Alternatives to Hysterectomy
The indications for hysterectomy discussed are not universally accepted, as other conservative approaches may be considered first. Current alternatives are so effective that they have had a direct bearing on the negative tendency in hysterectomy rates. Medical treatments can be considered as a first step in the management of menorrhagia, as they can reduce the growth of uterine volume and stop hypermenorrhea and menstrual bleeding prior to surgery. However, they tend to be only temporarily effective and often have important side effects. Other more conservative alternatives that can be offered include endometrial ablation, the progestin intrauterine device, myomectomy and uterine embolization.
Sexual steroids are widely used for controlling uterine bleeding. Oral estro–progestin combinations or even progestin alone exert great control over menorrhagia and dysmenorrhea, but their efficacy is short rather than long term.
Gonadotropin-releasing hormone agonists can lead to amenorrhea and a diminishment of myoma size in 35–65% of cases within 3 months of treatment, thereby creating a menopause status in the short term. However, the significant menopause symptoms (i.e., vasomotor effect and negative impact on bone density) and the gradual recurrent growth of myomas associated with cessation of treatment rule out the long-term use of these drug.
Mifepristone, an antiprogesterone agent, has proved its usefulness in controlling the symptoms of leiomyoma. Several studies of high-dose mifepristone have reported a reduction of leiomyoma volume of 26–74%, which is comparable to that achieved with analogs. Although amenorrhea is a common adverse effect, no negative impact on bone mineral density has been demonstrated, while the presence of de novo endometrial hyperplasia and elevation of transaminase levels are the most frequent side effects. Further studies are required for this agent to be included in the medical algorithm treatment of menorrhagia.
Myomectomy is one of the most effective options for when aiming to spare fertility. Although a surgical approach, the risks it represents are similar to those of hysterectomy. It is a safe and effective treatment of menorrhagia, with a resolution rate that has reached 80%. The recurrence rate of leiomyoma is estimated at 11% 1 year after surgery and up to 80% after 8 years. The reoperation rate is lower, at 6.7% at 5 years and 16% at 18 years, with a definite hysterectomy rate of approximately 10%. One of the risks that must be assumed with this approach is an unexpected hysterectomy owing to surgical complications, in particular, intraoperative bleeding.
In the past, myomectomy has usually been performed abdominally but, nowadays, a laparoscopy/hysteroscopy is feasible. Owing to the complex nature of dissection and suturing, a high grade of surgical skill is required.
Hysteroscopy constitutes another endoscopic method of myoma management and has a good outcome when these are submucous. Myomas are the cause of approximately 10% of uterine bleeding and pain, and are successfully removed in a high percentage of cases with this technique (85–95%). As with abdominal/laparoscopic myomectomy, secondary surgery is required in approximately 5–15% of cases. Effectiveness decreases over time, with a success rate of 76% at 5 years follow-up, and other procedures, such as endometrial ablation, are often necessary.
Several new technologies may reduce the need for hysterectomy and, among them, endometrial ablation is currently one of the most employed. We can distinguish between two methods of this technology: selective and nonselective.
Selective methods include endometrial resection with a urological type resectoscope, a rollerball or laser ablation. All require previous endometrial preparation in order to diminish the thickness of the endometrium, usually with a gonadotropin-releasing hormone agonist. Observational studies and randomized trials have found no differences between the clinical outcomes of the different techniques employed.[99–101] Generally, these outcomes are positive, with high satisfaction rates (~75%) and QoL measures and a positive balance in post-treatment hemoglobins being reported. This approach has been compared with hysterectomy in randomized trials, yielding better outcomes in operation time, hospital stay and direct costs.[102,103]
These treatments are known as first-generation endometrial ablation techniques, which distinguishes them from the wide range of new methods for removing or destroying the endometrium more rapidly and safely. They do not depend heavily on the skill of the surgeon, contrary to selective methods, which explains the positive development of these new technologies. Many nonselective ablation techniques have been developed. In short, a thermal probe is introduced inside the uterine cavity in order to raise the endocavity temperature sufficiently during a short interval (10–15 min) during which the endometrial tissue is destroyed. This procedure can also be performed with a frozen probe. A recently updated Cochrane review on endometrial-destruction techniques concluded that efficacy and user satisfaction with the first- and second-generation endometrial destruction techniques are similar. It is expected that, in the future, they will be used in day-out protocols with a similar efficacy to that of selective endometrial procedures and at a lower cost.
However, hysterectomy produces significantly better patient-satisfaction rates than endometrial ablation. How can this be explained? One of the problems of ablation is the need for further surgical intervention with time. It is estimated that 15% of cases undergo a second endometrial ablation within 5 years, while 20% of patients eventually undergo a hysterectomy, both of which increase the direct cost of the process, thus calling into question the real efficacy of the procedure.[107–109]
Levonorgestrel-releasing Intrauterine Device
The LNG-IUD is one of the most important advances in the conservative management of menorrhagia. Its simplicity, efficacy and patient security offer a very attractive alternative to patients with hypermenorrhea, with or without myomas or adenomyosis. This device releases levonorgestrel over a period of 5 years through a rate-limiting membrane (20 µg/day). In addition, it is probably the best reversible contraception method, with a Pearl index of 0.11. Its mechanism works by inducing an endometrial atrophy, with an average reduction in menstrual blood loss of 90% over 6 months, and with 20–50% of patients experiencing amenorrhea in the first 2 years after insertion. Its benefits on QoL are evident and its outcome has been compared to that of hysterectomy, producing the same improvement in health-related QoL at 12-month follow-up at less than a third of the cost. Meta-analysis of trials comparing LNG-IUD with first-generation endometrial ablation techniques have shown that satisfaction rates are similar, despite the former producing a smaller reduction of blood loss and lower amenorrhea rate. In this way, LNG-IUD is probably the best of the conservative approaches to treating menorrhagia.
In spite of the aforementioned evidence, medical therapy (e.g., progestins and anovulatories) is sometimes preferred as an economical option in the treatment of menorrhagia. However, the costs associated with long-term use of oral therapy can be surprisingly high, while LNG-IUD has been shown to incur the lowest cost among available therapies. That said, in many countries, oral progestins continue to be the most frequently prescribed medical therapy for menorrhagia.
Uterine Artery Embolization
Transcatheter bilateral uterine artery embolization is a relatively new conservative treatment of symptomatic myoma but one that is rapidly becoming common.
The procedure is performed under local anesthesia or sedation, and an angiography catheter is guided percutaneously via the patient's femoral artery into the ipsilateral or contralateral uterine artery. Particles of polyvinyl alcohol 300–500 µm are injected in boluses until blood flow has ceased. The catheter is then withdrawn from the uterine artery, and the procedure is then repeated with the contralateral uterine artery. Randomized trials regarding the efficacy of uterine artery embolization are yet to be reported. Reduction of uterine and myoma size is one of the easiest and most objective measures of confirming the efficacy of this treatment using ultrasound scan or MRI. However, menorrhagia and its symptoms, which are clinical, are the most relevant aspects to evaluate, and these have a resolution rate of almost 90% at short-term follow-up. One randomized trial demonstrated this method to be the most economic strategy for women with symptomatic myoma.
This procedure represents some complications that should be taken into account. One technical difficulty is the impossibility of cannulating the artery owing to anatomical variations, tortuosity of the vessels or inadvertent vessel damage. Fibroid expulsion constitutes another drawback in approximately 10% of cases, particularly in cases of submucous myomas. This can cause a good deal of pain due to infection with prolonged leucorrhea, and can require surgical intervention when expulsion is incomplete. Uterine embolization induces pain in variable degrees because of myoma ischemia, requiring treatment with opiates, which rules out the day-out procedure. Another important concern regarding the side effects of this procedure is secondary amenorrhea due to ovarian compromise. For clinicians, these complications represent barriers to the implantation of this procedure, with the exception of patients with menorrhagia, for whom it offers an option of conservative management. Nevertheless, the complication rate associated with uterine artery embolization is lower than that of hysterectomy and, if the management of events following embolization is improved, particularly with respect to those regarding fertility, this approach can constitute an effective alternative.
The rationale of ultrasound-focused therapy is based on ultrasound-energy penetration of a defined tissue (in our case, a myoma), which produces a structural and functional alteration of that tissue. This targeted treatment causes irreversible cell damage, leading to coagulative necrosis due to thermal and nonthermal effects produced in the exposed area. The depth between the skin and the targeted tissue is a determining aspect: when too deep, the ultrasound energy attenuates exponentially. For correct and effective use, an endoscopic probe or interstitial applicator is necessary, usually with a MRI/ultrasound-guided system. Although few trials with this method have been reported until now, the results are encouraging. Shrinkage of the myoma volume is often low, with a rate of 12–48% being reported, but early clinical improvement (e.g., pain or heavy bleeding) is significant. Long-term results are necessary in order to discern its real cost–effectiveness.
Expert Rev of Obstet Gynecol. 2009;4(6):673-685. © 2009 Expert Reviews Ltd.
Cite this: Overview of Current Trends in Hysterectomy - Medscape - Nov 01, 2009.