economic Data in Decision Making. J Minim Invasive Gynecol 2018; 25:418-425. [DOI: 10.1016/j.jmig.2017.08.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 07/17/2017] [Accepted: 08/03/2017] [Indexed: 11/20/2022]
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9
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Brennan A, Hickey M. Abnormal uterine bleeding: managing endometrial dysfunction and leiomyomas. Med J Aust 2018; 208:90-95. [PMID: 29385977 DOI: 10.5694/mja17.00726] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 10/26/2017] [Indexed: 01/30/2023]
Abstract
Abnormal uterine bleeding refers to any change in the regularity, frequency, heaviness or length of menstruation. There are several potential causes for bleeding disturbance, the two most common being primary endometrial dysfunction and fibroids. Management of abnormal uterine bleeding involves both medical and surgical options and will largely depend on a patient's fertility plans. The use of levonorgestrel-releasing intrauterine devices for heavy menstrual bleeding is increasing in Australia, and they are considered first-line medical management for women accepting of hormonal therapies. Tranexamic acid, non-steroidal anti-inflammatory drugs, the combined oral contraceptive pill and oral progestins offer alternatives. Hysterectomy offers a definitive surgical approach to abnormal uterine bleeding and is associated with high levels of patient satisfaction. Women wishing to preserve their fertility, or avoid hysterectomy, may be offered myomectomy. Submucosal fibroids should be removed via hysteroscopy in symptomatic or infertile patients. Intramural and subserosal fibroids may be removed via an open or laparoscopic approach. There are several minimally invasive options, including uterine artery embolisation, magnetic resonance-guided focused ultrasound and endometrial ablation, but patients should be aware that there is insufficient evidence to ensure fertility preservation with these procedures and further research is needed. Areas for additional research include cost-effectiveness of treatments and quality of life comparisons between management options using patient reported outcome measures to evaluate patient satisfaction.
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Famuyide AO, Laughlin-Tommaso SK, Shazly SA, Hall Long K, Breitkopf DM, Weaver AL, McGree ME, El-Nashar SA, Lemens MA, Hopkins MR. Medical therapy versus radiofrequency endometrial ablation in the initial treatment of heavy menstrual bleeding (iTOM Trial): A clinical and economic analysis. PLoS One 2017; 12:e0188176. [PMID: 29141040 PMCID: PMC5687740 DOI: 10.1371/journal.pone.0188176] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 10/28/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Radiofrequency endometrial ablation (REA) is currently a second line treatment in women with heavy menstrual bleeding (MHB) if medical therapy (MTP) is contraindicated or unsatisfactory. Our objective is to compare the effectiveness and cost burden of MTP and REA in the initial treatment of HMB. METHODS We performed a randomized trial at Mayo Clinic Rochester, Minnesota. The planned sample size was 60 patients per arm. A total of 67 women with HMB were randomly allocated to receive oral contraceptive pills (Nordette ®) or Naproxen (Naprosyn®) (n = 33) or REA (n = 34). Primary 12-month outcome measures included menstrual blood loss using pictorial blood loss assessment chart (PBLAC), patients' satisfaction, and Menorrhagia Multi-Attribute Scale (MMAS). Secondary outcomes were total costs including direct medical and indirect costs associated with healthcare use, patient out-of-pocket costs, and lost work days and activity limitations over 12 months. RESULTS Compared to MTP arm, women who received REA had a significantly lower PBLAC score (median [Interquartile range, IQR]: 0 [0-4] vs. 15 [0-131], p = 0.003), higher satisfaction rates (96.8%vs.63.2%, p = 0.003) and higher MMAS (median [IQR]: 100 [100-100] vs. 100 [87-100], p = 0.12) at 12 months. Direct medical costs were higher for REA ($5,331vs.$2,901, 95% confidence interval (CI) of mean difference:$727,$4,852), however, when indirect costs are included, the difference did not reach statistical significance ($5,469 vs. $3,869, 95% CI of mean difference:-$339, $4,089). CONCLUSION For women with heavy menstrual bleeding, initial radiofrequency endometrial ablation compared to medical therapy offered superior reduction in menstrual blood loss and improvement in quality of life without significant differences in total costs of care. CLINICAL TRIAL REGISTRATION NCT01165307.
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Affiliation(s)
- Abimbola O. Famuyide
- Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Shannon K. Laughlin-Tommaso
- Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Sherif A. Shazly
- Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Kirsten Hall Long
- K. Long Health Economics Consulting LLC, St. Paul, Minnesota, United States of America
| | - Daniel M. Breitkopf
- Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Amy L. Weaver
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Michaela E. McGree
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Sherif A. El-Nashar
- Division of Female Pelvic Medicine and Reconstructive Surgery, University Hospitals, Cleveland, Ohio, United States of America
| | - Maureen A. Lemens
- Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Matthew R. Hopkins
- Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, United States of America
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11
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Munro MG. Endometrial ablation. Best Pract Res Clin Obstet Gynaecol 2017; 46:120-139. [PMID: 29128205 DOI: 10.1016/j.bpobgyn.2017.10.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 10/06/2017] [Indexed: 10/18/2022]
Abstract
Endometrial ablation (EA) includes a spectrum of procedures performed with or without hysteroscopic direction, designed to destroy the endometrium for the treatment of the symptom of heavy menstrual bleeding (HMB) secondary to a spectrum of causes, but most commonly those that are endometrial in origin (AUB-E) or ovulatory disorders (AUB-O). Resectoscopic endometrial ablation (REA) is often mistakenly referred to as the "first generation" technique, while proprietary devices that do not use the resectoscope (nonresectoscopic EA or NREA) are often misperceived as "second generation" devices. Indeed, the origins of NREA date back to the late 19th century with the use of steam, and the early and mid 20th century, when radiofrequency and cryotherapy based NREA techniques were published - long before the resectoscope was used and reported. The NREA devices have also been mislabeled as "global", a misleading term borrowed from the marketing departments of device manufacturers - there is no device that predictably treats the entire endometrium. Consequently, none can be construed as being "global". Instead, EA is a procedure designed for women as an alternative to hysterectomy, or, perhaps, medical therapy, when future fertility is no longer desired. Women who select EA should anticipate a relatively low risk procedure that will likely reduce their HMB to normal levels or less. This paper will review the spectrum of EA techniques and devices, their clinical outcomes and adverse events, and explore their value compared to hysterectomy and selected medical therapies.
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Affiliation(s)
- Malcolm G Munro
- Department of Obstetrics & Gynecology, David Geffen School of Medicine at UCLA, Director of Gynecologic Services, Kaiser Permanente, Los Angeles Medical Center, Los Angeles, CA, United States.
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12
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Malacarne DR, Ferrante KL, Brucker BM. Urologic and Gynecologic Sources of Pelvic Pain. Phys Med Rehabil Clin N Am 2017; 28:571-588. [PMID: 28676365 DOI: 10.1016/j.pmr.2017.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Gynecologic and urologic etiologies are the sources of pelvic pain for many individuals. This article aims to provide a comprehensive review of the various genitourinary sources of pelvic pain. It is important to recognize that although these disorders predominantly affect women, there are various conditions that affect both men and women, and these should be considered in the differential diagnosis of patients presenting with pelvic pain. Providers who encounter patients with pelvic pain should attempt to localize these symptoms and obtain a comprehensive history from the patient to help direct diagnostic evaluation.
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Affiliation(s)
- Dominique R Malacarne
- Department of Urology, NYU Langone Medical Center, 150 East 32nd Street, 2nd Floor, New York, NY 10016, USA; Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, NYU Langone Medical Center, 150 East 32nd Street, 2nd Floor, New York, NY 10016, USA
| | - Kimberly L Ferrante
- Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, New York University School of Medicine, 462 1st Avenue, Room 9 E2, New York, NY 10016, USA; Department of Urology, New York University School of Medicine, 462 1st Avenue, Room 9 E2, New York, NY 10016, USA
| | - Benjamin M Brucker
- Female Pelvic Medicine and Reconstructive Surgery, Neurourology and Voiding Dysfunction, Tisch Hospital, NYU Langone Medical Center, 12 East, New York, NY 10016, USA; Department of Urology, NYU Langone Medical Center, 150 East 32nd Street, 2nd Floor, New York, NY 10016, USA; Department of Obstetrics and Gynecology, NYU Langone Medical Center, 150 East 32nd Street, 2nd Floor, New York, NY 10016, USA.
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13
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Neis KJ, Zubke W, Römer T, Schwerdtfeger K, Schollmeyer T, Rimbach S, Holthaus B, Solomayer E, Bojahr B, Neis F, Reisenauer C, Gabriel B, Dieterich H, Runnenbaum IB, Kleine W, Strauss A, Menton M, Mylonas I, David M, Horn LC, Schmidt D, Gaß P, Teichmann AT, Brandner P, Stummvoll W, Kuhn A, Müller M, Fehr M, Tamussino K. Indications and Route of Hysterectomy for Benign Diseases. Guideline of the DGGG, OEGGG and SGGG (S3 Level, AWMF Registry No. 015/070, April 2015). Geburtshilfe Frauenheilkd 2016; 76:350-364. [PMID: 27667852 PMCID: PMC5031283 DOI: 10.1055/s-0042-104288] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background: Official guideline "indications and methods of hysterectomy" to assign indications for the different methods published and coordinated by the German Society of Gynecology and Obstetrics (DGGG), the Austrian Society of Gynecology and Obstetrics (OEGGG) and the Swiss Society of Gynecology and Obstetrics (SGGG). Besides vaginal and abdominal hysterectomy, three additional techniques have been implemented due to the introduction of laparoscopy. Organ-sparing alternatives were also integrated. Methods: The guideline group consisted of 26 experts from Germany, Austria and Switzerland. Recommendations were developed using a structured consensus process and independent moderation. A systematic literature search and quality appraisal of benefits and harms of the therapeutic alternatives for symptomatic fibroids, dysfunctional bleeding and adenomyosis was done through MEDLINE up to 6/2014 focusing on systematic reviews and meta-analysis. Results: All types of hysterectomy led in studies to high rates of patient satisfaction. If possible, vaginal instead of abdominal hysterectomy should preferably be done. If a vaginal hysterectomy is not feasible, the possibility of a laparoscopic hysterectomy should be considered. An abdominal hysterectomy should only be done with a special indication. Organ-sparing interventions also led to high patient satisfaction rates, but contain the risk of symptom recurrence. Conclusion: As an aim, patients should be enabled to choose that therapeutic intervention for their benign disease of the uterus that convenes best to them and their personal life situation.
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Affiliation(s)
- K. J. Neis
- Klinik für Frauenheilkunde, Geburtshilfe und Reproduktionsmedizin der Universitätsklinik des Saarlandes
| | - W. Zubke
- Frauenklinik des Universitätsklinikum Tübingen
| | - T. Römer
- Evangelisches Krankenhaus Köln-Weyertal
| | | | - T. Schollmeyer
- Klinik für Gynäkologie und Geburtshilfe Universitätsklinikum Schleswig-Holstein
| | - S. Rimbach
- Klinik für Gynäkologie und Geburtshilfe Krankenhaus Agatharied GmbH
| | - B. Holthaus
- Klinik für Frauenheilkunde und Geburtshilfe St. Elisabeth Krankenhaus Damme
| | - E. Solomayer
- Klinik für Frauenheilkunde, Geburtshilfe und Reproduktionsmedizin der Universitätsklinik des Saarlandes
| | - B. Bojahr
- Klinik für MIC Minimal Invasive Chirurgie am Ev. Krankenhaus Hubertus in Berlin
| | - F. Neis
- Frauenklinik des Universitätsklinikum Tübingen
| | | | - B. Gabriel
- Klinik für Gynäkologie und Geburtshilfe St. Josefs-Hospital Wiesbaden
| | | | - I. B. Runnenbaum
- Universitätsklinikum Jena Klinik für Frauenheilkunde und Geburtshilfe
| | - W. Kleine
- Universitätsklinikum Mannheim Klink für Frauenheilkunde und Geburtshilfe
| | - A. Strauss
- Klinik für Gynäkologie und Geburtshilfe Christian-Albrechts-Universität zu Kiel
| | | | - I. Mylonas
- Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe Klinikum der Universität München
| | - M. David
- Campus Virchow-Klinikum Charité Klinik für Gynäkologie
| | - L-C. Horn
- Institut für Pathologie Universitätsklinikum Leipzig
| | | | - P. Gaß
- Universitätsklinikum Erlangen Frauenklinik
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14
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Abstract
Hysterectomy is the most frequently performed major surgical intervention in gynecology. Although surgically removing the uterus is invasive, it represents the most definitive treatment option for heavy menstrual bleeding. In this article, we will discuss the indications for hysterectomy as a treatment for heavy menstrual bleeding, the different approaches to perform the hysterectomy, the complications which may occur during and after this procedure and finally the outcomes in comparison with other treatment options.
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Affiliation(s)
- Eva van der Meij
- Department of Obstetrics & Gynecology, VU University Medical Center, Amsterdam, The Netherlands
| | - Mark Hans Emanuel
- Department of Obstetrics & Gynecology, Spaarne Gasthuis, Haarlem/Hoofddorp, The Netherlands
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15
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Singh M, Hosni MM, Jones SE. Is endometrial ablation protective against endometrial cancer? A retrospective observational study. Arch Gynecol Obstet 2015; 293:1033-7. [DOI: 10.1007/s00404-015-3909-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Accepted: 10/09/2015] [Indexed: 10/22/2022]
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16
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Laberge P, Leyland N, Murji A, Fortin C, Martyn P, Vilos G, Leyland N, Wolfman W, Allaire C, Awadalla A, Dunn S, Heywood M, Lemyre M, Marcoux V, Potestio F, Rittenberg D, Singh S, Yeung G. Endometrial Ablation in the Management of Abnormal Uterine Bleeding. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2015; 37:362-79. [DOI: 10.1016/s1701-2163(15)30288-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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17
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Patient satisfaction and amenorrhea rate after endometrial ablation by ThermaChoice III or NovaSure: a retrospective cohort study. ACTA ACUST UNITED AC 2015. [DOI: 10.1007/s10397-015-0880-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Levy-Zauberman Y, Fernandez H, Pourcelot AG, Legendre G. [Does repeated endometrial destruction procedure decrease abnormal uterine bleeding, and does it reduce the number of hysterectomies in this indication?]. ACTA ACUST UNITED AC 2013; 43:35-9. [PMID: 24286929 DOI: 10.1016/j.jgyn.2013.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 09/29/2013] [Accepted: 10/16/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Hysteroscopic endometrial resection or destruction in the indication of abnormal uterine bleeding or post-menopausal bleeding represents an alternative to hysterectomy, as it carries a lower morbidity rate. In case of failure of such procedure though, hysterectomy will most often be proposed as a second line of treatment. The place of the repetition of an endometrial destruction procedure has not yet been evaluated. The aim of our study is to evaluate the efficiency and the satisfaction after two consecutive techniques of endometrial destruction in case of abnormal uterine bleeding or post-menopausal bleeding. MATERIAL AND METHODS Nineteen patients presenting with recurring abnormal uterine bleeding after one procedure of endometrial destruction, underwent in our department, between 2004 and 2011, a second conservative endometrial procedure. RESULTS No complication occurred during the repeated procedure. Sixteen of the nineteen patients (84.2 %) included answered a questionnaire. The mean delay since the second procedure was 27 months [25; 29]. Eight patients (i.e. 50 %) later underwent a hysterectomy, with 5 of them (31.25 % of all 16 patients) being directly attributed to treatment failure. Patients said to be satisfied with the management of their condition in 68.75 % of cases, and 93.75 % of them would recommend it to a friend. CONCLUSION Our results suggest that a second conservative management in case of recurrence of AUB is effective. Hysterectomy could be avoided in 50 % of cases. A second conservative treatment could be an interesting option for patients with medical contra-indication for heavier surgery, as well as for patients willing to keep their uterus.
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Affiliation(s)
- Y Levy-Zauberman
- Service de gynécologie-obstétrique, hôpital de Bicêtre, Assistance publique-Hôpitaux de Paris, , 94276 Le Kremlin-Bicêtre cedex, France.
| | - H Fernandez
- Service de gynécologie-obstétrique, hôpital de Bicêtre, Assistance publique-Hôpitaux de Paris, , 94276 Le Kremlin-Bicêtre cedex, France; CESP-Inserm, U1018, équipe 7, genre, santé sexuelle et reproductive, université Paris Sud, 94276 Le Kremlin-Bicêtre cedex, France.
| | - A-G Pourcelot
- Service de gynécologie-obstétrique, hôpital de Bicêtre, Assistance publique-Hôpitaux de Paris, , 94276 Le Kremlin-Bicêtre cedex, France.
| | - G Legendre
- Service de gynécologie-obstétrique, hôpital de Bicêtre, Assistance publique-Hôpitaux de Paris, , 94276 Le Kremlin-Bicêtre cedex, France; CESP-Inserm, U1018, équipe 7, genre, santé sexuelle et reproductive, université Paris Sud, 94276 Le Kremlin-Bicêtre cedex, France.
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19
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Abstract
Global endometrial ablation techniques are a relatively new surgical technology for the treatment of heavy menstrual bleeding that can now be used even in an outpatient clinic setting. A comparison of global ablation versus earlier ablation technologies notes no significant differences in success rates and some improvement in patient satisfaction. The advantages of the newer global endometrial ablation systems include less operative time, improved recovery time, and decreased anesthetic risk. Ablation procedures performed in an outpatient surgical or clinic setting provide advantages both of potential cost savings for patients and the health care system and improved patient convenience.
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Affiliation(s)
- Sarah Woods
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, 853 Jefferson Avenue, Rm E102, Memphis, TN 38163, USA
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20
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Wright JD, Herzog TJ, Tsui J, Ananth CV, Lewin SN, Lu YS, Neugut AI, Hershman DL. Nationwide trends in the performance of inpatient hysterectomy in the United States. Obstet Gynecol 2013; 122:233-241. [PMID: 23969789 PMCID: PMC3913114 DOI: 10.1097/aog.0b013e318299a6cf] [Citation(s) in RCA: 508] [Impact Index Per Article: 46.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To examine the use of inpatient hysterectomy and explore changes in the use of various routes of hysterectomy and patterns of referral. METHODS The Nationwide Inpatient Sample was used to identify all women aged 18 years or older who underwent inpatient hysterectomy between 1998 and 2010. Weighted estimates of national trends were calculated and the number of procedures performed estimated. Trends in hospital volume and across hospital characteristics were examined. RESULTS After weighting, we identified a total 7,438,452 women who underwent inpatient hysterectomy between 1998 and 2010. The number of hysterectomies performed annually rose from 543,812 in 1998 to a peak of 681,234 in 2002; it then declined consistently annually and reached 433,621 cases in 2010. Overall, 247,973 (36.4%) fewer hysterectomies were performed in 2010 compared with 2002. From 2002 to 2010 the number of hysterectomies performed for each of the following indications declined: leiomyoma (-47.6%), abnormal bleeding (-28.9%), benign ovarian mass (-63.1%), endometriosis (-65.3%), and pelvic organ prolapse (-39.4%). The median hospital case volume decreased from 83 procedures per year in 2002 to 50 cases per year in 2010 (P<.001). CONCLUSION The number of inpatient hysterectomies performed in the United States has declined substantially over the past decade. The median number of hysterectomies per hospital has declined likewise by more than 40%. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jason D Wright
- Departments of Obstetrics and Gynecology and Medicine and the Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, and the Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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21
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Chapter 4 Surgical Management. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2013. [DOI: 10.1016/s1701-2163(15)30737-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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22
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Potti S, Uppal S, Chatwani AJ, Hernandez E, Dandolu V. Novasure as a mechanical endometrial preparation agent in large uteri. JSLS 2013; 16:537-41. [PMID: 23484560 PMCID: PMC3558888 DOI: 10.4293/108680812x13462882736853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Novasure ablation as a means of mechanical endometrial preparation prior to roller ball ablation appeared to be a superior alternative to medical preparation with GnRH agonists in patients with large uteri. Objective: We evaluated Novasure ablation as a mechanical endometrial preparation agent before Roller Ball endometrial ablation in lieu of GnRH agonists in large uteri. Methods: A retrospective chart review of 20 consecutive patients undergoing Novasure ablation for mechanical endometrial preparation before Roller Ball ablation (RB-Novasure group) was conducted and the results compared to that of 23 consecutive patients who received GnRH agonist (Leuprolide acetate) as a medical endometrial preparation before Roller Ball ablation (RB-Lupron group). The postoperative follow-up time frame was divided into immediate (3 mo), intermediate (3 to 12 mo) and long-term (12 to 32 mo). Rates of amenorrhea, heavy bleeding, cramping, and failure (repeat ablation or hysterectomy for heavy bleeding or persistent pain) were compared between the 2 groups. Results: The mean rates of amenorrhea for the patients not lost to follow-up at 3 mo, 3 to 12 mo, and 12 to 32 mo visits were 45.5%, 58.8%, and 44.4% for the RB-Lupron group, and 80%, 86.7%, and 100% for the RB-Novasure group (P = .02, P = .08, and P = .02). Failure rates were 4.8%, 6.2%, and 55.6% for the RB-Lupron group; and 0 (0/20), 12.5% (2/16) and 0 (0/8) for the RB-Novasure group (P = .51, P = .50, and P = .02). The RB-Novasure group had a significantly lower rate of heavy bleeding and cramping. 86.4%, 58.8%, and 33.3% patients reported satisfaction with their treatment in the RB-Lupron group and 100%, 87.5%, and 75% in RB-Novasure group (P = .13, P = .07, and P = .11). Conclusion: Novasure ablation, for mechanical endometrial preparation before Roller Ball ablation, appears to be a superior alternative to medical preparation with GnRH agonists in patients with large uteri.
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Affiliation(s)
- Sushma Potti
- Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA, USA.
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23
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Abstract
BACKGROUND Heavy menstrual bleeding (HMB) is a common symptom that leads women to seek medical treatment. Sources of HMB are variable; patients may present with obvious uterine pathology, systemic disease, or even localized hemostatic dysregulation that defies clinical measurement. Whereas surgical intervention even in the absence of overt pathology had historically been the most common route of treatment for HMB, an expanding therapeutic armamentarium provides greater options and the possibility of maintaining fertility in affected women. SCOPE A descriptive literature review was performed to identify relevant articles discussing the management of HMB. The PubMed database was searched using the terms 'heavy menstrual bleeding', 'menorrhagia', 'abnormal uterine bleeding', or 'dysfunctional uterine bleeding' in combination with 'diagnosis', 'treatment', 'management', or 'guidelines'. Results were limited to articles published in English within the past 10 years. Additional statements, consensus documents, and clinical guidelines were located through review of professional society websites. FINDINGS For practical purposes, a subjective definition of HMB (i.e., excessive menstrual blood loss that is not tolerated by the patient and adversely affects quality of life) rather than objective measures can be used by the clinician as the basis for further investigation. Standard diagnostic examinations and initiation of therapy are well within the purview of the general practitioner. A wide variety of medical therapy options are available, although few treatments are specifically indicated for the management of HMB. The approval of tranexamic acid in the United States specifically for the treatment of HMB is a recent development that provides practitioners with an effective, noncontraceptive alternative medical therapy. For women without evidence of uterine pathology, invasive/surgical procedures are generally considered as a second-line treatment option. CONCLUSIONS Given the breadth of available medical and surgical treatment choices, identifying a suitable therapeutic strategy should be feasible for all patients, even in this highly heterogeneous population.
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Affiliation(s)
- Kenneth E Fox
- Family Medical Associates Research Department, Levittown, PA 19056, USA.
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24
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Chen I, Bajzak KI, Guo Y, Singh SS. A national survey of endoscopic practice among gynaecologists in Canada. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2012; 34:257-263. [PMID: 22385669 DOI: 10.1016/s1701-2163(16)35186-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess the current status of endoscopic gynaecological surgery in Canada, as well as the attitudes, perceptions, and educational preferences regarding endoscopy among Canadian obstetrician-gynaecologists. METHODS An electronic online survey was sent to 630 obstetrician-gynaecologists in Canada through the Society of Obstetricians and Gynaecologists of Canada electronic mailing list. Survey respondents were asked about demographic variables, level of training and current practice of endoscopic procedures, reasons for and barriers to performing endoscopy, and interest in continuing surgical education in laparoscopy and hysteroscopy. RESULTS A total of 178 responses (28.3%) were collected and 152 (85.4%) analyzed. The majority of respondents were general obstetrician-gynaecologists (78.0%). More gynaecologic surgeons performed abdominal (92.7%) and vaginal hysterectomies (89.7%) than laparoscopic (68.4%) and robotic hysterectomies (2.2%). Even though 93.2% of respondents selected the endoscopic approach as the preferred approach to surgery for their patients, 38.7% of respondents did not feel that they had adequate training during residency to perform endoscopy. Lack of operating room resources and lack of time and opportunity for further training were frequently selected as major barriers to performing endoscopy. Participants identified weekend continuing medical education courses and trained endoscopic surgeon outreach as preferred methods of acquiring endoscopic skills. CONCLUSION This survey provides a contemporary assessment of the current endoscopic practice patterns of Canadian obstetrician-gynaecologists, and it helps to identify some potentially modifiable factors hindering the practice of endoscopy and some possible solutions to overcoming these barriers.
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Affiliation(s)
- Innie Chen
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton AB
| | - Krisztina I Bajzak
- Discipline of Obstetrics and Gynecology, Memorial University, St John's NL
| | - Yanfang Guo
- Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa ON
| | - Sukhbir S Singh
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa ON
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Matteson KA, Abed H, Wheeler TL, Sung VW, Rahn DD, Schaffer JI, Balk EM. A systematic review comparing hysterectomy with less-invasive treatments for abnormal uterine bleeding. J Minim Invasive Gynecol 2011; 19:13-28. [PMID: 22078015 DOI: 10.1016/j.jmig.2011.08.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 08/04/2011] [Accepted: 08/12/2011] [Indexed: 10/15/2022]
Abstract
STUDY OBJECTIVE To compare hysterectomy with less-invasive alternatives for abnormal uterine bleeding (AUB) in 7 clinically important domains. DESIGN Systematic review. SETTING Randomized clinical trials comparing bleeding, quality of life, pain, sexual health, satisfaction, need for subsequent surgery, and adverse events between hysterectomy and less-invasive treatment options. PATIENTS Women with AUB, predominantly from ovulatory disorders and endometrial causes. INTERVENTIONS Systematic review of the literature (from inception to January 2011) comparing hysterectomy with alternatives for AUB treatment. Eligible trials were extracted into standardized forms. Trials were graded with a predefined 3-level rating, and the strengths of evidence for each outcome were evaluated with the Grades for Recommendation, Assessment, Development and Evaluation system. MEASUREMENTS AND MAIN RESULTS Nine randomized clinical trials (18 articles) were eligible. Endometrial ablation, levonorgestrel intrauterine system, and medications were associated with lower risk of adverse events but higher risk of additional treatments than hysterectomy. Compared to ablation, hysterectomy had superior long-term pain and bleeding control. Compared with the levonorgestrel intrauterine system, hysterectomy had superior control of bleeding. No other differences between treatments were found. CONCLUSION Less-invasive treatment options for AUB result in improvement in quality of life but carry significant risk of retreatment caused by unsatisfactory results. Although hysterectomy is the most effective treatment for AUB, it carries the highest risk for adverse events.
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Singh N, Hassanaein M. Comparing satisfaction rates of Microwave and Bipolar Impedance controlled endometrial ablation. Arch Gynecol Obstet 2011; 285:1301-5. [PMID: 22057859 DOI: 10.1007/s00404-011-2126-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2011] [Accepted: 10/18/2011] [Indexed: 11/26/2022]
Abstract
PURPOSE To compare the satisfaction rates of Microwave and Bipolar Impedance controlled endometrial ablations. METHODS Anonymized questionnaires were sent to patients who had undergone endometrial ablations in a two and a half year period, which ended 6 months prior to the start of the study. The same questionnaires printed in pink and white sheets of paper were sent to patients who had undergone Bipolar Impedance controlled and Microwave endometrial ablations, respectively. Returned questionnaires were then analysed. RESULTS There were no statistically significant differences in satisfaction rates of Microwave or Bipolar Impedance controlled endometrial ablations, where control of pain or menstrual bleeding was concerned. Similarly there was no difference in hysterectomy rates and the percentage of women in each group recommending the procedure to others as well as those reporting a significant improvement in quality of life after the procedure. CONCLUSIONS Microwave endometrial ablation and Bipolar Impedance controlled endometrial ablation are both equally successful at controlling heavy menstrual bleeding with satisfaction rates around 80% for both procedures.
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Affiliation(s)
- Nilanjana Singh
- James Paget University Hospital NHS Foundation Trust, Lowestoft Road, Gorleston, Great Yarmouth NR31 6JY, UK.
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Treatment options for dysfunctional uterine bleeding: evaluation of clinical results. ACTA ACUST UNITED AC 2011. [DOI: 10.1007/s10397-011-0674-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Cocuzza MA, Cocuzza M, Maciel GAR, da Motta EV, Cardoso APT, Soares JM, Baracat EC. Development of an animal model for endometrial ablation using trichloroacetic acid. Fertil Steril 2011; 95:2418-21. [PMID: 21497335 DOI: 10.1016/j.fertnstert.2011.03.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Revised: 03/03/2011] [Accepted: 03/22/2011] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To develop an animal model of endometrial ablation, and to evaluate the histologic effects of trichloroacetic acid (TCA) in the uterine cavity. DESIGN Experimental prospective. SETTING Department of gynecology. PATIENT(S) Thirty female adult rats. INTERVENTION(S) Animals were submitted to injection of TCA in one uterine horn and saline solution in the other. Group 1 was sacrificed the day after the procedure. Group 2 was sacrificed in phase of diestrus. Superficial epithelia of the endometrium, stromal thickness, endometrial glands, and myometrium thickness were compared among the uterine horns of the same rats of group 1. The same evaluation was performed in group 2. Endometrial regeneration was evaluated. MAIN OUTCOME MEASURE(S) Histologic effects. RESULT(S) In group 1, histologic parameters showed endometrial destruction on TCA injected uterine horn. In group 2, four rats died after the procedure, and six rats had no viable material. In the rest of the group, TCA-injected uterine horns showed endometrial destruction. Superficial epithelia of the endometrium and stromal thickness were similar between TCA uterine horn from groups. However, the number of endometrial glands was higher in group 1. CONCLUSION(S) The study developed an experimental model for endometrial ablation. TCA acid is a potent agent for endometrial ablation in rat model. No endometrial regeneration was observed after recovery of cycle.
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Combining NovaSure® endometrial ablation and Essure® hysteroscopic sterilization: a feasibility study to evaluate the confirmation tests. ACTA ACUST UNITED AC 2010. [DOI: 10.1007/s10397-010-0625-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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HIRST JE, ROACH V. Microwave ablation after perforation of the uterus: Use of laparoscopic guidance. Aust N Z J Obstet Gynaecol 2009; 49:237-8. [DOI: 10.1111/j.1479-828x.2009.00956.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
BACKGROUND Heavy menstrual bleeding (HMB) significantly impairs the quality of life of many otherwise healthy women. Perception of HMB is subjective and management usually depends upon what symptoms are acceptable to the individual. Medical treatment options include oral medication and a hormone-releasing intrauterine system (LNG-IUS). Surgical options include conservative surgery (uterine resection or ablation) and hysterectomy. OBJECTIVES To compare the effectiveness, safety and acceptability of surgery versus medical therapy for HMB. SEARCH STRATEGY In September 2005 we searched the Cochrane Menstrual Disorders and Subfertility Group trials register Cochrane Controlled Trials Register (The Cochrane Library Issue 3, 2005), MEDLINE EMBASE, Current Contents, Biological Abstracts, PsycINFO, and CINAHL. We also searched reference lists of articles retrieved and contacted pharmaceutical companies and experts in the field. SELECTION CRITERIA Controlled randomised trials comparing conservative surgery or hysterectomy versus medical therapy (oral or intrauterine) for HMB DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trials for quality and extracted data . MAIN RESULTS The eight included trials randomised 821 women. In comparisons of oral medication versus surgery, 58% of women randomised to medical treatment had received surgery by two years. Compared to oral medication, endometrial resection was significantly more effective in controlling bleeding (at four months: OR 10.62, 95% CI 5.30 to 21.27) and significantly less likely to cause side effects (at four months: OR 0.15, 95% CI 0.07 to 0.31) and hysterectomy resulted in significantly greater improvements in mental health (at six months p = 0.04). In comparisons of LNG-IUS versus conservative surgery or hysterectomy, at one year there was no statistically significant difference in satisfaction rates or quality of life, though adverse effects were significantly less likely with conservative surgery (OR 0.24, 95% CI 0.11 to 0.49). Two trials found conservative surgery significantly more effective than LNG-IUS in controlling bleeding at one year (OR 3.99, 95% CI 1.53 to 10.38). Two other small trials with longer follow-up found no difference or favoured LNG-IUS - however in both these studies the data were skewed and fewer than two thirds of participants were analysed. Hysterectomy stopped all bleeding but caused serious complications for some women. AUTHORS' CONCLUSIONS Surgery, especially hysterectomy, reduces menstrual bleeding at one year more than medical treatments but LNG-IUS appears equally effective in improving quality of life. The evidence for longer term comparisons is weak and inconsistent. Oral medication suits a minority of women long term.
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Affiliation(s)
- J Marjoribanks
- Cochrane Menstrual Disorders and Subfertility Group, Obstetrics and Gynaecology, University of Auckland, PO Box 92019, Auckland, New Zealand, 1003.
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