Medical Management of Endometriosis, Uterine Fibroids and Dysfunctional Uterine Bleeding

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Summary

Hysterectomy is one of the most common abdominal surgical procedures performed in women today with 600,000 hysterectomies in the USA annually, one in three women undergoing hysterectomy, and 6–20% in European countries. Despite the availability of other conservative medical and surgical options, hysterectomy continues to be used frequently in the treatment of benign gynaecological conditions such as endometriosis, dysfunctional uterine bleeding (DUB) and fibroids. Hysterectomy procedures (abdominal, vaginal, laparoscopic) for benign gynaecological disease are not without risk, with death occurring in 1 of 1000 cases. Other complications of postoperative fever (unexplained 1.4–20%, operative site infections 4–42%; urinary tract infection <1–5%), haemorrhage (intraoperative 0.2–4%; postoperative 0.2–6%; transfusions 2–12%) and injury to adjacent organs (bladder 0.5–2%; bowel 0.1–0.5%; urethra 0.1–0.3%) also occur.1

The reasons for choosing hysterectomy include patient age, extent of disease and fertility aspirations but remuneration, gender of the gynaecologist and social class of the patient may also play a part.2,3 

Fibroids

Better use of medical treatment alone or in combination with more conservative surgical approaches should be considered if the needs of the patient are to be fulfilled. For example, in patients with uterine fibroids, the preoperative use of a gonadatrophin-releasing hormone analogue (GnRHa) such as Zoladex (goserelin) has been shown to induce amenorrhoea in the majority of patients. This is particularly useful in those who have heavy menorrhagia or who are anaemic, where an improvement in haemoglobin concentration has been reported. Preoperative use of GnRHas may also limit blood transfusions and reduce both uterine and fibroid volumes enabling a more conservative surgical approach, or a vaginal or laparoscopic myomectomy with the potential avoidance of hysterectomy.4 Some gynaecologists worry about missing a leiomyosarcoma and would use this as a reason for hysterectomy. However, such tumours occur in 1 in 10,000 cases.

DUB

In patients with DUB, antifibrinolytic agents, coils impregnated with a progestogenic agent and the use of a GnRHa together with addback therapy provide alternative approaches to the long-term treatment of DUB.5 For those not wishing to retain their fertility, prethinning the endometrium with a GnRHa followed by endometrial ablation has resulted in avoidance of further surgical intervention in the majority of cases.6,7

Endometriosis

In the treatment of endometriosis, the following options need to be considered in the earlier stages of the disease to have a greater chance of success with delayed disease recurrence following the end of treatment.8–11

• A combination of conservative surgery with pre- and/or postoperative GnRHa alone or in combination with addback.

• GnRHa alone or with addback.

In addition, some gynaecologists are using GnRHas as a diagnostic tool in symptomatic patients. With the addition of addback, repeat treatments may now be possible making these drugs more useful in the management of this chronic recurring disease.

Conclusion

In the coming years, the gynaecologist will be faced with more younger women presenting with endometriosis or DUB requiring long-term treatment. Many of these women will wish to retain their fertility and for them a hysterectomy will not be an option. It beholds the gynaecologist to consider now, more thoroughly, the other available medical and surgical options. Hysterectomy will still have a place but let us hope it will be used more wisely in the future.

References:

References

1. HILL DJ. Complications of hysterectomy. Bailliere’s Clin Obstet Gynaecol 11(1): 181–197, 1997.

2. LILFORD RJ. Hysterectomy: will it pay the bills in 2007? BMJ 314: 160–161, 1997.

3. DOMENIGHETTI G, CASABIANCA A. Rate of hysterctomy is lower among female doctors and lawyers wives. BMJ 314: 1417, 1997.

4. BENAGIANO G, KIVINEN ST, FADINI R, CRONJE H, KLINTOP S, VAN-DER-SPUY ZM. ‘Zoladex’ (goserelin acetate) and the anemic patient: results of a multicenter fibroid study. Fertil Steril 66: 223–229, 1996.

5. THOMAS EJ, OKUDA KJ, THOMAS NM. The combination of a depot gonadotrophin releasing hormone agonist and cyclical hormone replacement therapy for dysfunctional uterine bleeding. Br J Obstet Gynaecol 98: 1155–1159, 1991.

6. DONNEZ J, VILOS G, GANNON MJ, STAMPE-SORENSON S, KLINTE I, MILLER RM. Goserelin acetate (‘Zolade’) plus endometrial ablation for dysfunctional uterine bleeding: a large randomised, double-blind study. Fertil Steril 68: 29–36, 1997.

7. DONNEZ J, VILOS G, GANNON MJ, STAMPE-SORENSON S, KLINTE I. AZTEC study follow-up: ‘Zoladex’ plus endometrial ablation for dysfunctional uterine bleeding. Gynecol Endocrinol 13: 26 Abstr 52, 1999.

8. SHAW RW, STUDY GROUP. An open randomised comparative sutdy of the effect of goserelin depot and danazol in the treatment of endometriosis. Fertil Steril 58: 265–272, 1992.

9. SHAW RW. A prospective randomised open study comparing goserelin plus surgery and surgery alone in the management of ovarian endometriosis. 5th World Congress of Endometriosis 59; Abs 0-113, 1996.

10. WALLER KG, SHAW RW. Gonadotropin-releasing hormone analogues for endometriosis: recurrence after treatment. Br J Obstet Gynaecol 100: 777, 1993.

11. MOGHISSI KS, SCHLAFF WD, OLIVE DL, SKINNER MA, YIN H. Goserelin acetate (Zoladex) with or without hormone replacement therapy for the treatment of endometriosis. Fertil Steril 69: 1056–1061, 1998.