Outcome of hysterectomy for pelvic pain in premenopausal women

Correction to: Chronic Postoperative Pain After Robot-Assisted Laparoscopic Hysterectomy for Endometrial Cancer by Lunde S, Petersen KK, Kugathasan P, Arendt-Nielsen L and Søgaard-Andersen E. Journal of Gynecologic Surgery 2019;35(3);140-146. DOI: 10.1089/gyn.2018.0068

[This corrects the article DOI: 10.1089/gyn.2018.0068.].

Research Priorities in Pelvic Venous Disorders in Women: Recommendations from a Multidisciplinary Research Consensus Panel

Pelvic venous disorders (PeVDs) in women can present with chronic pelvic pain, lower-extremity and vulvar varicosities, lower-extremity swelling and pain, and left-flank pain and hematuria. Multiple evidence gaps exist related to PeVDs with the consequence that nonvascular specialists rarely consider the diagnosis. Recognizing this, the Society of Interventional Radiology Foundation funded a Research Consensus Panel to prioritize a research agenda to address these gaps. This paper presents the proceedings and recommendations from that Panel.

Impact of Pelvic Pain and Endometriosis on Patient-Reported Outcomes and Experiences of Benign Hysterectomy: A Study from the Swedish National Register for Gynecological Surgery

BACKGROUND

The study objective was to analyze and compare patient-reported experience measures (PREMs) and patient-reported outcome measures (PROMs) after hysterectomy in women with and without a preoperative complaint of pelvic pain associated with and without a confirmed diagnosis of endometriosis.

METHODS

Retrospective nationwide register study. Data on 28,776 hysterectomies performed on benign indication between 2004 and 2016 were retrieved from the Swedish National Register for Gynecological Surgery. Multivariable logistic regression models were used to compare the PREMs and PROMs items. The results are presented as adjusted odds ratios (aORs) and 95% confidence intervals (CI).

RESULTS

Regardless of the occurrence of pelvic pain preoperatively and a diagnosis of endometriosis, 1 year after surgery, the women were satisfied or very satisfied (>90%) with the hysterectomy, and their medical condition was improved or much improved (>95%). The women with a preoperative complaint of pelvic pain and endometriosis more often reported excessively short hospital stays (aOR 1.45, 95% CI 1.17-1.79), more severe complications after discharge (aOR 2.02, 95% CI 1.59-2.66) at the 8-week follow-up and at the 1-year follow-up (aOR 2.31, 95% CI 1.57-3.39), and more dissatisfaction with the operation (aOR 1.83, 95% CI 1.35-2.48) than preoperative pelvic pain-free women without endometriosis at the 1-year follow-up.

CONCLUSIONS

The majority of the women were satisfied after their hysterectomy. The women with pelvic pain and endometriosis were at a higher risk of being dissatisfied. Pelvic pain per se seemed to be the main factor affecting the rating in the PREMs and PROMs, and the endometriosis was a significant contributing factor.

Medical, surgical and alternative treatments for chronic pelvic pain in women: a descriptive review

Several causes of chronic pelvic pain (CPP) are recognised, but in many women a definite diagnosis cannot be made. Few randomised controlled trials on treatment of CPP have been conducted. In a Cochrane systematic review, only medroxy-progesterone acetate, counselling, a multidisciplinary approach and lysis of deep adhesions had a proven benefit. The aim of this descriptive review is to describe the management of CPP, which can focus on treating the pain itself, the underlying cause, or both. Combination drug therapy with medications with different mechanisms of action may improve therapeutic results. Pelvic denervating procedures should be indicated in selected circumstances, as the magnitude of the effect is undefined. Several alternative non-invasive treatments have been proposed including exercise programmes, cognitive and behavioural medicine, physical therapy, dietary modification, massage and acupuncture. When the woman has completed her family and particularly when pelvic varices have been demonstrated, hysterectomy can be considered after a careful pre-operative assessment. However, substantial pain relief may be achieved in no more than 60-70% of the cases. A minority of patients (3-5%) will experience worsening of pain or will develop new symptoms after surgery. Treatment of CPP, generally, requires acceptance of the concept of managing rather than curing symptoms.

Chronic pain after hysterectomy

BACKGROUND

Chronic pain is a well-known adverse effect of surgery, but the risk of chronic pain after gynaecological surgery is less established.

METHOD

This review summarizes studies on chronic pain following hysterectomy. The underlying mechanisms and risk factors for the development of chronic post-hysterectomy pain are discussed.

RESULTS AND CONCLUSION

Chronic pain is reported by 5-32% of women after hysterectomy. A guideline is proposed for future prospective studies.

The association of hysterectomy and menopause: a prospective cohort study

OBJECTIVE

To determine whether or not hysterectomy leads to an earlier onset of the menopause.

DESIGN

A prospective cohort study.

SETTING

Gynaecology service of large urban hospital.

POPULATION

Premenopausal women with and without hysterectomy.

METHODS

Multivariate survival analysis techniques were used to adjust for differences in initial follicle stimulating hormone (FSH) levels, body mass index, smoking and unilateral oophorectomy between the groups.

MAIN OUTCOME MEASURES

FSH levels were measured for five years following hysterectomy and compared with the comparison group. Menopause was defined as a single FSH measurement of at least 40 IU/L.

RESULTS

Two hundred and fifty-seven women undergoing hysterectomy were compared with 259 women who had not undergone a hysterectomy. Fifty-three women (20.6%) in the hysterectomy group and 19 women (7.3%) in the comparison group reached menopause over the five years of the study. Women in the hysterectomy group with a pre-operative FSH <10 IU/L reached menopause 3.7 years (95% CI 1.5-6.0 years) earlier than women in the comparison group independent of BMI, smoking and unilateral oophorectomy. Twenty-eight women in the hysterectomy group had unilateral oophorectomy and 10 (35.7%) of these women reached menopause over the five years of follow up. Women in the hysterectomy group with unilateral oophorectomy reached menopause 4.4 years (95% CI 0.6, 7.9 years) earlier than women with both ovaries in the hysterectomy group independent of baseline FSH, BMI and smoking.

CONCLUSIONS

Hysterectomy is associated with an earlier onset of menopause. Hysterectomy with unilateral oophorectomy is associated with an even earlier onset of the menopause in this study.

Total and subtotal abdominal hysterectomy

Hysterectomy is one of the most frequently performed operations in the world, accounting for 500,000-600,000 procedures annually in the USA; the abdominal route for hysterectomy is the preferred route in 60-80% of these operations. Although the number of total abdominal hysterectomies performed annually has decreased, the number of subtotal abdominal hysterectomies increased by >400%. The major indications for abdominal hysterectomy include abnormal uterine bleeding, myomata uteri, adenomyosis, endometriosis, neoplasia, and chronic salpingitis. The basis for selection for subtotal versus total hysterectomy has little in the way of factual data to support it and may actually present some significant disadvantages, such as continued menstruation and cervical prolapse. The detailed technique for performing intrafascial abdominal hysterectomy relies heavily on precise knowledge of pelvic anatomy and compulsive detail to tissue handling. The consistent and correct usage of prophylactic antimicrobials, measures to prevent thromboemboli, and procedures to avoid urinary retention are key to the overall success of the surgery.

Uterine fibroids and gynecologic pain symptoms in a population-based study

OBJECTIVE

To determine the association between dyspareunia, dysmenorrhea, and noncyclic pelvic pain and the presence and characteristics of uterine fibroids.

DESIGN

Population-based cross-sectional study.

SETTING

Desio, Italy.

PATIENT(S)

Six hundred thirty-five non-care-seeking participants of the Seveso Women's Health Study with an intact uterus who underwent transvaginal ultrasound.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Ultrasound-detected presence of uterine fibroids and fibroid characteristics including volume, number, location, and position. Current dyspareunia, dysmenorrhea, and noncyclic pelvic pain was measured by self-report on a visual analog scale.

RESULT(S)

Uterine fibroids were detected in 96 women (15%). Women with fibroids were more likely to report moderate or severe dyspareunia (adjusted odds ratio [OR] = 2.8, 95% confidence interval [CI] = 0.9-8.3, statistically significant trend) and moderate or severe noncyclic pelvic pain (adjusted OR = 2.6, 95% CI = 0.9-7.6, statistically significant trend) than women without fibroids. Moderate or severe dysmenorrhea was not associated with the presence of fibroids (adjusted OR = 1.1, 95% CI = 0.5-2.6). Number and total volume of fibroids were not related to pain.

CONCLUSION(S)

This is the first population-based study of gynecologic pain symptoms and fibroids. Dyspareunia and noncyclic pelvic pain, but not dysmenorrhea, increased in severity with the presence of uterine fibroids. Fibroid-associated pain symptomatology in a non-care-seeking population may be different from that of a clinic population.

Diagnosis and management of chronic pelvic pain

Chronic pelvic pain is difficult to diagnose and to treat [81] because of the multiple and often overlapping causes [82]. A systematic approach aids in the thorough evaluation and appropriate therapy. At the initial visit(s), a thorough history should be taken and complete physical examination performed. Screening for co-existing conditions, such as depression, narcotic dependency, and physical, sexual, or emotional abuse is crucial so these issues may be addressed immediately while additional causes for pelvic pain are evaluated. The relative likelihood of gastrointestinal, urologic, musculoskeletal, or gynecologic etiology must be considered to guide a more thorough initial evaluation. With gynecologic chronic pelvic pain, differentiation between hormonally responsive and nonresponsive conditions is helpful for diagnosis and treatment. Therapy can then be instituted or an appropriate referral made.

A prospective study of the short-term outcomes of hysterectomy with and without oophorectomy

OBJECTIVE

To determine the symptom profile and satisfaction rate for women undergoing hysterectomy with and without oophorectomy

STUDY DESIGN

Women under 46 years of age who underwent hysterectomy with (n = 266) and without oophorectomy (n = 57) were followed for six months.

RESULTS

Satisfaction was high at six months. In-hospital complication rates were 28% in Group 1 and 39% in Group 2 (p = 0.11). Pelvic pain was reported in more than half the women at six weeks. A reduction in constipation, diarrhoea, abdominal and pelvic pain, and depression was reported at six months. Quality of sexual function in women did not improve. New symptoms of pelvic pain or depression were present at six months in more than 16% to 37% of the women. Regrets about loss of fertility were increased at six months.

CONCLUSIONS

Although levels of satisfaction with the procedure of hysterectomy were high, new symptoms and regrets about the loss of fertility were commonly reported.

Symptom experience in women after hysterectomy

OBJECTIVE

To review the literature addressing the symptom experience of women after hysterectomy.

DATA SOURCES

Computerized searches in MEDLINE and CINAHL, as well as texts and references cited in articles. Key concepts in the searches included hysterectomy, sleep disturbance and pain, hysterectomy and fatigue, hysterectomy, depression, and depressed mood.

STUDY SELECTION

Articles and comprehensive works relevant to key concepts and published after 1970, with an emphasis on new findings from 1990 to 2000. Sixty-four citations were identified as useful to this review.

DATA EXTRACTION

Data were organized under the following headings: women and hysterectomy, biopsychosocial perspectives, common symptoms after hysterectomy (pain, disturbed sleep, fatigue, depressed mood, anxiety), and significance of review (implications).

DATA SYNTHESIS

Literature suggests that after a hysterectomy, women experience complications during the postoperative recovery period that may vary with the type of surgical procedure. During this period, the quantity and quality of sleep as well as other symptoms (pain, fatigue, anxiety, and depression) are influenced by various physiologic, psychologic, and social factors. Despite limited evidence that sleep problems may occur frequently during the recovery period, only a few researchers have systematically examined sleep patterns in women after hysterectomy. None of these studies, however, used objective sleep measures or examined multiple dimensions of these women's lives.

CONCLUSIONS

This review conceptualized the women's symptom experience as the experience of specific symptoms (pain, sleep disturbance, fatigue, depressed mood, and anxiety) that were influenced by biopsychosocial factors.

Uterine artery embolization for symptomatic uterine myomas

OBJECTIVE

To evaluate the role of uterine artery embolization as treatment for symptomatic uterine myomas.

DESIGN

Medline literature review, cross-reference of published data, and review of selected meeting abstracts.

RESULT(S)

Results from clinical series have shown a consistent short-term reduction in uterine size, subjective improvement in uterine bleeding, and reduced pain following treatment. Posttreatment hospitalization and recovery tend to be shorter after uterine artery embolization compared with hysterectomy. Randomized controlled trials have not been conducted, and long-term efficacy has not been studied. A limited number of deliveries have been reported following uterine artery embolization for uterine myomas.

CONCLUSION(S)

Uterine artery embolization is a unique new treatment for symptomatic uterine myomas. Even without controlled studies, demand for this procedure has increased rapidly. Uterine artery embolization may be considered an alternative to hysterectomy, or perhaps myomectomy, in well-selected cases. At the present time, however, uterine artery embolization should not be routinely recommended for women who desire future fertility.

Surgical management of endometriosis

A systematic literature review of the last two decades was performed to evaluate the effect of pelvic denervations in addition to conservative surgery on dysmenorrhoea and deep dyspareunia associated with endometriosis. Chronic pelvic pain relief after hysterectomy or adhesiolysis was also assessed. In the five non-comparative studies on the effect of pre-sacral neurectomy, the frequency of dysmenorrhoea recurrence or persistence after treatment ranged from 4 to 40%. The pooled frequency of non-responders at the end of follow-up was 23% (95% confidence interval (CI), 19 to 27%). Only two of the three comparative, non-randomized trials demonstrated a significant treatment benefit of pre-sacral neurectomy, and the results of the two identified randomized controlled trials are discordant. Significant quantitative heterogeneity among studies prevented pooling of data on dysmenorrhoea. The common odds ratio of deep dyspareunia persistence was 0.69 (95% CI, 0.31 to 1.54). In the 10 non-comparative studies on the effect of uterosacral ligament resection, the frequency of dysmenorrhoea and deep dyspareunia persistence after treatment ranged, respectively, from 0 to 50% and from 6 to 42%. The pooled frequency of non-responders at the end of follow-up was 23% (95% CI, 20 to 27%) and 13% (95% CI, 8 to 18%), respectively. Routine performance of complementary denervating procedures cannot be recommended based on the quality of the evidence available. The results of the five studies on the effect of hysterectomy on chronic pelvic pain of presumed uterine origin consistently demonstrated that 83-97% of operated women reported pain relief or improvement 1 year after surgery. There is no consensus on the outcome of adhesiolysis in patients with chronic pain, and the role of pelvic adhesions in causing symptoms is under scrutiny.