Abstract
“The advantages of hysterectomy compared with endometrial ablation alone have been widely demonstrated and are essentially based on a complete resolution of the condition and improved patient satisfaction.”
One of the most remarkable events of the human body occurs in the uterus: within it the menstrual cycle is one of the most fascinating occurrences in the human body. Each month, in the absence of fecundation, a complete shedding and regeneration of the endometrium is witnessed. This process recurs hundreds of times; it is therefore obvious that anomalies may occur throughout the course of a woman's life [1].
The standard definition of abnormal bleeding, when it exceeds 80 ml per menstrual cycle, is regularly different from the evaluation of the patient, which is often more decisive in choosing the appropriate clinical treatment [2]. The concept of abnormal uterine bleeding falls into a range of conditions, the assessment of which is strongly influenced by the subjectivity of the patient.
However, if we take into account the statistics, the problem does not appear to be merely of a marginal nature. In fact, 25% of American women are faced with having to undergo a hysterectomy.
“…hysterectomy does not come without physical and psychological consequences, as well as short- and long-term side effects, such as early menopause and an increased risk of urinary incontinence.”
In the UK, each year, one in 20 women between 30 and 49 years of age sees a general practitioner for abnormal uterine bleeding [2]. In the USA, surgical treatment, that is hysterectomy, is considered to bring resolution for approximately 600,000 women per year [3]. In the UK, 100,000 patients undergo a hysterectomy each year [4].
These figures suggest that the indication is not necessarily that of a malignant condition. In fact, 90% of hysterectomies are performed in cases of abnormal uterine bleeding in women of childbearing age [4].
The basic pharmacologic treatment alone bears significant costs for the health budget of a state [2], and has little or scarce effectiveness, since 60% of women end up having a hysterectomy within 5 years [5].
However, it is paramount for the patient to fully understand all of the treatment options and whether they might all be equally effective.
The NICE guidelines on heavy menstrual bleeding recommend that within a spectrum of options that range from medical therapy to surgery, hysterectomy should not normally be considered as a first-choice treatment, but should come into play only after trying alternative routes [6].
If the patient does not request the preservation of fertility, a surgical treatment, albeit conservative, has greater efficacy than medical therapy alone [7].
In 76% of cases, patients are satisfied with the surgical treatment, even though conservative, compared with 27% of those undergoing medical therapy alone [1].
It is necessary to question why patients would choose to undergo demolitive surgery, rather than a conservative surgical treatment. The answers are likely to be multifaceted and require a rather extensive evaluation.
It is widely accepted that if a woman undergoes a hysterectomy, she does so only because of the awareness that it will definitively solve her problem [8]. However, despite undeniable success in the resolution of the disease, it is important to point out that hysterectomy does not come without physical and psychological consequences, as well as short- and long-term side effects, such as early menopause [9,10] and an increased risk of urinary incontinence [11–13]. It must be emphasized that in a third of cases the removed uterus is perfectly normal [14]. We must not overlook the fact that many women prefer a conservative treatment.
Which one is the most suitable course of action: hysterectomy or endometrial ablation? In other words: can a less radical surgery always solve the problem, and when might it be preferred? The comparison would certainly be easier if hysterectomy was a unique procedure. In reality, the different techniques make the comparison difficult, not only with endometrial ablation, but also among hysterectomic procedures themselves. Perhaps a more appropriate comparison is that between the more conservative techniques: laparoscopic hysterectomy and endometrial ablation [15].
Both clinical and psychological aspects play a role in this choice [16]. The uterine pathology is obviously indicative of the surgical path to follow:
Hysterectomy is second only to cesarean section among surgical interventions carried out in women of fertile age [17]. Treatment is required in 35–64% of the 70,000 patients with dysfunctional uterine bleeding in the UK, and needless to say it is the only technique that has a 100% success rate [17]. The belief that a hysterectomized woman is psychologically undermined after undergoing a hysterectomy is beginning to falter. Several recent studies have shown that often a woman's psychological condition is not altered by the surgery, but rather it had already developed such alterations before this event. This aspect had never been considered in earlier studies [16].
Conservative treatment (i.e., endometrial ablation), requires the complete removal of the basal layer in order to stop the strong regenerative capacity of the tissue. The first attempt to destroy the endometrium dates back to the early 1980s, although it took almost a decade to see some satisfactory results [1]. The number of supporters has increased over the years.
“Hysterectomy has intraoperative complications in one patient out of 30, and postoperative ones in one patient out of ten.”
Endometrial ablation can be performed under hysteroscopic control or through the use of disposables that produce heat energy to induce necrosis of the entire endometrium. The patented devices operate differently depending on whether one is looking at cryoablation, hot saline solution irrigation, hyperthermy laser diode (heating), microwave ablation, or the photodynamic therapy heated balloon system. The employment of devices reduces the risk of intraoperative complications and, in theory, should increase the success of the conservative surgical treatment [18]. In fact, in expert hands the use of such devices appears comparable to the effectiveness of ablation performed with a resectoscope [17].
The resolution of a problem, however, requires specific treatments. Not all forms of abnormal uterine bleeding are, in fact, solved by endometrial ablation.
The patient must be properly assessed before being treated surgically and she must also be aware that, although conservative, this technique leads to loss of reproductive capacity [1]. Ablation should be considered if a patient of childbearing age has already renounced pregnancy.
The advantages of a conservative treatment are associated with reduced invasiveness, resulting in less trauma and shorter hospital stay, as well as minimizing the need for general anesthesia. In addition, there appears to be a substantial reduction in the management costs of these patients, to the advantage of hospital budgets [2]. In fact, the latter is valid only for patients whose initial treatment is definitive. Long-term follow-up studies show that often patients require a second ablation treatment or hysterectomy.
The overall incidence of complications after endometrial ablation is between 1.25 and 4.8% [17,19]. Hysterectomy has intraoperative complications in one patient out of 30, and postoperative ones in one patient out of ten [20].
Endometrial ablation is associated with a lower operative complication rate with sepsis, hemorrhage, blood transfusion, urinary retention, postoperative anemia, vault hematoma and wound hematoma [21].
The most common complication is intravasation, estimated to occur in 4% of cases. The most relevant side effect in this case, however, is the nonresolution of the condition with the appearance of long-term pain and the onset of a malignant disease not identified during surgical treatment [17]. The great proliferative capacity of the endometrium means that an incomplete ablation treatment may favor a somewhat early regeneration with rapid recurrence of symptoms.
However, it should be considered that the ablative treatment does not bring about any advantage in cases of very large uterine cavities, deep adenomyosis and intramural myomas [1]. If the two techniques are compared, a univocal outcome in favor of one or the other cannot be reached. The results appear to indicate an efficacy advantage of hysterectomy in the improvement of bleeding [22,23].
Following ablation, 6 months after surgery, 37% of patients are amenorrheic [1], while 86% of patients who continue to have menstrual blood loss usually define it as milder [1]. The number of patients who have resolved the problem 1 year after surgery is lower among those who underwent endometrial ablation, as opposed to those who underwent a hysterectomy. After longer periods of time the gap tends to level off, but this is probably due to the percentage of patients who are reoperated on for a second ablation [2]. Over a period of 7 years, 21% of patients submitted to endometrial ablation undergo a hysterectomy [1].
Quality-of-life measures were not remarkably different between the two types of surgery, although there was evidence that those who had a hysterectomy perceived a greater benefit in their general health than those who had hysteroscopic surgery at 1 and 2 years after surgery. Participants who had a hysterectomy also had a more significant improvement in social functioning and experienced less pelvic pain 2 years following surgery. No other aspect of quality of life differed between the two groups [21].
Undoubtedly, the reduced duration of both surgery and hospitalization supports conservative treatment. However, it is difficult to compare the two techniques. The different surgical approaches to hysterectomy and the duration of hospital stay, sometimes also related to health policy conditions, do not give homogeneous results comparable with the data on endometrial ablation. In centers where the figures on laparoscopic surgery are significant, the length of hospital stay is short and only slightly longer than that for endometrial ablation.
Time to return to work might also have varied according to other factors besides physical and mental recovery from surgery. Variations in the type of surgery and in socioeconomic status could account for these results [21].
The patient's will is a crucial factor affecting the decision-making process. The increased amount of choice available to women contributes greatly to the final outcome. The patient willingly accepts that the ablative treatment may be decisive in only 50% of cases [24,25]. The treatment is considered acceptable in 40% of patients even if menstruation only becomes slightly lighter [24].
“The role of endometrial ablation, regardless of the method applied, is still sadly severely limited by problems relating to both the pathology and the technique itself.”
In addition, if the patient is comprehensively informed about the chance of recurrent abnormal bleeding, she may decide she would rather undergo definitive surgery [18,26].
At this point, it is appropriate to attempt to predict the future of surgery in the treatment of abnormal bleeding.
Can we assume that the future will bring a reduction in hysterectomies and an increase in conservative treatments? At this moment in time, has endometrial ablation reached definitely reliable standards?
Perhaps this idea is not yet realistic; a ‘brighter’ future may not be that near yet. The role of endometrial ablation, regardless of the method applied, is still sadly severely limited by problems relating to both the pathology and the technique itself. A patient who is well prepared and properly guided will willingly accept, if properly instructed, a partial success and will undergo subsequent surgical treatments. It is obvious, however, that in this situation, in which the limiting factors are more than one, success is still severely limited and not always achieved.
The advantages of hysterectomy compared with endometrial ablation alone have been widely demonstrated and are essentially based on a complete resolution of the condition and improved patient satisfaction [2,15]. The possibility for patients eligible for a partially conservative treatment to be submitted to a procedure such as supracervical hysterectomy, falls into this perspective [15]. Let us not forget that those who have more arrows in their quiver are able to choose the best path more freely and with serenity. An absolute technique for the treatment of abnormal bleeding does not exist, but a successful outcome probably lies more with the beliefs of the surgeon than with the condition itself.
Acknowledgements
The authors wish to thank Katrina Anne Malcolm for her great support.
Footnotes
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.