1
|
Oderkerk TJ, van de Kar MRD, Cornel KMC, Bongers MY, Geomini PMAJ. Endometrial cancer after endometrial ablation: a systematic review. Int J Gynecol Cancer 2022; 32:1555-1560. [PMID: 36375895 DOI: 10.1136/ijgc-2022-003866] [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: 11/16/2022] Open
Abstract
OBJECTIVE To investigate whether a previously performed endometrial ablation is associated with the development and diagnosis of endometrial cancer. METHODS First, a systematic review was performed of the articles reporting the incidence of endometrial cancer in patients treated with endometrial ablation. Second, a systematic review was performed to identify all individual cases of endometrial cancer after ablation to evaluate presenting symptoms, diagnostic work-up, potential risk factors, and the type and stage of the endometrial cancer. A systematic search was performed, using Medline, EMBASE, and the Cochrane Library databases, from inception through February 24, 2022. RESULTS Based on 11 included studies, the incidence of endometrial cancer in a population of 29 102 patients with a prior endometrial ablation ranged from 0.0% to 1.6%.A total of 38 cases of endometrial cancer after ablation were identified. In 71% of cases (17 of 24 cases), vaginal bleeding was the first presenting symptom. With transvaginal ultrasound it was possible to identify and measure the endometrial thickness in eight cases. Endometrium sampling was successful in 16 of 18 described cases (89%). In 18 of 20 cases (90%) pathologic examination showed early-stage endometrioid adenocarcinoma (International Federation of Gynecology and Obstetrics stage I). CONCLUSION Previous endometrial ablation is not associated with the development of endometrial cancer. Diagnostic work-up is not impeded by previous endometrial ablation. In addition, endometrial cancers after endometrial ablation are not detected at an advanced stage.
Collapse
Affiliation(s)
- Tamara J Oderkerk
- Department of Obstetrics and Gynecology, Máxima Medical Centre Location Veldhoven, Veldhoven, The Netherlands .,School for Oncology and Reproduction (GROW), Maastricht University, Maastricht, Limburg, The Netherlands
| | - Mileen R D van de Kar
- Department of Obstetrics and Gynecology, Máxima Medical Centre Location Veldhoven, Veldhoven, The Netherlands
| | - Karlijn M C Cornel
- Department of Obstetrics and Gynecology, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
| | - Marlies Y Bongers
- Department of Obstetrics and Gynecology, Máxima Medical Centre Location Veldhoven, Veldhoven, The Netherlands.,School for Oncology and Reproduction (GROW), Maastricht University, Maastricht, Limburg, The Netherlands
| | - Peggy M A J Geomini
- Department of Obstetrics and Gynecology, Máxima Medical Centre Location Veldhoven, Veldhoven, The Netherlands
| |
Collapse
|
2
|
Flöter Rådestad A, Dahm-Kähler P, Holmberg E, Bjurberg M, Hellman K, Högberg T, Kjölhede P, Marcickiewicz J, Rosenberg P, Stålberg K, Åvall-Lundqvist E, Borgfeldt C. Long-term incidence of endometrial cancer after endometrial resection and ablation: A population based Swedish gynecologic cancer group (SweGCG) study. Acta Obstet Gynecol Scand 2022; 101:923-930. [PMID: 35624547 DOI: 10.1111/aogs.14385] [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: 02/02/2022] [Revised: 04/02/2022] [Accepted: 05/03/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Minimally invasive methods to reduce menorrhagia were introduced in the 1980s and 1990s. Transcervical endometrial resection (TCRE) and endometrial ablation (EA) are two of the most frequently used methods. As none of them can guarantee a complete removal of the endometrium, there are concerns that the remaining endometrium may develop to endometrial cancer (EC) later in life. The primary aim was to analyze the long-term incidence of EC after TCRE and EA in a nationwide population. The secondary aim was to assess the two treatment modalities separately. MATERIAL AND METHODS The Swedish National Patient Registry and National Quality Registry for Gynecological Surgery were used for identification of women who had TCRE or EA performed between 1997-2017. The cohort was followed from the first TCRE or EA until hysterectomy, diagnosis of EC, or death. Follow-up data were retrieved from the National Cancer Registry and the National Death Registry. Expected incidence for EC in Swedish women was calculated using Swedish data retrieved from the NORDCAN project after having taken into account differences of age and follow-up time. Cumulative incidence of EC after TCRE and EA, was calculated. A standardized incidence ratio was calculated based on the expected and observed incidence, stratified by age and year of diagnosis. RESULTS In total, 17 296 women (mean age 45.1 years) underwent TCRE (n = 8626) or EA (n = 8670). Excluded were 3121 who had a hysterectomy for benign causes during follow up. During a median follow-up time of 7.1 years (interquartile range 3.1-13.3 years) the numbers of EC were 25 (0.3%) after TCRE and 2 (0.02%) after EA, respectively. The observed incidence was significantly lower than expected (population-based estimate) after EA but not after TCRE, giving a standardized incidence ratio of 0.13 (95% confidence interval [CI] 0.03-0.53) after EA and 1.27 (95% CI 0.86-1.88) after TCRE. Median times to EC were 3.0 and 8.3 years after TCRE and EA, respectively. CONCLUSIONS There was a significant reduction of EC after EA, suggesting a protective effect, whereas endometrial resection showed an incidence within the expected rate.
Collapse
Affiliation(s)
- Angelique Flöter Rådestad
- Department of Women's and Children's Health, Division of Neonatology, Obstetrics and Gynecology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Pernilla Dahm-Kähler
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
| | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, and Region Västra Götaland, Regional Cancer Center West, Gothenburg, Sweden
| | - Maria Bjurberg
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Kristina Hellman
- Department of Gynecologic Cancer, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Högberg
- Department of Medical Oncology, Institute of Clinical Sciences, Lund University, Lund, Sweden
| | - Preben Kjölhede
- Department of Obstetrics and Gynecology in Linköping, Linköping University, Linköping, Sweden.,Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | | | - Per Rosenberg
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Department of Oncology, Linköping University, Linköping, Sweden
| | - Karin Stålberg
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Elisabeth Åvall-Lundqvist
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Department of Oncology, Linköping University, Linköping, Sweden
| | - Christer Borgfeldt
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund University, Lund, Sweden
| |
Collapse
|
3
|
Touboul C, Legendre G, Agostini A, Akladios C, Bendifallah S, Bolze PA, Bouet PE, Chauvet P, Collinet P, Dabi Y, Delotte J, Deffieux X, Dion L, Gauthier T, Kerbage Y, Koskas M, Millet P, Narducci F, Ouldamer L, Ploteau S, Santulli P, Golfier F. [Guidelines for Clinical Practice of the French College of Obstetricians and Gynecologists 2021: Prophylactic procedures associated with gynecologic surgery]. ACTA ACUST UNITED AC 2021; 49:805-815. [PMID: 34520857 DOI: 10.1016/j.gofs.2021.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To draw up recommendations on the use of prophylactic gynecologic procedures during surgery for other indications. DESIGN A consensus panel of 19 experts was convened. A formal conflict of interest policy was established at the onset of the process and applied throughout. The entire study was performed independently without funding from pharmaceutical companies or medical device manufacturers. The panel applied the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system to evaluate the quality of evidence on which the recommendations were based. The authors were advised against making strong recommendations in the presence of low-quality evidence. Some recommendations were ungraded. METHODS The panel studied 22 key questions on seven prophylactic procedures: 1) salpingectomy, 2) fimbriectomy, 3) salpingo-oophorectomy, 4) ablation of peritoneal endometriosis, 5) adhesiolysis, 6) endometrial excision or ablation, and 7) cervical ablation. RESULTS The literature search and application of the GRADE system resulted in 34 recommendations. Six were supported by high-quality evidence (GRADE 1+/-) and 28 by low-quality evidence (GRADE 2+/-). Recommendations on two questions were left ungraded due to a lack of evidence in the literature. CONCLUSIONS A high level of consensus was achieved among the experts regarding the use of prophylactic gynecologic procedures. The ensuing recommendations should result in improved current practice.
Collapse
Affiliation(s)
- C Touboul
- Service de Gynécologie Obstétrique et Médecine de la Reproduction de l'Hôpital Tenon (AP-HP), Sorbonne Université, 4, rue de la Chine, 75020 Paris, France.
| | - G Legendre
- Service de Gynécologie Obstétrique et Médecine de la Reproduction du CHU Anger, 4, rue Larrey, 49933 Angers cedex 9, France
| | - A Agostini
- Service de Gynécologie Obstétrique et Médecine de la Reproduction de l'Hôpital de la Conception (AP-HM), Marseille, France
| | - C Akladios
- Service de Gynécologie Obstétrique et Médecine de la Reproduction des hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - S Bendifallah
- Service de Gynécologie Obstétrique et Médecine de la Reproduction de l'Hôpital Tenon (AP-HP), Sorbonne Université, 4, rue de la Chine, 75020 Paris, France
| | - P A Bolze
- Service de Gynécologie Obstétrique et Médecine de la Reproduction de l'hôpital Lyon Sud, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France
| | - P E Bouet
- Service de Gynécologie Obstétrique et Médecine de la Reproduction du CHU Anger, 4, rue Larrey, 49933 Angers cedex 9, France
| | - P Chauvet
- Service de Gynécologie Obstétrique et Médecine de la Reproduction du CHU Estaing, 1, place Lucie-Aubrac, 63000 Clermont-Ferrand, France
| | - P Collinet
- Service de Gynécologie Obstétrique et Médecine de la Reproduction de l'Hôpital Jeanne-de-Flandre, avenue Eugène-Avinée, 59000 Lille, France
| | - Y Dabi
- Service de Gynécologie Obstétrique et Médecine de la Reproduction de l'Hôpital Tenon (AP-HP), Sorbonne Université, 4, rue de la Chine, 75020 Paris, France
| | - J Delotte
- Service de Gynécologie Obstétrique et Médecine de la Reproduction de l'Hôpital de l'Archet 2, 151, route de Saint-Antoine, 06200 Nice, France
| | - X Deffieux
- Service de Gynécologie Obstétrique et Médecine de la Reproduction de l'hôpital A.-Béclêre (AP-HP), 157, rue de la Porte-de-Trivaux, 92140 Clamart, France
| | - L Dion
- Service de Gynécologie Obstétrique et Médecine de la Reproduction du Centre Hospitalier Universitaire de Rennes, 16, boulevard de Bulgarie, 35200 Rennes, France
| | - T Gauthier
- Service de Gynécologie Obstétrique et Médecine de la Reproduction du CHU de Limoges, 8, avenue Dominique-Larrey, 87000 Limoges, France
| | - Y Kerbage
- Service de Gynécologie Obstétrique et Médecine de la Reproduction de l'Hôpital Jeanne-de-Flandre, avenue Eugène-Avinée, 59000 Lille, France
| | - M Koskas
- Service de Gynécologie Obstétrique et Médecine de la Reproduction de de l'hôpital Bichat (AP-HP), 46, rue Henri-Huchard, 75018 Paris, France
| | - P Millet
- Service de Gynécologie Obstétrique et Médecine de la Reproduction de l'Hôpital de l'Archet 2, 151, route de Saint-Antoine, 06200 Nice, France
| | - F Narducci
- Département de Cancérologie Gynécologique, Centre de Lutte Contre le Cancer Oscar-Lambret, Lille, France
| | - L Ouldamer
- Service de Gynécologie Obstétrique et Médecine de la Reproduction du CHU de Tours, 2, boulevard Tonnellé, 37000 Tours, France
| | - S Ploteau
- Service de Gynécologie Obstétrique et Médecine de la Reproduction du CHU de Nantes, 38 bd Jean-Monnet, 44093 Nantes cedex 1, France
| | - P Santulli
- Service de Gynécologie Obstétrique et Médecine de la Reproduction de l'Hôpital Cochin (AP-HP), 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - F Golfier
- Service de Gynécologie Obstétrique et Médecine de la Reproduction de l'hôpital Lyon Sud, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France
| |
Collapse
|
4
|
Dion L, Agostini A, Golfier F, Legendre G, Touboul C, Koskas M. In which cases should endometrial destruction be performed during an operative hysteroscopy? Clinical practice guidelines from the French College of Gynaecologists and Obstetricians (CNGOF). J Gynecol Obstet Hum Reprod 2021; 50:102188. [PMID: 34166864 DOI: 10.1016/j.jogoh.2021.102188] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 06/16/2021] [Accepted: 06/18/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To provide guidelines from the French College of Obstetricians and Gynaecologists (CNGOF), based on the best evidence available, concerning the impact of endometrial destruction on bleeding and endometrial cancer risk reduction in patients candidates for operative hysteroscopy. METHODS Recommendations were made according to AGREE II and the GRADE® (Grading of Recommendations Assessment, Development and Evaluation) systems to determine separately the quality of evidence (QE) and in the level of recommendation. RESULTS In a retrospective study comparing the incidence of endometrial cancer in 4776 patients with menorrhagia treated with endometrial destruction vs 229 945 patients with a medical treatment. There was a non-significant reduced risk of developing endometrial cancer (HR, 0.45; 95% CI, 0.15-1.40; p = .17). In premenopausal women, five studies compared the incidence of endometrial cancer in patients treated with endometrial ablation/destruction (EA/D) to the incidence of endometrial cancer in a comparable population of women from national registers, all of which show reduced risk of endometrial cancer after endometrectomy. In case of menopausal metrorrhagia, the prevalence of endometrial cancer is 9%, by analogy with the results found in premenopausal patients, the combination of endometrial ablation during operative hysteroscopy seems justified. In a retrospective cohort of 177 non-menopausal patients treated with myomectomy for metrorrhagia and/or menorrhagia, a significantly better control of bleeding at 12 months was found when myomectomy was combined with endometrectomy using roller-ball (OR: 0.18 [95% Cl 0.05-0.63]; p = 0.003). CONCLUSION In premenopausal women with heavy menstrual bleeding, when an operative hysteroscopy is performed, it is recommended to propose an endometrial ablation/destruction in order to prevent the risk of endometrial cancer, (QE3) and to prevent recurrence of bleeding (QE2). In menopausal women, it is probably recommended to also perform an endometrial ablation/destruction in case of operative hysteroscopy in order to prevent the risk of endometrial cancer (QE1).
Collapse
Affiliation(s)
- L Dion
- Department of Gynaecology, Rennes University Hospital, 16 Bd de Bulgarie, 35000 Rennes, France.
| | - A Agostini
- Department of Obstetrics and Gynaecology, APHM, 147 Bd Baille, 13005 Marseille, France
| | - F Golfier
- Department of Obstetrics and Gynaecology, CHU Lyon, 69000 Lyon, France
| | - G Legendre
- Department of Obstetrics and Gynaecology, CHU Angers, 49000 Angers, France
| | - C Touboul
- Department of Obstetrics and Gynaecology, APHP.6 Sorbonne Université, Tenon Hospital, 4 rue de la Chine, 75020 Paris, France
| | - M Koskas
- Department of Obstetrics and Gynaecology, APHP, Hôpital Bichat - Claude-Bernard, 46 rue Henri-Huchard, 75018 Paris, France
| |
Collapse
|
5
|
Office-based Approach to Evaluation and Management of Abnormal Uterine Bleeding. Clin Obstet Gynecol 2019; 62:712-726. [DOI: 10.1097/grf.0000000000000477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
6
|
Histopathology and Clinical Outcomes of 151 Women with Postmenopausal Bleeding Treated with Resectoscopic Surgery. J Minim Invasive Gynecol 2019; 27:763-773. [PMID: 31202823 DOI: 10.1016/j.jmig.2019.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/22/2019] [Accepted: 06/05/2019] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE Because postmenopausal bleeding (PMB) is associated with up to 10% of endometrial neoplasia and office endometrial sampling fails in approximately 10% and is inadequate in 30% of cases, the objective was to determine the role of hysteroscopic endometrial resection (HER) for the diagnosis and treatment of women with PMB. DESIGN A retrospective cohort. SETTING A university-affiliated teaching hospital. PATIENTS One hundred fifty-one women with PMB (September 1990-December 2010). INTERVENTION HER in the operating room. MEASUREMENTS AND MAIN RESULTS The median (range) age and body mass index were 58 (50-87) years and 29 (21-52) kg/m2, respectively. Office endometrial biopsy failed in 30 (19.8%), was inadequate in 20 (13.2%), identified nonatypical endometrial hyperplasia (NAH) in 21 (14%), atypical hyperplasia (AH) in 4 (2.6%), and endometrial cancer (EC) in 2 (1.3%) women. HER in 151 women identified 7 new cases of AH (3 from failed/inadequate office biopsy and 4 from NAH) and 9 EC (5 from failed/inadequate office biopsy, 1 from proliferative endometrium, 2 from NAH, and 1 from AH). All 27 women with NAH were treated by HER alone. Of 8 women with AH, 6 were treated with HER and 2 with hysterectomy; no residual endometrium was found in hysterectomy specimens. Of the 11 women with EC, 2 refused hysterectomy and are well 10 and 15 years after HER. Hysterectomy was performed for 9 of 11 EC cases, 2 of 8 AH cases, and 1 for abnormal uterine bleeding. Six women had repeat HER for persistent abnormal uterine bleeding, and 10 were lost to follow-up. At a median follow-up of 11.5 years (range, 7-20 years), 132 (12 hysterectomies + 10 lost) of 151 (87.4%) women were satisfied with no further bleeding. CONCLUSION In women with PMB, hysteroscopic endometrial resection concomitantly with resection of intrauterine pathology by experienced surgeons is feasible, safe, and effective for diagnosis in all cases and treatment of the majority of intrauterine pathology including NAH and selected cases of AH and EC.
Collapse
|
7
|
Abstract
Global endometrial ablation is a commonly performed, minimally invasive technique aimed at improving/resolving abnormal uterine bleeding and menorrhagia in women. As non-resectoscopic techniques have come into existence, endometrial ablation performance continues to increase due to accessibility and decreased requirements for operating room time and advanced technical training. The increased utilization of this method translates into increased imaging of patients who have undergone the procedure. An understanding of the expected imaging appearances of endometrial ablation using different modalities is important for the abdominal radiologist. In addition, the frequent usage of the technique naturally comes with complications requiring appropriate imaging work-up. We review the expected appearance of the post-endometrial ablated uterus on multiple imaging modalities and demonstrate the more common and rare complications seen in the immediate post-procedural time period and remotely.
Collapse
|
8
|
The case against endometrial ablation for treatment of heavy menstrual bleeding. Curr Opin Obstet Gynecol 2018; 30:287-292. [DOI: 10.1097/gco.0000000000000463] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
9
|
Kalampokas E, McRobbie S, Payne F, Parkin DE. Endometrial cancer after endometrial ablation or resection for menorrhagia. Int J Gynaecol Obstet 2018; 142:84-90. [DOI: 10.1002/ijgo.12503] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 02/07/2018] [Accepted: 04/04/2018] [Indexed: 11/06/2022]
Affiliation(s)
| | - Sarah McRobbie
- Department of Obstetrics and Gynecology; Aberdeen Royal Infirmary; Aberdeen UK
| | - Fiona Payne
- Department of Pathology; Aberdeen Royal Infirmary; Aberdeen UK
| | - David E. Parkin
- Department of Gynecologic Oncology; Aberdeen Royal Infirmary; Aberdeen UK
| |
Collapse
|
10
|
MacMahon C, Hatti A, Bakour S, Ewies AAA. Challenges of endometrial assessment after ablation in women with postmenopausal bleeding – A case series. J OBSTET GYNAECOL 2018; 38:432-434. [PMID: 29361866 DOI: 10.1080/01443615.2017.1306838] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Caroline MacMahon
- Sandwell and West Birmingham Hospitals NHS Teaching Trust, Birmingham, UK
| | - Archana Hatti
- Sandwell and West Birmingham Hospitals NHS Teaching Trust, Birmingham, UK
| | - Shagaf Bakour
- Sandwell and West Birmingham Hospitals NHS Teaching Trust, Birmingham, UK
- Medical School, Aston University, Birmingham, UK
| | - Ayman A. A. Ewies
- Sandwell and West Birmingham Hospitals NHS Teaching Trust, Birmingham, UK
- The College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
| |
Collapse
|
11
|
Spencer JC, Louie M, Moulder JK, Ellis V, Schiff LD, Toubia T, Siedhoff MT, Wheeler SB. Cost-effectiveness of treatments for heavy menstrual bleeding. Am J Obstet Gynecol 2017; 217:574.e1-574.e9. [PMID: 28754438 DOI: 10.1016/j.ajog.2017.07.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 07/12/2017] [Accepted: 07/18/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Heavy menstrual bleeding affects up to one third of women in the United States, resulting in a reduced quality of life and significant cost to the health care system. Multiple treatment options exist, offering different potential for symptom control at highly variable initial costs, but the relative value of these treatment options is unknown. OBJECTIVE The objective of the study was to evaluate the relative cost-effectiveness of 4 treatment options for heavy menstrual bleeding: hysterectomy, resectoscopic endometrial ablation, nonresectoscopic endometrial ablation, and the levonorgestrel-releasing intrauterine system. STUDY DESIGN We formulated a decision tree evaluating private payer costs and quality-adjusted life years over a 5 year time horizon for premenopausal women with heavy menstrual bleeding and no suspected malignancy. For each treatment option, we used probabilities derived from literature review to estimate frequencies of minor complications, major complications, and treatment failure resulting in the need for additional treatments. Treatments were compared in terms of total average costs, quality-adjusted life years, and incremental cost-effectiveness ratios. Probabilistic sensitivity analysis was conducted to understand the range of possible outcomes if model inputs were varied. RESULTS The levonorgestrel-releasing intrauterine system had superior quality-of-life outcomes to hysterectomy with lower costs. In a probabilistic sensitivity analysis, levonorgestrel-releasing intrauterine system was cost-effective compared with hysterectomy in the majority of scenarios (90%). Both resectoscopic and nonresectoscopic endometrial ablation were associated with reduced costs compared with hysterectomy but resulted in a lower average quality of life. According to standard willingness-to-pay thresholds, resectoscopic endometrial ablation was considered cost effective compared with hysterectomy in 44% of scenarios, and nonresectoscopic endometrial ablation was considered cost effective compared with hysterectomy in 53% of scenarios. CONCLUSION Comparing all trade-offs associated with 4 possible treatments of heavy menstrual bleeding, the levonorgestrel-releasing intrauterine system was superior to both hysterectomy and endometrial ablation in terms of cost and quality of life. Hysterectomy is associated with a superior quality of life and fewer complications than either type of ablation but at a higher cost. For women who are unwilling or unable to choose the levonorgestrel-releasing intrauterine system as a first-course treatment for heavy menstrual bleeding, consideration of cost, procedure-specific complications, and patient preferences can guide the decision between hysterectomy and ablation.
Collapse
Affiliation(s)
- Jennifer C Spencer
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Michelle Louie
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Janelle K Moulder
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Victoria Ellis
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Lauren D Schiff
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Tarek Toubia
- Department of Obstetrics and Gynecology, Jennie Stuart Medical Center, Hopkinsville, KY
| | - Matthew T Siedhoff
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| |
Collapse
|
12
|
|
13
|
Cheong Y, Cameron IT, Critchley HOD. Abnormal uterine bleeding. Br Med Bull 2017; 123:103-114. [PMID: 28910998 DOI: 10.1093/bmb/ldx027] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 07/24/2017] [Indexed: 11/13/2022]
Abstract
INTRODUCTION It is not uncommon for a woman to suffer from abnormal uterine bleeding (AUB) or heavy menstrual bleeding (HMB) at some point during her lifetime. Once pathology is excluded, in practice, management needs to be individualised, taking into account the improvement of the woman's symptoms and quality of life. SOURCES OF DATA Peer-reviewed journals, governmental and professional society publications. AREAS OF AGREEMENT There is now agreement on a structured, universal approach to the diagnosis of AUB, with the aide memoirs PALM (polyps, adenomyosis, leiomyoma, malignancy) and COEIN (coagulopathies, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified). Once malignancy and significant pelvic pathology have been ruled out, medical treatment is an effective first-line therapeutic option, with surgery, including endometrial ablation and hysterectomy, offered when medical management has failed to resolve symptoms and fertility is no longer desired. AREAS OF CONTROVERSY There remains controversy around the management of the types and subtypes of adenomyosis and leiomyoma, and understanding their impact on clinical reproductive outcomes. AREAS CURRENTLY UNDER DEVELOPMENT Standardised assessment tools for measuring outcomes of AUB are being developed. AREAS TIMELY FOR DEVELOPING RESEARCH Novel diagnostic and monitoring tools should be developed to help stratify treatment for women with AUB, particularly relating to 'unclassified' and 'endometrial' causes.
Collapse
Affiliation(s)
- Ying Cheong
- Faculty of Medicine, University of Southampton.,University Hospital Southampton NHS Foundation Trust
| | - Iain T Cameron
- Faculty of Medicine, University of Southampton.,University Hospital Southampton NHS Foundation Trust
| | | |
Collapse
|
14
|
Laberge P. Response to Letter to the Editor: Author's Reply. J Minim Invasive Gynecol 2017; 24:685-687. [DOI: 10.1016/j.jmig.2017.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 02/09/2017] [Indexed: 11/28/2022]
|
15
|
Abstract
Most menopausal women experience vasomotor symptoms with bothersome symptoms often lasting longer than one decade. Hormone therapy (HT) represents the most effective treatment for these symptoms with oral and transdermal estrogen formulations having comparable efficacy. Findings from the Women's Health Initiative and other recent randomized clinical trials have helped to clarify the benefits and risks of combination estrogen-progestin and estrogen-alone therapy. Absolute risks observed with HT tended to be small, especially in younger women. Neither regimen increased all-cause mortality rates. Given the lower rates of adverse events on HT among women close to menopause onset and at lower baseline risk of cardiovascular disease, risk stratification and personalized risk assessment appear to represent a sound strategy for optimizing the benefit-risk profile and safety of HT. Systemic HT should not be arbitrarily stopped at age 65 years; instead treatment duration should be individualized based on patients' risk profiles and personal preferences. Genitourinary syndrome of menopause represents a common condition that adversely affects the quality of life of many menopausal women. Without treatment, symptoms worsen over time. Low-dose vaginal estrogen represents highly effective treatment for this condition. Because custom-compounded hormones have not been tested for efficacy or safety, U.S. Food and Drug Administration (FDA)-approved HT is preferred. A low-dose formulation of paroxetine mesylate currently represents the only nonhormonal medication FDA-approved to treat vasomotor symptoms. Gynecologists and other clinicians who remain abreast of data addressing the benefit-risk profile of hormonal and nonhormonal treatments can help menopausal women make sound choices regarding management of menopausal symptoms.
Collapse
|
16
|
Hokenstad AN, El-Nashar SA, Khan Z, Hopkins MR, Famuyide AO. Endometrial Ablation in Women With Abnormal Uterine Bleeding Related to Ovulatory Dysfunction: A Cohort Study. J Minim Invasive Gynecol 2015; 22:1225-30. [DOI: 10.1016/j.jmig.2015.06.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 06/05/2015] [Accepted: 06/24/2015] [Indexed: 11/26/2022]
|
17
|
Bakkum-Gamez JN. Repurposing the vaginal tampon for endometrial cancer detection. Biomark Med 2015; 9:715-7. [PMID: 26230218 DOI: 10.2217/bmm.15.44] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Jamie N Bakkum-Gamez
- Department of Obstetrics & Gynecology, Division of Gynecologic Surgery, Eisenberg Lobby 71, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| |
Collapse
|
18
|
Endometrial cancer after endometrial ablation vs medical management of abnormal uterine bleeding. J Minim Invasive Gynecol 2014; 22:509-10. [PMID: 25461687 DOI: 10.1016/j.jmig.2014.10.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 10/15/2014] [Indexed: 11/21/2022]
|
19
|
Preoperative uterine bleeding pattern and risk of endometrial ablation failure. Am J Obstet Gynecol 2014; 211:556.e1-6. [PMID: 25019488 DOI: 10.1016/j.ajog.2014.07.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 05/10/2014] [Accepted: 07/03/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The objectives of the study were to compare among women who had an endometrial ablation the risks of treatment failure and subsequent gynecological procedures between women with regular and irregular heavy uterine bleeding and to determine other characteristics associated with the risk of treatment failure. STUDY DESIGN This study was a retrospective cohort of 968 women who underwent endometrial ablation between January 2007 and July 2009. Preoperative bleeding pattern was categorized as regular or irregular. Treatment failure was defined as reablation or hysterectomy. Subsequent gynecological procedures included endometrial biopsy, dilation and curettage, hysteroscopy, reablation, or hysterectomy. We calculated the odds of treatment failure and gynecological procedures using multiple logistic regression. RESULTS Bleeding pattern prior to ablation was heavy and regular in 30% (n = 293), heavy and irregular in 36% (n = 352), and unspecified in 30% (n = 286). We found no differences in treatment failure (13% vs 12%, P = .9) or subsequent procedures (16% vs 18%, P = .7) between women with regular and irregular bleeding. Compared with the women with regular bleeding, the women with irregular bleeding were not at increased odds of treatment failure or subsequent procedures (odds ratio [OR], 1.07; 95% confidence interval [CI], 0.65-1.74 and OR, 1.17; 95% CI, 0.76-1.80, respectively). Factors associated with an increased odds of treatment failure and subsequent procedures included tubal ligation (OR, 1.94; 95% CI, 1.30-2.91 and OR, 1.71; 95% CI, 1.20-2.43, respectively); dysmenorrhea (OR, 2.42; 95% CI, 1.44-4.06 and OR, 1.93; 95% CI, 1.20-3.13, respectively); and obesity (OR, 1.82; 95% CI, 1.21-2.73 and OR, 1.75; 95% CI, 1.22-2.50, respectively). CONCLUSION Preoperative bleeding pattern did not appear to affect failure rates or the need for gynecological procedures after endometrial ablation. Other risk factors for ablation failure identified included preoperative dysmenorrhea, prior tubal ligation, and obesity.
Collapse
|