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Abnormal Uterine Bleeding: Surgical or Medical Therapy?



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Am Fam Physician. 2005 Jan 15;71(2):364.

Hysterectomy is more common in the United States than in other developed countries, with considerable regional variation. Observational studies have reported improvement in sexual function and quality of life after hysterectomy, but this procedure also can result in early ovarian failure, incontinence in later life, and death. In this randomized trial, Kuppermann and colleagues compared a medical and a surgical approach to the treatment of uncontrolled abnormal uterine bleeding in women whose symptoms persisted despite medical treatment for a median of four years.

Premenopausal women 30 to 50 years of age with abnormal uterine bleeding who were treated previously with cyclic medroxyprogesterone were randomized to further medical treatment or hysterectomy and followed for two years. Outcome measures included health-related quality of life, symptom resolution, body image and sexual function, and psychologic distress and well-being.

Sixty-three women who failed to improve with medroxyprogesterone treatment were assigned randomly to receive expanded medical treatment or hysterectomy. The former group received a variety of treatment regimens; in the latter group, some women had abdominal hysterectomy, and some had vaginal hysterectomy. At four weeks, the patients who had hysterectomy experienced a decrease in physical health but had a somewhat higher mental health score than those in the medical groups.

At six months, the surgery group reported significantly greater improvement in quality of life, symptom resolution, satisfaction with degree of symptom resolution, sexual function and desire, and other parameters. These improvements were maintained after two years, at which time the medical group also experienced improvements. The only remaining difference between groups was an increase in sexual desire that favored the surgery group. However, by the end of two years, 53 percent of the women had crossed over to the hysterectomy group, with significant improvements in quality of life and in 11 of the 13 other measured outcomes, compared with no significant improvements in quality of life but improvements in seven of 13 other outcome measures in women who stayed with medical management.

The authors conclude that, with respect to outcomes such as quality of life and mental health, women who have hysterectomies for refractory abnormal uterine bleeding do better than women who are treated medically. This difference is substantial, particularly at six months, before the bulk of medical group crossover to hysterectomy occurred in this study. This improvement was attenuated at two years, and the difference between groups was nonsignificant in quality-of-life measures by the end of the study. However, many women in the medical group eventually opted for hysterectomy. Even so, many of the women who did not cross over to surgery experienced significant improvement in a variety of outcome measures.

Kuppermann M, et al., for the Ms Research Group. Effect of hysterectomy vs medical treatment on health-related quality of life and sexual functioning. The medicine or surgery (Ms) randomized trial. JAMA. March 24/31, 2004;291:1447–55.



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