Skip the meds and cut to the chase

New research shows that hysterectomies, not meds, vastly improve quality of life in premenopausal women with abnormal uterine bleeding

By William D Donaldson

Hysterectomy, one of the most common of all surgical procedures, has traditionally achieved high reported rates of satisfaction in premenopausal women suffering from abnormal uterine bleeding. But gynecologists know it can have unfortunate long-term repercussions such as urinary incontinence and early onset of menopause, and are often more wary of the procedure.

As a result, the number of hysterectomies performed in Canada has fallen by about a third in the last 25 years. In 1998-99, 462 hysterectomies were performed per 100,000 women aged 20 or older.

In the US, hysterectomy rates tend to be significantly higher than in other developed nations, particularly in poorer parts of the country and among underprivileged sections of the population. Concern over this discrepancy led a team of American doctors to follow patients who underwent hysterectomy for abnormal uterine bleeding, and compare them to women who took medical treatment for the same condition. The results were published in the March 24 issue of the Journal of the American Medical Association.

All 63 subjects in this trial underwent drug therapy without success. In fact, all had tried the new gold standard treatment, medroxyprogesterone acetate, and many were recruited directly from a trial of that progestin. The median duration of symptoms in these patients was four years.

Only patients who were willing to be randomized into either the hysterectomy or the medical treatment groups were eligible. Naturally, many women were concerned about their treatment, a factor that explains the small sample size. After randomization, half of these patients underwent hysterectomy and half received drug treatment.

In the medication group, participating gynecologists were free to choose the exact treatment. The preferred regimen was a low-dose oral contraceptive, with a prostaglandin synthetase inhibitor added for five days each month during menses.

What the study lacked in numbers, it made up for in the thoroughness of the testing for patient satisfaction and quality of life. A number of validated questionnaires were used, such as the Mental Component Summary and the Physical Component Summary, as well as other endpoints.

The hysterectomy patients' self-reported physical well-being naturally dipped immediately following surgery, but their mental well-being climbed faster than that of patients in the medication group. By six months, the hysterectomy group reported significantly greater improvements in terms of satisfaction, symptom resolution, sexual desire, sleep problems and overall health.

By the end of followup at 24 months, just over half of the women in the medication group had requested and received hysterectomies because they'd seen the clear benefits of surgery. Sure enough, by the one-year point this group's outcome scores had climbed to a point where there was no significant difference from the hysterectomy group in any measure except sexual desire.

"Women who were assigned to take the alternate medical regimen and who continued on medication for the entire two-year study period also showed improvements," said lead author Dr Miriam Kuppermann of the University of California at San Francisco. "However, these improvements were smaller in magnitude than those of women who underwent hysterectomy."