Medical debulking with gonadotrophin-releasing hormone agonists to facilitate vaginal hysterectomy

Although the superiority of vaginal compared to abdominal hysterectomy is well established, most gynaecologists still prefer the abdominal route for removal of benign large uteri >14 weeks. Gonadotrophin-releasing hormone agonists such as goserelin can reduce uterine bulk by up to 60% and was initially used to convert a midline to Pfannenstiel incision in abdominal hysterectomy. The conversion of an abdominal to a potential vaginal hysterectomy by uterine size reduction would prove advantageous, and the authors present data from a case control study of 12 women with uteri >14 weeks who successfully underwent vaginal hysterectomy following preoperative treatment with goserelin. Women scheduled for hysterectomy for menorrhagia with non-prolapsing clinical uterine size of >14 weeks were offered an attempt at vaginal hysterectomy after pre-treatment with goserelin. A group of women with comparable uterine size who underwent abdominal hysterectomy for similar indication served as control. Pre- and postoperative data such as haemoglobin, myoma size, uterine weight, duration of procedure and complications were collected prospectively. Both groups had comparable preoperative haemoglobin, subjective preoperative uterine bulk (median 16 weeks) and body mass index. The vaginal hysterectomy group received a median of two goserelin injections prior to surgery, and the uterine weight at histology was similar in both groups (median 580 vs 609 g, p < 0.05). The duration of surgery was twice as long in vaginal compared to abdominal hysterectomy (153.7 vs 85 min, p < 0.05), but analgesia use and the length of inpatient stay were lower in the study group (2.62 vs 3.5 days, p < 0.05). In women with >14 week-size uteri, treatment with gonadotrophin agonists reduces uterine size sufficiently to allow safe vaginal hysterectomy. Although duration of surgery was longer, women who underwent vaginal hysterectomy required less analgesia and had shorter inpatient stay.