Clinical practice guideline for abnormal uterine bleeding: hysterectomy versus alternative therapy

Study ObjectiveTo develop recommendations in selecting treatments for abnormal uterine bleeding (AUB).DesignClinical practice guidelines.SettingRandomized clinical trials compared bleeding, quality of life, pain, sexual health, satisfaction, the need for subsequent surgery, and adverse events between hysterectomy and less-invasive treatment options.PatientsWomen with AUB, predominantly from ovulatory disorders and endometrial causes.InterventionsOn the basis of findings from a systematic review, clinical practice guidelines were developed. Rating the quality of evidence and the strength of recommendations followed the Grades for Recommendation Assessment, Development, and Evaluation system.Measurements and Main ResultsThis paper identified few high-quality studies that directly compared uterus-preserving treatments (endometrial ablation, levonorgestrel intrauterine system and systemically administered medications) with hysterectomy. The evidence from these randomized clinical trials demonstrated that there are trade-offs between hysterectomy and uterus-preserving treatments in terms of efficacy and adverse events.ConclusionSelecting an appropriate treatment for AUB requires identifying a woman’s most burdensome symptoms and incorporating her values and preferences when weighing the relative benefits and harms of hysterectomy versus other treatment options.     

A systematic review comparing hysterectomy with less-invasive treatments for abnormal uterine bleeding

Study ObjectiveTo compare hysterectomy with less-invasive alternatives for abnormal uterine bleeding (AUB) in 7 clinically important domains.DesignSystematic review.SettingRandomized clinical trials comparing bleeding, quality of life, pain, sexual health, satisfaction, need for subsequent surgery, and adverse events between hysterectomy and less-invasive treatment options.PatientsWomen with AUB, predominantly from ovulatory disorders and endometrial causes.InterventionsSystematic review of the literature (from inception to January 2011) comparing hysterectomy with alternatives for AUB treatment. Eligible trials were extracted into standardized forms. Trials were graded with a predefined 3-level rating, and the strengths of evidence for each outcome were evaluated with the Grades for Recommendation, Assessment, Development and Evaluation system.Measurements and Main ResultsNine randomized clinical trials (18 articles) were eligible. Endometrial ablation, levonorgestrel intrauterine system, and medications were associated with lower risk of adverse events but higher risk of additional treatments than hysterectomy. Compared to ablation, hysterectomy had superior long-term pain and bleeding control. Compared with the levonorgestrel intrauterine system, hysterectomy had superior control of bleeding. No other differences between treatments were found.ConclusionLess-invasive treatment options for AUB result in improvement in quality of life but carry significant risk of retreatment caused by unsatisfactory results. Although hysterectomy is the most effective treatment for AUB, it carries the highest risk for adverse events.     

Emergency peripartum hysterectomy: The experience of a tertiary referral hospital

Objective(s)The aim of this study was to review the frequency, indication, associated risk factors, rates of maternal morbidity and mortality as well as neonatal outcome after emergency peripartum hysterectomy at a tertiary care referral hospital.Study designA retrospective observational study carried out from November 2008 to 2011.Patients and methodsThe study comprised of 29 patients at Mansoura University Hospitals a tertiary referral hospital Egypt. Frequency, indications, associated risk factors and maternal morbidity and mortality were reported as well as neonatal survival and outcome.ResultsThe frequency of emergency peripartum hysterectomy in our study period was (29/10000 deliveries = 0.29%) and the mean age and parity of the patients were 36.4 ± 8.9 years and 2.9 ± 1.56 respectively. The mean gestational age at the time of delivery was 35.45 ± 2.9 weeks. Twenty-five patients (86.2%) had a history of previous cesarean delivery(ies) meanwhile the others (4/29 = 13.8%) had vaginal delivery(ies). Abnormally adherent placenta and severe postpartum hemorrhage were the main indication for the procedure (11/29 = 37.9%). Other indications included rupture uterus (7/29 = 24.1%), severe uterine atony (7/29 = 24.1%), multiple uterine fibroid (3/29 = 10.3%) and 1 case with severe uterine infection (1/29 = 3.4%). All women received blood transfusion, 5 cases (17.2%) required intensive care unit admission, and 3 cases (10.3%) developed intraoperative arrest, 5 patients (17.2%) had urinary bladder injuries and 2 cases (6.8%) had wound infection. The maternal mortality occurred in 4 cases (13.8%) while overall neonatal survival rate was 86.2% (25/29).ConclusionEmergency peripartum hysterectomy is still high in our locality representing a significant risk for the mother and the baby; hence health care authorities should raise the problem to decrease this burden.     

Mandated preterm delivery: its prevalence and impact at a tertiary referral center

Objective : To determine the prevalence and impact of mandated preterm deliveries at a tertiary referral center. Methods : A chart review was conducted at our institution on all livebirths from 24 weeks to completion of 37 weeks' gestation between 1 January 1998 and 31 December 1999. Mandated delivery was defined as intentional intervention because of a deteriorating maternal or fetal condition. Reasons for intervention and intrapartum courses were compared with two other preterm groups (premature ruptured membranes, spontaneous labor) delivering during the same period. Statistical analyses included the Student t test, univariate ANOVA, &#104 2 test and Mann-Whitney test. Results : A total of 894 pregnancies delivered preterm, with 132 (14.8%) being mandated. Primary reasons for mandated delivery included severe pre-eclampsia (69.0%), vaginal bleeding (11.4%), deteriorating maternal illness (10.6%), worsening fetal growth restriction (6.1%) or major fetal malformation (3.0%). Delivery at less than 34 weeks was more common in the mandated group (68.9%) than in the ruptured membranes group (41.2%, p < 0.005) or in the spontaneous labor group (46.5%; p < 0.01). Cesarean section rates were higher in the mandated group (69.7%) than in the ruptured membranes group (18.3%; p < 0.001) or in the spontaneous labor group (21.5%; p < 0.001). The presence of an unfavorable cervix, unsuccessful trial of labor, non-cephalic fetal presentation, or fetal intolerance of labor explained the high rate of surgery. Conclusions : Conditions mandating delivery accounted for 14.8% of all preterm births. Mandated delivery is associated with a greater need for delivery before 34 weeks, often by Cesarean section.     

Impact of payer status on treatment of cervical cancer at a tertiary referral center

Objectives

The study aims to determine the impact of payer status on the likelihood of receiving definitive treatment for invasive cervical cancer at a tertiary medical center.

Methods

All consecutive patients presenting to Johns Hopkins Hospital with a diagnosis of invasive cervical cancer between 1/1/95-12/31/08 were retrospectively identified from the tumor registry. Demographic and clinical information were abstracted from the medical record. Payer status was categorized as private, public, no insurance, or unknown. Treatment was defined as surgery, chemo-radiation, chemotherapy, radiation, or no definitive therapy. The likelihood of receiving no definitive therapy was analyzed using Pearson chi-square analysis, univariate and multivariate models.

Results

A total of 306 patients were identified. Median age was 47 and 60% of patients had early stage disease at diagnosis (stages IA-IIA). Fifty-six percent of the cohort had private insurance, 34% had public insurance, and 6% had no insurance. Having no insurance was the single most significant risk factor associated with receiving no standard therapy. While 7% of privately insured and 4% of publicly insured patients did not receive definitive therapy, 16% of uninsured patients did not receive definitive treatment. In multivariate analysis controlling for age, race, stage, histology, and comorbidities, uninsured payer status was a significant and independent predictor of receiving no definitive treatment (OR 8.01, CI 1.265-50.694, p = 0.027) than patients with public insurance.

Conclusions

In this study, uninsured payer status was significantly associated with a higher likelihood of not receiving standard therapy for cervical cancer. Additional studies are warranted to characterize specific barriers to care for this at-risk population.     

Mandated preterm delivery: its prevalence and impact at a tertiary referral center.

OBJECTIVE: To determine the prevalence and impact of mandated preterm deliveries at a tertiary referral center. METHODS: A chart review was conducted at our institution on all livebirths from 24 weeks to completion of 37 weeks' gestation between 1 January 1998 and 31 December 1999. Mandated delivery was defined as intentional intervention because of a deteriorating maternal or fetal condition. Reasons for intervention and intrapartum courses were compared with two other preterm groups (premature ruptured membranes, spontaneous labor) delivering during the same period. Statistical analyses included the Student t test, univariate ANOVA, X2 test and Mann-Whitney test. RESULTS: A total of 894 pregnancies delivered preterm, with 132 (14.8%) being mandated. Primary reasons for mandated delivery included severe pre-eclampsia (69.0%), vaginal bleeding (11.4%), deteriorating maternal illness (10.6%), worsening fetal growth restriction (6.1%) or major fetal malformation (3.0%). Delivery at less than 34 weeks was more common in the mandated group (68.9%) than in the ruptured membranes group (41.2%, p < 0.005) or in the spontaneous labor group (46.5%; p < 0.01). Cesarean section rates were higher in the mandated group (69.7%) than in the ruptured membranes group (18.3%; p <0.001) or in the spontaneous labor group (21.5%; p < 0.001). The presence of an unfavorable cervix, unsuccessful trial of labor, non-cephalic fetal presentation, or fetal intolerance of labor explained the high rate of surgery. CONCLUSIONS: Conditions mandating delivery accounted for 14.8% of all preterm births. Mandated delivery is associated with a greater need for delivery before 34 weeks, often by Cesarean section.     

The management of perimenopausal abnormal uterine bleeding

Abnormal uterine bleeding around the time of the menopause is common and may be a sign of premalignancy such as endometrial hyperplasia or even endometrial carcinoma. All such women therefore need uterine assessment, which may include transvaginal scan combined with endometrial biopsy, hysteroscopy or a sonohysterogram. Having excluded (pre) cancer, treatment can then be offered. Medical treatment options include tranexamic acid to reduce blood loss, low-dose contraceptive pills, the levonorgestrel intra-uterine device and cyclic progestins. Surgical options include resecting sub-mucus fibroids hysteroscopically, endometrial ablation and hysterectomy.     

The management of perimenopausal abnormal uterine bleeding

Abnormal uterine bleeding in the perimenopause is a common gynaecological disorder and may affect 20–50 % of all women. It may be the first sign of premalignant or malignant disease. All women require assessment by means of pelvic ultrasound and an endometrial biopsy to exclude sinister pathology, identify other causes, and plan appropriate treatment. Pharmacological treatment includes antifibrinolytics, non-steroidal anti-inflammatories, combined hormonal contraception, cyclical progestogens and the levonorgestrel intrauterine system (LNG – IUS). Second line treatments may include endometrial ablation, uterine artery embolization, myomectomy or hysterectomy depending on the nature of the pathology. Minimal access techniques though the hysteroscopic, laparoscopic/robotic or vaginal route are increasingly used as the preferred surgical options. Novel treatments, either pharmacological or in the outpatient setting are likely to have a significant contribution in the future.     

Current treatment options for abnormal uterine bleeding: an evidence-based approach

Heavy menstrual bleeding is the predominant complaint in women with abnormal uterine bleeding. Treatment options are drug therapy, and first- and second-generation endometrial resection. Many women will subsequently have a hysterectomy. Uterine fibroids are the most common solid pelvic tumours in women, and although many fibroids seem to cause no symptoms, they can have serious adverse effects and impact on quality of life. As women postpone having children, gynaecologists will have to manage fibroids and polyps in a conservative manner. The past decade has witnessed the development of highly sophisticated diagnostic and therapeutic technology for women suffering from menorrhagia, fibroids and polyps, including minimally invasive uterine therapy. The tools currently at our disposal permit greater management flexibility, which must be tailored to the individual clinical situation. This chapter reviews the evidence-based approach and minimally invasive therapy.     

Hysteroscopic evaluation of intrauterine progesterone contraceptive system as a treatment for abnormal uterine bleeding

Intrauterine Progesterone Contraceptive System has been used in twenty patients aged 45 to 52, affected by dysfunctional uterine bleeding due to glandular hyperplasia (6 cases), focal glandular hyperplasia (8 cases), cystic hyperplasia (4 cases) and adenomatous hyperplasia (2 cases). Hysteroscopy and endometrial biopsy were performed every two months after insertion of IPCS. Complete regression or clear improvement were observed in all cases. The question if regression may be considered permanent or temporary remains to be answered.     

Single port access laparoscopic subtotal hysterectomy using contained manual morcellation: Experience from a tertiary referral center in Taiwan

Objective

To describe the surgical outcomes of single port access laparoscopic subtotal hysterectomy (LSH) using in-bag manual morcellation and evaluate the feasibility of this procedure.

微波子宫内膜去除术治疗异常子宫出血的临床观察

目的探讨微波子宫内膜去除术(MEA)治疗异常子宫出血的疗效、适应证和并发症。方法应用MEA治疗良性病变所致异常子宫出血患者168例,术前行刮宫术薄化子宫内膜,然后“Z”字形烧灼宫腔后再以“W”形烧灼宫腔,术后1、3、6、12、24个月随访患者的月经、贫血症状改善及并发症发生情况。结果平均手术时间为(286±75)s;平均随访时间(22±6)个月。绝经前患者156例中,术后闭经97例(62.2%),月经正常56例(35.9%),少量不规则阴道出血3例(1.9%);治疗满意率为98.1%(153/156)。119例随访到术后2年以上,疗效稳定。107例合并贫血,术前血红蛋白为(83±24)g/L,术后3个月升至(117±18)g/L,手术前后比较,差异有统计学意义(P<0.01)。痛经改善率为74.5%(35/47)。绝经后患者12例,术后均无出血。168例中47例合并严重内科疾病,全部手术成功,术中无并发症发生。术后发生子宫内膜炎12例,2例宫腔积血,1例因输卵管绝育子宫内膜去除术后综合征行子宫切除术。结论MEA操作简单、安全、疗效好,适用于多种良性疾病所致的异常子宫出血。尤其适用于有严重内科合并症的患者。充分且完整地破坏子宫内膜全层,是治疗成功的关键。严格掌握适应证可减低并发症的发生。     

宫腔镜检查术在异常子宫出血中的诊断价值

探讨宫腔镜检查术在各种异常子宫出血中的诊断价值。方法应用宫腔镜检查异常子宫出血患者３１４例,术中行定位取材或诊断性刮宫。结果宫腔镜诊断子宫内膜息肉的敏感性为９６．１５％,子宫粘膜下肌瘤为８５．７１％,子宫内膜增殖症为６０．９４％,子中内膜癌６０％,结论宫腔镜检查异常子宫出血,可提高对子宫内膜肉及粘膜子下宫肌瘤的诊断率,尽管对子宫内膜增殖症及宫内膜癌的舔生与单纯诊刮相似,但可观察到更详细的形态学变经     

A patient-preference cohort study of office versus inpatient uterine polyp treatment for abnormal uterine bleeding

Uterine polyps can cause abnormal bleeding in women. Conventional practise is to remove them under general anaesthesia but advances in technology have made it possible to perform polypectomy in the office setting. We conducted a patient-preference study to explore women’s preferences for treatment setting and to evaluate the effectiveness and treatment experience of women undergoing uterine polypectomy. Three hundred ninety-nine women with abnormal uterine bleeding who were found to have uterine polyps at diagnostic hysteroscopy were recruited. Office polypectomies were performed in office hysteroscopy clinics, and inpatient procedures were undertaken in operating theatres. Three hundred twenty-four of 399 (81 %) expressed a preference for office treatment. There was no difference found between office treatment and inpatient treatment in terms of alleviating abnormal uterine bleeding as assessed by patients and in improving disease-specific quality of life. Acceptability was lower and patient pain scores were significantly higher in the office group. When offered a choice of treatment setting for uterine polypectomy, patients have a preference for office over inpatient treatment. Ambulatory gynaecology services should be available within healthcare systems to meet patient demand.     

Instrumentation and distention media for the hysteroscopic treatment of abnormal uterine bleeding

New hysteroscopes and resectoscopes with continuous-flow designs have greatly facilitated diagnostic and therapeutic hysteroscopy. Saline is the ideal distending medium for hysteroscopic procedures in which mechanical or bipolar instruments are used; 5% mannitol may be the safest medium for resectoscopic surgery. Regardless of the medium chosen, careful fluid monitoring is essential.