BMJ 1994;309:979-983 (15 October)

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Randomised trial of hysterectomy, endometrial laser ablation, and transcervical endometrial resection for dysfunctional uterine bleeding

S B Pinion, D E Parkin, D R Abramovich, A Naji, D A Alexander, I T Russell, H C Kitchener 

Aberdeen Royal Infirmary and University of Aberdeen, Aberdeen Correspondence to: Dr S B Pinion, Department of Obstetrics and Gynaecology, Victoria Hospital, Kirkcaldy, Fife KY2 5AH.

Abstract

Objective : To evaluate the effectiveness and safety of endometrial laser ablation and transcervical resection of the endometrium compared with hysterectomy in the surgical treatment of women with dysfunctional uterine bleeding.
Design : Prospective randomised controlled trial.
Setting : Gynaecology department of a large teaching hospital.
Subjects : 204 women who would otherwise have been undergoing hysterectomy for menorrhagia were recruited between August 1990 and March 1992 and randomly allocated to hysterectomy (n=99) or conservative (hysteroscopic) surgery (transcervical resection (n=52) and laser ablation (n=53)).
Main outcome measures : Operative complications, postoperative recovery, relief of menstrual and other symptoms, patient satisfaction with treatment after six and 12 months. Results - Women treated by hysteroscopic surgery had less early morbidity and a significantly shorter recovery period than those treated by hysterectomy (median time to full recovery 2-4 weeks v 2-3 months, P<0.001). Twelve months later 17 women in the hysteroscopy group had had a hysterectomy, 11 for continuing symptoms; 11 women had had a repeat hysteroscopic procedure; 45 were amenorrhoeic or had only a brown discharge; and 35 had light periods. Dysmenorrhoea and premenstrual symptoms improved in most women in both groups. After 12 months 89% (79/89) in the hysterectomy group and 78% (75/96) in the hysteroscopy group were very satisfied with the effect of surgery (P<0.05); 95% (85/89) and 90% (86/96) thought that there had been an acceptable improvement in symptoms, and 72% (64/89) and 71% (68/96) would recommend the same operation to others.
Conclusions : Hysteroscopic endometrial ablation was superior to hysterectomy in terms of operative complications and postoperative recovery. Satisfaction after hysterectomy was significantly higher, but between 70% and 90% of the women were satisfied with the outcome of hysteroscopic surgery. Hysteroscopic surgery can be recommended as an alternative to hysterectomy for dysfunctional uterine bleeding.

Clinical implications

  • Clinical implications

  • Hysteroscopic surgery for dysfunctional uterine bleeding has significantly less morbidity and a significantly reduced hospital stay and recovery period compared with hysterectomy

  • This randomised trial of hysterectomy and hysteroscopic surgery found that 12 months after the conservative surgery around 80% of women were amenorrhoeic or hypomenorrhoeic

  • Dysmenorrhoea and premenstrual symptoms also improved in most women after operative treatment for dysfunctional uterine bleeding

  • Although satisfaction with hysterectomy was significantly higher, around 80% of the women who would currently have been treated by hysterectomy were entirely satisfied with the effect of hysteroscopic surgery

  • Gynaecologists should be encouraged to offer hysteroscopic surgery as first line surgical treatment for dysfunctional uterine bleeding


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