Randomised trial comparing hysterectomy with endometrial ablation for dysfunctional uterine bleeding: psychiatric and psychosocial aspects

OBJECTIVE: To compare in psychiatric and psychosocial terms the outcome of hysterectomy and endometrial ablation for the treatment of dysfunctional uterine bleeding. DESIGN: Prospective randomised controlled trial. SETTING--Obstetrics and gynaecology department of a large teaching hospital. SUBJECTS: 204 women with dysfunctional bleeding for whom hysterectomy would have been the preferred treatment were recruited over 24 months and randomly allocated to hysterectomy (99 women) or to hysteroscopic surgery (transcervical resection (52 women) or laser ablation (53 women). MAIN OUTCOME MEASURES: Mental state, martial relationship, psychosocial and sexual adjustment in assessments conducted before the operation and one month, six months, and 12 months later. RESULTS: Both treatments significantly reduced the anxiety and depression present before the operation, and there were no differences in mental health between the groups at 12 months. Hysterectomy did not lead to postoperative psychiatric illness. Sexual interest after the operation did not vary with treatment. Overall, 46 out of 185 (25%) women reported a loss sexual interest and 50 out of 185 (27%) reported increased sexual interest. Marital relationships were unaffected by surgery. Personality and duration of dysfunctional uterine bleeding played no significant part in determining outcome. CONCLUSIONS: Hysteroscopic surgery and hysterectomy have a similar effect on psychiatric and psychosocial outcomes. There is no evidence that hysterectomy leads to postoperative psychiatric illness.     

Chlorhexidine as a root canal medicament for treating inflammatory lesions in the periodontal space

OBJECTIVE: Abnormal uterine bleeding is a common and troublesome problem in human immunodeficiency virus (HIV)-infected women. We sought to evaluate endometrial pathology among HIV-infected women requiring hysterectomy to explore if endometritis may be common among these patients. METHODS: We performed a retrospective analysis of uterine pathology specimens obtained from HIV-infected and control patients requiring hysterectomy in two urban hospitals between 1988 and 1997 matched for age, surgical indication, and history of gonadotropin-releasing hormone (GnRH) use. Cases were evaluated for the presence of plasma cells and assigned a grade between 0 and 3. RESULTS: Indications included cervical dysplasia (4), carcinoma in situ (2), abnormal uterine bleeding (3), and adnexal mass (3). Some degree of abnormal uterine bleeding occurred in all cases. Plasma cell endometritis was twice as common in HIV-infected women compared to HIV-negative specimens (11/11 versus 11/22) (P < 0.05). Plasma cell endometritis was also of a higher grade in specimens from HIV-infected women than in controls (P = 0.001). CONCLUSION: Chronic endometritis was common and of a higher grade among HIV-infected women requiring hysterectomy in our series. Diagnosis and treatment of endometritis should be considered in HIV-infected women with uterine bleeding and/or tenderness. We speculate that antiretroviral and/or antimicrobial treatment for endometritis may effectively treat endometritis and eliminate the need for surgery in some HIV-infected women. We suggest that consideration and treatment of endometritis in HIV-1 infected women being evaluated for possible hysterectomy has the potential to reduce costs and morbidity for patients and providers who may be exposed during surgical procedures.     

Conversion ratio of tryptophan to niacin in rats fed a vitamin B1-free diet

Patients with persistent uterine bleeding that is unresponsive to conservative therapy may opt for endometrial ablation over total hysterectomy because of concerns over subsequent sexual dysfunction or other nonclinical issues. Twelve such women with healthy cervices who failed endometrial ablation, and eight candidates for ablation were offered subtotal vaginal hysterectomy as a definitive primary surgical intervention instead of endometrial ablation. Our experience suggests the safety and utility of subtotal vaginal hysterectomy in properly selected patients. Randomized, comparative studies of this technique as an alternative to hysteroscopic ablation or resection may be warranted.     

Hysteroscopic resection of the endometrium: an alternative to hysterectomy?

A study carried out on 342 cases of endometrial resection, with a follow up of 3 to 36 months, has allowed us to precise: 1. The indications of this technique: patients more than 40 years, suffering of abnormal uterine bleeding. 2. The endometrial ablation was performed by electrosurgery through an operating channel of the hysteroscopic sheet (9 mm) and with a glycocol distended media (1.5%). The mean time to complete the operation was 35 +/- 10 minutes, the mean length of the hospital stay was 1 day. We had no serious complications. 3. And the rate of success (amenorrhea or hypomenorrhea) was 95% at 3 months but decreased at 90% at 36 months. The rate of secondary hysterectomy was 10%, due to the associated lesions: myoma with adenomyosis in 50% of the cases. There was some evidence of superior health related quality of life among hysterectomy patients. It's the reason why it is necessary to make a serious selection of the patients who are to be treated by this method in order to avoid complications and secondary hysterectomy.     

Operative hysteroscopy: minimally invasive surgery to control of menorrhagia

Diagnostic hysteroscopy is a valuable method for evaluation of intrauterine disorders. After diagnosing, the endoscopic treatment of these pathologies is the major question of past decade. Possibility of solving cause of infertility or abnormal uterine bleeding without laparotomy or hysterotomy/hysterectomy is the great advantage of operative hysteroscopic methods. In Department of Obstetrics and Gynaecology of University Medical School of Debrecen more than 1400 hysteroscopic interventions were performed from 1 September 1989 to 31 December 1996. In treatment of intractable uterine bleeding 347 operative hysteroscopy (targeted biopsy, polypectomy, transcervical endometrial ablation, fibroid resection etc.) were performed. The rate of complications was low, only 2% (4 perforations and 2 bleedings). The high success rate and low rate of complications offers a modern, safe, minimally invasive method for treatment of menorrhagia.     

Ataxia-telangiectasia in the Japanese population: identification of R1917X, W2491R, R2909G, IVS33+2T-->A, and 7883del5, the latter two being relatively common mutations

Postmenopausal uterine bleeding is an indication to sample the endometrium for diagnostic purposes. The endometrial brush cytologies of 20 advanced postmenopausal women collected at the time of hysterectomy in order to benchmark the expected morphology of postmenopausal endometrial brushings were reviewed. No women had symptoms or gross findings of primary endomyometrial disease. Endometrium was collected at the surgical pathology laboratory using the Tao Brush and CytoRich Fixative System. After formalin fixation of the uterus, the entire endometrium was embedded for routine histology. Sixteen endometrial brushings and matched endometrial sections showed endometrial atrophy, one brushing showed many ciliated epithelial cells, and three brushings showed focal (less than 10%) epithelial-cell atypia. In two atypias, abnormal endometrial epithelial-cell sheets contained enlarged, clear nuclei with nuclear notches and grooves resembling papillary thyroid cancer. One case showed no histological counterpart to this finding. The other case showed thickening of the pericornual fundic endometrium with cystic glands. The third case with epithelial atypia showed abnormal endometrial-cell sheets with nuclei resembling atypical hyperplasia or type I endometrial adenocarcinoma; corresponding endometrial tissue sections showed rare, irregular glands and back-to-back gland clusters with equivalent nuclear features. Atypical epithelium may be found in atrophic uteri in the absence of gross endometrial thickening. This may be a common event related either to de novo intraepithelial dysplasia in a noncycling endometrium or to hyperplasia that has partly regressed with estradiol withdrawal. This study shows that, in addition to endometrial intraepithelial carcinoma (EIC), isolated atypical glands with morphological and immunohistochemical features of atypical hyperplasia or type I endometrial adenocarcinoma may be found in grossly normal advanced postmenopausal endometrium of asymptomatic patients. This atypical epithelium is readily apparent in endometrial brush preparations, but requires serial sectioning of the endometrium to be demonstrated histologically. We have not established the natural history of this lesion, and in the absence of EIC or gross endometrial thickening indicative of atypical hyperplasia, we do not know whether this degree of epithelial atypia should be an indication for hysterectomy.     

Vacuum aspiration: an efficient outpatient screening technic for endometrial disease

In an effort to find a safe, efficient, and inexpensive means of ruling out the existence of a neoplastic process causing abnormal vaginal bleeding form the uterine cavity, 103 patients over 34 years of age had preoperative aspiration (Vabra aspirator) of the endometrial cavity. The tissue obtained at the time of D&C and hysterectomy was correlated with that obtained by the outpatient diagnostic procedure. In this pilot study, the aspirator was 98% accurate in evaluating high-risk women with abnormal uterine bleeding for malignant disease. In the two neoplasms missed, both women had had a recent D&C.     

Geographic variations in breast cancer mortality: do higher rates imply elevated incidence or poorer survival?

A 46-year-old women presented with an inoperable low-grade endometrial stromal sarcoma. Two doses of Depo-Lupron, 7.5 mg, and Megace, 160 mg/day, were given to control uterine bleeding and shrink the tumor mass. In 9 weeks, significant reduction in the tumor occurred allowing for surgical resection. Total abdominal hysterectomy with bilateral salpingo-oophorectomy is the mainstay for primary treatment. The role of chemotherapy, radiation therapy, and hormonal therapy is poorly defined. This is a case report of neoadjuvant hormonal therapy which may improve outcomes in patients with endometrial stromal sarcomas. Additional research is needed to define the exact role of these agents.     

Thermoregulated radiofrequency endometrial ablation

OBJECTIVE: To test the hypothesis that treating dysfunctional uterine bleeding by automated application of electrothermal energy to the uterine cavity, with precise regional control, might yield results equivalent to those reported for hysteroscopically directed laser and electrosurgical endometrial ablations. MATERIALS AND METHODS: Patients with life style compromising menorrhagia, referred to six gynecologic surgical centers for hysterectomy or endometrial ablation, were admitted to the study if they had normal cervical cytology, a benign endometrial biopsy, no defined cause for their bleeding, and consented to participate in the evaluation of a newly developed Vesta DUB Treatment System. The device consists of a silicone-inflatable electrode carrier to be inserted into the uterine cavity and a controller to monitor and distribute current from a matched electrosurgical generator. Treatment involved a 3-minute or shorter warm-up period and a 4-minute treatment phase. RESULTS: Three- to 24-month follow-up data were available for 187 patients, with a mean follow-up of 14.8 months. The amenorrhea rate was 38%. Bleeding was reduced in 95% of patients. Actuarially, 88 +/- 3% of patients should expect to be free of menorrhagia, dissatisfaction, or need for a second procedure out to 24 months. CONCLUSIONS: The unique regional feed-back control offered by this system causes thorough, evenly distributed, thermal destruction 4-5 mm into the myometrium that reduces bleeding with durability equivalent to published reports of hysteroscopic endometrial ablation.     

Endometrial resection for refractory menorrhagia. An alternative to hysterectomy

ENDOMETRIAL RESECTION: Whether resection is total or partial, the superficial layer of the myometrium is exposed to a certain degree of damage. SEVERAL METHODS: Radiofrequency thermal resection, the standard method, offers the advantage of allowing histology examination. Other destructive methods have also been proposed including the more recent laser Ng-Yag ablation technique. INDICATION: Ideally, endometrial resection is indicated in women with a small uterus who develop drug resistant menometrorrhagia after the age of 40 years. MODERATE RATE OF SUCCESS: In a personal series of 105 patients who underwent radiofrequency thermal resection and with a mean follow-up of 15.5 +/- 6.6 months, results were in agreement with data reported in the literature: perforation of the uterus < 5%, hemorrhage < 1%, metabolic syndrome < 2%. Patients were entirely satisfied in 58% of the cases but secondary hysterectomy was required in 14%. PRECISE INDICATIONS: Despite the advantages over hysterectomy, endometrial resection should be reserved for selected patients in order to avoid an unsatisfactory high rate of failure.     

In cell amplification

130 total hysteroscopic resections of the endometrium (RE) were performed at the Department of Gynecology and Obstetrics of the Deutschlandsberg Hospital from August 1, 1992 to May 31, 1997. 115 patients (88.5%) suffered from distinctive therapy-resistant uterine bleeding in terms of hypermenorrhea and menorrhagia, frequently combined with poly- and dysmenorrhea. 15 (11.5%) women who had previously been operated for breast cancer developed--during continuous treatment with tamoxifen--endometrial hyperplasia or polyps on which RE was performed after a hysteroscopic biopsy or resection had been carried out in a second setting. The operation showed that 98 out of 115 patients (85.2%) had pathologic anomalous uteri which were the organic cause of the uterine bleeding. Only 17 women (14.8%) suffered from dysfunctional uterine bleeding (12 cases) or from iatrogenically reduced coagulability (5 cases). The majority of the women (106 cases = 81.5%) were older than 40 (average 46.9 +/- 6.21 years). All RE were performed under inhalation anesthesia whereby the complete uterine cavity up to the inner orifice of the uterus was resected with the resectoscope loop. 92 out of 130 patients (70.8%) underwent a hysteroscopy or a dilatation and curettage before the RE. 77 patients (66.9%) received pretreatment with drugs to reduce the endometrium. 15 women (13.0%) underwent a laparoscopic tubal sterilization in the same setting. Finally, the results of 107 patients were analyzed excluding dropouts and patients who had undergone continuous treatment with tamoxifen and those who had an observation time of less than 6 months. After an observation period of 6-58 months, the success rate was 84.1%. For treatment of relapses 7 second resections were performed, whereby in 1 patient with a further uterine bleeding the uterus had to be extirpated. Nine of the 10 remaining patients had a hysterectomy, 1 patient refused any further treatment. The total hysterectomy rate was 12.2%. Basically, RE is absolutely practicable as far as the treatment of abnormal uterine bleeding is concerned, since hysterectomy can be avoided in a number of cases. Satisfactory long-term results, however, can only be achieved if indication and operation technique are of high quality. A problem which has not yet been solved is the indication and treatment of proliferating adenomyosis uteri interna.     

Changes of lipid peroxidation parameters in children being treated for cancer

STUDY OBJECTIVE: To determine sensitivity, specificity, positive predictive value, negative predictive value, and global diagnostic precision of hysteroscopic exploration in the diagnosis of endometrial hyperplasia and adenocarcinoma in women with abnormal uterine bleeding. DESIGN: Retrospective analysis. SETTING: University-affiliated hospital. PATIENTS: One thousand three hundred ninety-eight patients with abnormal uterine bleeding, 57.3% premenopausal and 42.6% postmenopausal. INTERVENTIONS: Diagnostic hysteroscopy and subsequent dilatation and curettage. MEASUREMENTS AND MAIN RESULTS: Endometrium was classified hysteroscopically as normal, atrophic, endometrial hyperplasia, and endometrial carcinoma. Histopathologic diagnosis was performed to determine the efficacy of hysteroscopy in diagnosing endometrial hyperplasia and adenocarcinoma. For endometrial hyperplasia in premenopausal women, sensitivity was 71.8%, specificity 96.4%, and global diagnostic precision 92.5%; in postmenopausal women, respective figures were 85. 1%, 100%, and 97.3%. For diagnosing adenocarcinoma in premenopausal patients, hysteroscopy was 100% sensitive, with specificity 99.4% and global diagnostic precision 99.5%; in postmenopausal women, respective figures were 100%, 99.4%, and 99.5%. CONCLUSIONS: In women with abnormal uterine bleeding, diagnostic hysteroscopy is a basic tool that allows precise diagnosis of endouterine lesions such as polyps and submucous myomas. It also is highly accurate for evaluating endometrial adenocarcinoma and hyperplasia.     

Flavone acetic acid enhances accumulation of IL-2 activated NK cells within established metastases

OBJECTIVE: In 1995, we presented our experience in hysteroscopic resection of hemorrhagic submucous fibroids in 196 patients. The objective of the present work was to analyze functional outcome three years later. PATIENTS: One hundred ninety-six patients with abnormal uterine bleeding were treated between 1987 and 1993. Equipment, techniques, characteristics of the procedures and early results were detailed in the previous article. RESULTS: With a mean follow-up of 73 months (range 50,104), results were: 13.8% of the patients were lost to follow-up; 68.4% had symptomatic improvement and failure was observed in 17.8% (subsequent hysterectomy in 12.7%). Forty-nine patients had repeat resection in this series; 61 became menopausal after surgery, and 21 were taking hormone replacement therapy with good results. CONCLUSION: Developed as an alternative to hysterectomy, operative hysteroscopy has proven to be a safe and effective procedure. This treatment modality appears to give satisfactory long-term results, with a low rate of complications.     

Rural Eastern Carolina Health (REACH). A model community health improvement program

Most patients with chronic renal failure who are on maintenance hemodialysis are anovulatory and have menstrual abnormalities. This study was designed to determine the prevalence of organic causes of abnormal uterine bleeding in this group of patients exposed to unopposed estrogens. Eighteen patients with chronic renal failure and abnormal uterine bleeding underwent vacuum curettage. The histopathologic findings were compared with a group of 154 premenopausal women who had abnormal uterine bleeding without detectable organic causes. Excluding patients with secretory and atrophic endometrium, only 2 of 8 patients (25%) with chronic renal failure had endometrial lesions while 44 of 131 patients (33.6%) had either endometrial polyp, simple or atypical endometrial hyperplasia or endometrial carcinoma (p > 0.05). The uremic environment caused by chronic renal failure does not alter the endometrial responsiveness to unopposed estrogens and may lead to the development of endometrial lesions.     

Intermittent 50 Hz magnetic field and skin tumor promotion in SENCAR mice

Hysteroscopic surgery has been widely used in gynaecology for the treatment of endocavitary fibroids, synechias, uterine septum and abnormal uterine bleeding. Reports proposed preoperative medical therapy to improve the endometrials conditions. Attempts at inhibiting the thickness and vascularity of the endometrium and to reduce the fibroids size in preparation for hysteroscopic surgery by using different types of hormones have been reported. The suppression provided for a long period of time after the procedure by gonadotropin releasing hormone (GnRH) analogs, is likely to help inhibit endometrial regeneration and provided even better long time success, in endometrial ablation and submucous leiomyomatas hysteroscopic surgery. A literature review of the efficiency of the gonadotropins releasing hormone agonist, in endometrial inhibition before surgery and small regional experience is shown.     

Endometrial ablation. A review of the technics and results

The authors make a careful examination of a very new surgical hysteroscopic technique, endometrial ablation, which is proposed as an alternative to hysterectomy in cases of persistent uterine bleeding not supported by endometrial atypia or adenocarcinoma. In addition to examining the indications for this type of surgery the authors also assess the state of the art of two techniques currently used: the laser technique and the method based on electroresection. The risks, benefits, collateral effects and results are evaluated for each method.     

Pathophysiology of adenomyosis

Adenomyosis refers to endometrial glands and stroma located haphazardly deep within the myometrium. Similar histological alterations may be found in extrauterine locations such as the rectovaginal septum. The aetiology and pathogenic mechanism(s) responsible for adenomyosis are poorly understood. Both human and experimental studies favour the theory of endomyometrial invagination of the endometrium, although the de-novo development of adenomyosis from Mullerian rests in an extrauterine location is a possibility. The prerequisite for adenomyosis may be triggered or facilitated by either a 'weakness' of the smooth muscle tissue or an increased intrauterine pressure or both. Relatively high oestrogen concentrations and impaired immune-related growth control in ectopic endometrium may be necessary for the maintenance of adenomyosis. Smooth muscle cell hyperplasia and hypertrophy are a reflection of reactive change secondary to ectopic endometrial proliferation. Further studies are needed for insight into the precise aetiology and pathogenesis of adenomyosis. Adenomyosis is a relatively frequent endomyometrial pathology discovered in multiparous women between 40 and 50 years of age. About 2/3 of women are symptomatic with menorrhagia and dysmenorrhoea; 80% of adenomyotic cases are associated with leiomyomata uteri; and in women with endometrial adenocarcinoma, adenomyosis is relatively often seen. Definite diagnosis is made on hysterectomy specimens, although attempts are made at securing preoperative diagnosis by magnetic resonance imaging and myometrial biopsies. Definite treatment of symptomatic women is hysterectomy.     

A new method for measuring menstrual blood loss and its use in screening women before endometrial ablation

OBJECTIVE: 1. To develop and validate a method for measuring menstrual blood loss in a routine setting, and 2. To assess the value of measuring menstrual blood loss before endometrial ablation. DESIGN: A prospective, observational study. SETTING: Four Yorkshire hospitals: The General Infirmary at Leeds, St. James's University Hospital, Leeds, St. Luke's Hospital, Bradford and The Friarage Hospital, Northallerton. PARTICIPANTS: Three hundred and seventy-two women who had been offered endometrial ablation for menorrhagia. MEASUREMENT: Sanitary material was washed with a nonionic detergent in a known volume of water. The haemoglobin in a sample of solution was measured by mixing with sodium carbonate for spectrophotometric analysis. INTERVENTIONS: The menstrual blood loss result was revealed to each women. Electrosurgical endometrial ablation was performed for those who decided to have surgery. MAIN OUTCOME MEASURES: Proportion of women with normal menstrual blood loss (< or = 80 mL) who avoided surgery. Comparison of endometrial ablation outcome in women with and without genuine menorrhagia. RESULTS: Thirty-six women (10%) with normal menstrual blood loss who declined surgery continued to avoid surgery after a mean of 27 months. Two hundred and ninety-two women were followed up for one year after endometrial ablation. Those with genuine menorrhagia (n = 122) were less likely to be dissatisfied (9% vs 18%) (OR 2.5, 95% CI 1.1-4.7) or to require hysterectomy (4% vs 7%) (OR 1.8, 95% CI 0.6-5.2) than women with normal menstrual blood loss (n = 170). CONCLUSIONS: The objective diagnosis of menorrhagia can be undertaken in a routine setting and may provide some women, who have a normal menstrual blood loss, sufficient reassurance to refrain from surgery. Women with genuine menorrhagia have a better outcome after endometrial ablation than those with normal menstrual blood loss.     

Surgical hysteroscopy or hysterectomy in the treatment of benign uterine lesions. What to choose in 1998?

In the past, the treatment of benign uterine lesions required, in many instances, a hysterectomy. These days, most cases can be successfully treated by hysteroscopy. To be reliable, this technique must lead to a significant reduction in the number of hysterectomies performed for benign uterine lesions. The electroresection technique is preferred to that using the Nd-YAG laser because of its lower cost and its equivalent efficacy. By using the uterine perfusion pump device, the risk of resorption syndrome can be reduced to its minimum. Submucosal myomas < 1 cm, benign endometrial hyperplasia and adenomyosis are the commonest benign lesions treated. Dysfunctional uterine bleeding can also be treated by an endometrectomy. A preoperative workup includes a transvaginal ultrasound and a biopsy. This ensures that only benign lesions that are accessible to a hysteroscopy will be submitted to this technique and that no cases of endometrial cancer or atypical hyperplasia would be ignored. This study presents 270 cases of operative hysteroscopy with a follow-up to 4 years. 82.8% of myomatous lesions were treated with success. The results for patients with benign endometrial polyps or benign endometrial hyperplasia are also excellent with only 4.6% and 5.6% rate of secondary surgery respectively. Adenomyosis does not appear to be a good indication for hysteroscopy as only 37% of patients did not need a definitive hysterectomy. Rates of operative complications (post-operative bleeding, uterine perforation, resorption syndrome and difficulty of access) are acceptable and get less frequent as the surgeon experience increases.     

Hysteroscopic endometrium ablation to avoid hysterectomy in "high risk" patients

Hysteroscopic endometrial ablation under maximal anaesthesiological surveillance was performed in 34 high-risk patients to avoid hysterectomy. It was a collective of patients with heavy thrombo-embolic or thrombotic disease, either under permanent anticoagulation due to residual disease or multiple endoprosthetic treatment, or with endogenous coagulopathy. In all these women, hysterectomy was either a relative or an absolute contraindication. In 22 patients, treatment resulted in complete amenorrhoea or at least hypomenorrhoea (without menometrorrhagia) respectively cyclic spotting. In 6 further patients, amenorrhoea was achieved after a repeat procedure. Endometrial ablation was thus successful in 28 of 34 cases. In these patients, hysterectomy with the risk of major or even lethal complications, could thus be avoided. Hysterectomy, however, had to be performed in 2 women with extensive adenomyosis uteri interna. Within two respectively three years after endometrial ablation, two other patients died from causes unrelated to the surgical intervention (cardiac infarction, cerebral haemorrhage). Follow-up ranged from 1 to 5 years. Hysteroscopic endometrial ablation proved an effective therapeutic option in this selected group of patients. Other indications require further study.