Hysteroscopic surgery as an alternative to hysterectomy in the treatment of dysfunctional uterine bleeding

Abstract

The basis of this thesis is a prospective randomised trial comparing hysterectomy (n=99) with two methods of hysteroscopic surgery, endometrial laser ablation (n=53) and transcervical resection of the endometrium (n=52), in the treatment of dysfunctional uterine bleeding. Two women in each group refused the allocated treatment, but analysis was by intention to treat. The main outcome measures were efficacy in the relief of menstrual and related symptoms, operative complication rates, postoperative recovery, the effect of treatment on other symptoms, and on psychosocial morbidity, and patient satisfaction.In the hysterectomy group, all women (except one treated hysteroscopically) were amenorrhoeic at 12 months; in the hysteroscopy group, 93 (97%) were either amenorrhoeic or had light menstrual loss, although 32 women required a second procedure to achieve this status. The remainder had loss similar to that before treatment. At 12 months 13 (15%) of the hysterectomy group and 46 (58%) of the hysteroscopy group had continuing cyclical abdominal pain, although dysmenorrhoea improved in the majority.Major operative complications were rare in all groups, but minor morbidity, principally infection, was significantly more common following hysterectomy (difference 32%, 95% CI 20-44%, P< .001). There were major differences in postoperative recovery rates, with median time to self-reported recovery being two to three months in the hysterectomy group compared with two to four weeks in the hysteroscopy group (P< .0.001).Premenstrual symptoms improved in both groups and, although significantly less common in the hysterectomy group at six months, differences were no longer present at 12 months. Similarly there were no differences between the groups in the incidence of urinary or bowel symptoms, dyspareunia or menopausal symptoms.Anxiety and depression were common preoperatively, but improved significantly postoperatively, with a significant difference in favour of hysterectomy at six months, but no difference between the groups at 12 months. Other aspects of psychosocial functioning were studied and found to be no different between the two groups.Using self-reporting questionnaires, 89% of the hysterectomy group and 78% of the hysteroscopy group were very satisfied with treatment (difference 11%, 95 % CI 8- 13%, P< .05) and 95% and 90% respectively felt there had been an acceptable improvement in symptoms (P< .001). The same operation was recommended by 72% and 71% respectively (not significant).In conclusion, all but five women were satisfied with their outcome at 12 months, although, in the hysteroscopy group, 22 (21 %) had required a second operation for continuing symptoms. Those in the hysteroscopy group enjoyed a greatly reduced recovery time and significantly less postoperative morbidity. The data suggest that hysteroscopic surgery is a valuable alternative to hysterectomy for the treatment of dysfunctional uterine bleeding.