Safety and effectiveness of female tubal sterilisation by hysteroscopy, laparoscopy, or laparotomy: a register based study

OBJECTIVE

To determine the safety and effectiveness of female sterilisation in the Finnish population.

DESIGN

A national register-based study using record linkage.

SETTING

National data from Finland.

SAMPLE

A total of 16 272 female sterilisations performed in 2009-2014.

METHODS

The Register of Sterilisations was linked with the Hospital Discharge Register, Termination of Pregnancy Register, and the Medical Birth Register in order to investigate the occurrence of re-sterilisations, other surgical operations, and unwanted pregnancies after sterilisation, per method.

MAIN OUTCOME MEASURES

Outcome measures included all pregnancies after sterilisation (births, miscarriages, terminations of pregnancy, and ectopic pregnancies) and operations (repeat sterilisations, other hysteroscopic and laparoscopic procedures, hysterectomies, and re-operations for a complication). The outcomes were presented by method as risk ratio (RR) with 95% confidence intervals (95% CIs).

RESULTS

There was no significant difference in all spontaneous pregnancies between the groups. The risk ratio for any pregnancy was 1.27 (95% Cl 0.80-2.02) for Filshie^® versus Essure^® and 1.35 (95% Cl 0.92-1.96) for Pomeroy versus Essure^® . In total, 1394 (8.6%) selected operations were identified after primary sterilisation. Re-sterilisations and hysteroscopies were most frequent among Essure^® patients.

CONCLUSIONS

Patients undergoing hysteroscopic or laparoscopic sterilisation have a similar risk of unintended pregnancy. All sterilisations are safe, and the risk of re-operations because of complications is low. Women with Essure^® have a higher risk of undergoing re-sterilisation compared with patients undergoing laparoscopic sterilisation.

TWEETABLE ABSTRACT

Essure^® , Filshie^® , and Pomeroy sterilisations are equally effective and safe.

The effect of hysterectomy or levonorgestrel-releasing intrauterine system on cardiovascular disease risk factors in menorrhagia patients: a 10-year follow-up of a randomised trial

OBJECTIVE

To compare, whether women with menorrhagia, treated with either hysterectomy or LNG-IUS, differ in their cardiovascular risk profile during 10-year follow-up.

STUDY DESIGN

A total of 236 women were randomized to treatment by hysterectomy (n=117) or LNG-IUS (n=119). Their cardiovascular risk factors were analyzed at baseline, at 5 years, and at 10 years. As 55 originally randomized to the LNG-IUS group had hysterectomy during the follow-up, all analyzes were performed by actual treatment modality.

MAIN OUTCOME MEASURES

Waist circumference, body-mass index (BMI), blood pressure, and the levels of blood lipids, serum high-sensitivity CRP (hsCRP) and tumor necrosis factor alpha (TNF-α) were measured, and the use of medication for hypertension, diabetes, hypercholesterolemia, and ischemic heart disease was analyzed.

RESULTS

After 5 years, an increase in the use of diabetes medication during the follow-up was only detected in the hysterectomy group (from 1.7% to 6.7%, P=0.008 vs from 5.1% to 8.4%, P=0.08), as well as they had significantly higher serum levels of TNF-α (108.59 pg/ml vs 49.02 pg/ml, P=0.001) and hsCRP (1.55 μg/ml vs 0.78 μg/ml, P=0.038) at 5- and 10-years. There was no difference between the groups in the use of cardiovascular medication, neither was there difference in blood pressure, waist circumference, BMI, or concentrations of blood lipids.

CONCLUSIONS

Hysterectomy seems to be associated with increased levels of serum inflammatory markers and increased diabetes medication, which in turn, may predispose individual to future cardiovascular events.

Hysterectomy, endometrial ablation and Mirena® for heavy menstrual bleeding: a systematic review of clinical effectiveness and cost-effectiveness analysis

OBJECTIVE

The aim of this project was to determine the clinical effectiveness and cost-effectiveness of hysterectomy, first- and second-generation endometrial ablation (EA), and Mirena® (Bayer Healthcare Pharmaceuticals, Pittsburgh, PA, USA) for the treatment of heavy menstrual bleeding.

DESIGN

Individual patient data (IPD) meta-analysis of existing randomised controlled trials to determine the short- to medium-term effects of hysterectomy, EA and Mirena. A population-based retrospective cohort study based on record linkage to investigate the long-term effects of ablative techniques and hysterectomy in terms of failure rates and complications. Cost-effectiveness analysis of hysterectomy versus first- and second-generation ablative techniques and Mirena.

SETTING

Data from women treated for heavy menstrual bleeding were obtained from national and international trials. Scottish national data were obtained from the Scottish Information Services Division.

PARTICIPANTS

Women who were undergoing treatment for heavy menstrual bleeding were included.

INTERVENTIONS

Hysterectomy, first- and second-generation EA, and Mirena.

MAIN OUTCOME MEASURES

Satisfaction, recurrence of symptoms, further surgery and costs.

RESULTS

Data from randomised trials indicated that at 12 months more women were dissatisfied with first-generation EA than hysterectomy [odds ratio (OR): 2.46, 95% confidence interval (CI) 1.54 to 3.93; p = 0.0002), but hospital stay [WMD (weighted mean difference) 3.0 days, 95% CI 2.9 to 3.1 days; p < 0.00001] and time to resumption of normal activities (WMD 5.2 days, 95% CI 4.7 to 5.7 days; p < 0.00001) were longer for hysterectomy. Unsatisfactory outcomes associated with first- and second-generation techniques were comparable [12.2% (123/1006) vs 10.6% (110/1034); OR 1.20, 95% CI 0.88 to 1.62; p = 0.2). Rates of dissatisfaction with Mirena and second-generation EA were similar [18.1% (17/94) vs 22.5% (23/102); OR 0.76, 95% CI 0.38 to 1.53; p = 0.4]. Indirect estimates suggested that hysterectomy was also preferable to second-generation EA (OR 2.32, 95% CI 1.27 to 4.24; p = 0.006) in terms of patient dissatisfaction. The evidence to suggest that hysterectomy is preferable to Mirena was weaker (OR 2.22, 95% CI 0.94 to 5.29; p = 0.07). In women treated by EA or hysterectomy and followed up for a median [interquartile range (IQR)] duration of 6.2 (2.7-10.8) and 11.6 (7.9-14.8) years, respectively, 962/11,299 (8.5%) women originally treated by EA underwent further gynaecological surgery. While the risk of adnexal surgery was similar in both groups [adjusted hazards ratio 0.80 (95% CI 0.56 to 1.15)], women who had undergone ablation were less likely to need pelvic floor repair [adjusted hazards ratio 0.62 (95% CI 0.50 to 0.77)] and tension-free vaginal tape surgery for stress urinary incontinence [adjusted hazards ratio 0.55 (95% CI 0.41 to 0.74)]. Abdominal hysterectomy led to a lower chance of pelvic floor repair surgery [hazards ratio 0.54 (95% CI 0.45 to 0.64)] than vaginal hysterectomy. The incidence of endometrial cancer following EA was 0.02%. Hysterectomy was the most cost-effective treatment. It dominated first-generation EA and, although more expensive, produced more quality-adjusted life-years (QALYs) than second-generation EA and Mirena. The incremental cost-effectiveness ratios for hysterectomy compared with Mirena and hysterectomy compared with second-generation ablation were £1440 per additional QALY and £970 per additional QALY, respectively.

CONCLUSIONS

Despite longer hospital stay and time to resumption of normal activities, more women were satisfied after hysterectomy than after EA. The few data available suggest that Mirena is potentially cheaper and more effective than first-generation ablation techniques, with rates of satisfaction that are similar to second-generation techniques. Owing to a paucity of trials, there is limited evidence to suggest that hysterectomy is preferable to Mirena. The risk of pelvic floor surgery is higher in women treated by hysterectomy than by ablation. Although the most cost-effective strategy, hysterectomy may not be considered an initial option owing to its invasive nature and higher risk of complications. Future research should focus on evaluation of the clinical effectivesness and cost-effectiveness of the best second-generation EA technique under local anaesthetic versus Mirena and types of hysterectomy such as laparoscopic supracervical hysterectomy versus conventional hysterectomy and second-generation EA.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Hysterectomy, endometrial destruction, and levonorgestrel releasing intrauterine system (Mirena) for heavy menstrual bleeding: systematic review and meta-analysis of data from individual patients

OBJECTIVE

To evaluate the relative effectiveness of hysterectomy, endometrial destruction (both "first generation" hysteroscopic and "second generation" non-hysteroscopic techniques), and the levonorgestrel releasing intrauterine system (Mirena) in the treatment of heavy menstrual bleeding.

DESIGN

Meta-analysis of data from individual patients, with direct and indirect comparisons made on the primary outcome measure of patients' dissatisfaction.

DATA SOURCES

Data were sought from the 30 randomised controlled trials identified after a comprehensive search of the Cochrane Library, Medline, Embase, and CINAHL databases, reference lists, and contact with experts. Raw data were available from 2814 women randomised into 17 trials (seven trials including 1359 women for first v second generation endometrial destruction; six trials including 1042 women for hysterectomy v first generation endometrial destruction; one trial including 236 women for hysterectomy v Mirena; three trials including 177 women for second generation endometrial destruction v Mirena). Eligibility criteria for selecting studies Randomised controlled trials comparing hysterectomy, first and second generation endometrial destruction, and Mirena for women with heavy menstrual bleeding unresponsive to other medical treatment.

RESULTS

At around 12 months, more women were dissatisfied with outcome with first generation hysteroscopic techniques than with hysterectomy (13% v 5%; odds ratio 2.46, 95% confidence interval 1.54 to 3.9, P<0.001), but hospital stay (weighted mean difference 3.0 days, 2.9 to 3.1 days, P<0.001) and time to resumption of normal activities (5.2 days, 4.7 to 5.7 days, P<0.001) were longer for hysterectomy. Unsatisfactory outcomes were comparable with first and second generation techniques (odds ratio 1.2, 0.9 to 1.6, P=0.2), although second generation techniques were quicker (weighted mean difference 14.5 minutes, 13.7 to 15.3 minutes, P<0.001) and women recovered sooner (0.48 days, 0.20 to 0.75 days, P<0.001), with fewer procedural complications. Indirect comparison suggested more unsatisfactory outcomes with second generation techniques than with hysterectomy (11% v 5%; odds ratio 2.3, 1.3 to 4.2, P=0.006). Similar estimates were seen when Mirena was indirectly compared with hysterectomy (17% v 5%; odds ratio 2.2, 0.9 to 5.3, P=0.07), although this comparison lacked power because of the limited amount of data available for analysis.

CONCLUSIONS

More women are dissatisfied after endometrial destruction than after hysterectomy. Dissatisfaction rates are low after all treatments, and hysterectomy is associated with increased length of stay in hospital and a longer recovery period. Definitive evidence on effectiveness of Mirena compared with more invasive procedures is lacking.

The effect of hysterectomy or levonorgestrel-releasing intrauterine system on sexual functioning among women with menorrhagia: a 5-year randomised controlled trial

OBJECTIVE

To compare among women with menorrhagia the effect of hysterectomy or levonorgestrel-releasing intrauterine system (LNG-IUS) on sexual functioning.

DESIGN

A randomised controlled trial.

SETTING

Five university hospitals in Finland.

SAMPLE

A total of 236 women, aged 35-49 years.

METHODS

Of the women, 117 were treated by hysterectomy and 119 by LNG-IUS.

MAIN OUTCOME MEASURES

Sexual functioning was evaluated by modified McCoy sexual scale at baseline and at 6 months, 12 months, and 5 years after initiation of treatment (hysterectomy or application of LNG-IUS).

RESULTS

Among women treated by hysterectomy, sexual satisfaction increased and sexual problems decreased. Among LNG-IUS users, satisfaction with partner decreased. In addition to treatment modality (P = 0.02), estrogen therapy (P = 0.01), smoking (P = 0.001), night sweats (P = 0.03), vaginal dryness (P = 0.04), hot flushes (P = 0.01), and having someone to ask for advice (P = 0.03) and to share worries (P = 0.01) explained changes in sexual functioning.

CONCLUSIONS

Among women with menorrhagia, hysterectomy improves sexual functioning, whereas LNG-IUS does not have such a positive effect.

Diagnosis and treatment of menorrhagia

One-third of all women experience heavy menstrual bleeding at some point in their life. In western countries, about 5% of women of reproductive age will seek help for menorrhagia annually. Half of all women who consult for hypermenorrhea have some uterine abnormality, most often fibroids (among patients under 40 years of age) and endometrial polyps (above 40 years of age). Appropriate treatment considerably improves the quality of life of these patients, and it is important to make a rigorous assessment of the patient to provide the best treatment options. This guideline provides instructions on how to examine and treat women of fertile age who have menorrhagia. The subject's own assessment of the amount of menstrual blood loss does not generally reflect the true amount. All patients should undergo a pelvic examination and, if the menstrual pattern has changed substantially or if anaemia is present, a vaginal sonography should be carried out as the most important supplemental examination. Vaginal sonography combined with an endometrial biopsy is a reliable method for diagnosing endometrial hyperplasia or carcinoma, but it is insufficient for diagnosing endometrial polyps and fibroids; these can be diagnosed more reliably by sonohysterography or hysteroscopy. Non-steroidal anti-inflammatory drugs and tranexamic acid reduce menstrual blood loss by 20-60%, and the effectiveness of a hormonal intrauterine system (IUS) is comparable with that of endometrial ablation or hysterectomy. Cyclic progestogens do not significantly reduce menstrual bleeding of women who ovulate. Treatment should be started with one of the drug therapies, i.e. the IUS, tranexamic acid, anti-inflammatory drugs, or oral contraceptive. Drug treatment should be used and evaluated before surgical interventions are considered. With an effective training and feedback system, it is possible to organise the diagnostics, medical treatment and follow-up of heavy menstrual bleeding in the primary health care setting or in outpatient clinics, which reduces the burden on specialist health care.

A randomized controlled trial of hysterectomy or levonorgestrel-releasing intrauterine system in the treatment of menorrhagia--effect on FSH levels and menopausal symptoms

BACKGROUND

The purpose of this study was to compare the effects of hysterectomy and a levonorgestrel-releasing intrauterine system (LNG-IUS) on serum FSH levels and menopausal symptoms.

METHODS

A total of 236 women referred for menorrhagia to five university hospitals were randomly assigned to treatment with hysterectomy (n = 117) or LNG-IUS (n = 119). Menopausal symptoms were characterized by the Kupperman menopausal distress test. Serum FSH and estradiol levels were measured at baseline and 6 and 12 months after hysterectomy or application of LNG-IUS. Analyses were by intention to treat.

RESULTS

After 6 months, there was no difference between the groups, but 12 months after follow-up hysterectomized women had higher FSH levels than women with LNG-IUS (P = 0.005). There was a significant association between FSH levels and treatment modality (P = 0.020). Hot flushes increased significantly in the hysterectomy group (P = 0.02). There was a significant association between hot flushes and both treatment modality and age (P = 0.02 and P = 0.01, respectively).

CONCLUSION

Hysterectomy may impair ovarian function shown by rising serum FSH levels and hot flushes. However, these results should be interpreted with caution, and longer follow-up is needed.

Comparison of ovarian cyst formation in women using the levonorgestrel-releasing intrauterine system vs. hysterectomy

OBJECTIVE

To analyze the effect of the levonorgestrel-releasing intrauterine system (LNG-IUS) on ovarian cyst formation, endometrial thickness and the size of uterus and uterine fibroids by ultrasonography.

SUBJECTS AND METHODS

This was a prospective, randomized trial comparing the LNG-IUS and hysterectomy in 236 women (age range 35-49 years) referred for menorrhagia. Transvaginal ultrasound examination was used to study the presence of ovarian cysts, uterine size, endometrial thickness, and the size of the uterus and uterine fibroids during a 12-month follow-up period.

RESULTS

At baseline examination, 12 ovarian cysts were detected, eight in the LNG-IUS group and four in the hysterectomy group. During the follow-up period, 14 new cysts had emerged at 6 months and 14 new cysts had emerged at 12 months in the LNG-IUS group, whereas the corresponding figures in the hysterectomy group were three and eight, respectively. All but one of the 14 new cysts (94.1%) detected at 6 months in the LNG-IUS group resolved spontaneously, whereas two out of the eight cysts detected at the baseline examination persisted for 12 months. Three cysts were removed at operation. The relative risk of the occurrence of ovarian cysts was significantly higher in women with LNG-IUS, compared with women who underwent hysterectomy. LNG-IUS did not affect the size of the uterus or uterine fibroids, but it was associated with a decrease in endometrial thickness. The occurrence of cysts did not correlate with age or follicle stimulating hormone levels, but a weak positive correlation between the occurrence of cysts and the presence of irregular bleeding was observed.

CONCLUSIONS

LNG-IUS use in the treatment of menorrhagia was associated with the development of ovarian cysts, but these were symptomless and showed a high rate of spontaneous resolution. LNG-IUS did not affect the size of the uterus or the size of uterine fibroids, but decreased the thickness of the endometrium.

Psychosocial and other characteristics of women complaining of menorrhagia, with and without actual increased menstrual blood loss

OBJECTIVE

To discover whether psychosocial factors can explain why many women with normal menstrual blood loss seek care for menorrhagia.

DESIGN

Cross-sectional comparative study of women referred for menorrhagia.

SETTING

Gynaecology departments of all five university teaching hospitals in Finland.

SAMPLE

Two hundred and twenty-six women aged 35-49 years complaining of menorrhagia.

MAIN OUTCOME MEASURES

Several psychosocial factors, seeking medical attention, menstrual blood loss.

RESULTS

Twenty-nine percent of the women had their menstrual blood loss in the normal range (menstrual blood loss <60 mL). By univariate analysis, unemployment, anxiety, perceived inconvenience, abdominal pain, haemoglobin level and serum ferritin concentration distinguished this group of women from those with true menorrhagia. Unemployment, perceived inconvenience, abdominal pain and serum ferritin remained significant variables by multivariate analysis.

CONCLUSIONS

A significant proportion of women with complaints of menorrhagia have their measured menstrual blood loss within the normal range. Psychosocial factors can have an impact on their seeking health care. Better understanding of the factors, which explain complaints of menorrhagia in women with normal bleeding could improve both medical outcomes and reduce the cost of treatment for menorrhagia.

Quality of life and cost-effectiveness of levonorgestrel-releasing intrauterine system versus hysterectomy for treatment of menorrhagia: a randomised trial

BACKGROUND

Heavy menstrual blood loss is a common reason for women to seek medical care. The levonorgestrel-releasing intrauterine system (IUS) is an effective medical treatment for menorrhagia. We report a randomised comparison of this approach with hysterectomy in terms of the quality of life of women with menorrhagia and cost-effectiveness.

METHODS

Of 598 women referred with menorrhagia to five university hospitals in Finland, 236 were eligible and agreed to take part. They were randomly assigned treatment with the levonorgestrel-releasing IUS (n=119) or hysterectomy (n=117). The amount of menstrual blood loss was objectively measured. The primary outcome measure was health-related quality of life at 12-month follow-up. Analyses were by intention to treat.

FINDINGS

In the group assigned the levonorgestrel-releasing IUS, 24 (20%) women had had hysterectomy and 81 (68%) continued to use the system at 12 months. Of the women assigned to the hysterectomy group, 107 underwent the operation. Health-related quality of life improved significantly in both the IUS and hysterectomy groups (change 0.10 [95% CI 0.06-0.14] in both groups) as did other indices of psychological wellbeing. There were no significant differences between the treatment groups except that women with hysterectomy suffered less pain. Overall costs were about three times higher for the hysterectomy group than for the IUS group.

INTERPRETATION

The significant improvement in health-related quality of life highlights the importance of treating menorrhagia. During the first year the levonorgestrel-releasing IUS was a cost-effective alternative to hysterectomy in treatment of this disorder.

Expression of sex steroid receptors and Ki-67 in the endometria of menorrhagic women: effects of intrauterine levonorgestrel

The levonorgestrel-releasing intrauterine system (LNG-IUS) has proven to be the most effective medical treatment in reducing the amount of menstrual blood loss. However, the molecular mechanisms underlying menorrhagia and/or accounting for the therapeutic effect of the LNG-IUS are still obscure. In this study, we used immunohistochemistry to compare the distribution of sex steroid receptors and the proliferation marker Ki-67 in the endometria of women with and without menorrhagia before and after 6 and 12 months of treatment with an LNG-IUS. The study sample included 67 women (aged 35-49 years) who had spontaneous ovulatory cycles. In women with menorrhagia, secretory phase endometrium exhibited more proliferative activity than in women without menorrhagia. No significant differences were found in the immunoreactivity of the oestrogen or progesterone receptors in women either with or without menorrhagia suggesting that, in addition to endocrine hormones, other factors are involved in the regulation of endometrial proliferation and menstrual blood loss. A total of 35 women were treated with LNG-IUS. After 6 months use of an LNG-IUS, the immunoreactivity of both epithelial and stromal progesterone receptors, as well as those of epithelial Ki-67 declined, and no differences were detectable between the women in the menorrhagia and control groups. Breakthrough bleeding remained a problem for nine (26%) LNG-IUS users, with no association with the pre-treatment amount of bleeding. No significant differences were found in the parameters studied between the women with and without breakthrough bleeding 6 months after insertion of an LNG-IUS.

Induction of endometrial plasminogen activator-inhibitor 1: a possible mechanism contributing to the effect of intrauterine levonorgestrel in the treatment of menorrhagia

OBJECTIVE

To elucidate molecular mechanisms accounting for excessive menstrual blood loss, and to present the therapeutic effect of an intrauterine levonorgestrel system (LNG-IUS) in menorrhagia.

DESIGN

A multicenter study comparing hysterectomy with the LNG-IUS in treating menorrhagia.

SETTING

A university hospital.

PATIENT(S)

Women with (n = 27) and without (n = 14) menorrhagia, and women with uterine fibroids but undetermined menstrual blood loss (n = 35).

INTERVENTION(S)

An LNG-IUS was inserted into the uterine cavity in 11 women with menorrhagia and six women experiencing normal menstrual blood loss.

MAIN OUTCOME MEASURE(S)

Expression of the messenger ribonucleic acid (mRNA) of tissue-type plasminogen activator (t-PA) and that of a specific PA inhibitor type 1 (PAI-1) in endometrial tissue samples, as evaluated with the use of Northern blot analysis.

RESULT(S)

t-PA mRNA was expressed in the endometrium throughout the menstrual cycle, with no statistically significant difference between a proliferative (n = 30) and a secretory endometrium (n = 40), or between women experiencing normal menstrual blood loss (n = 14) and those with menorrhagia (n = 27). The levels of t-PA mRNA in menstrual phase samples (n = 6) were significantly higher than those in proliferative or secretory endometrium. PAI-1 mRNA was detected in the endometrium during menstruation only. Both t-PA mRNA and PAI-1 mRNA were expressed in all endometrial samples (n = 17) obtained 6 months after an LNG-IUS was inserted, regardless of the menstrual cycle phase. The relative levels of both types of mRNA were significantly higher in LNG endometrium than in proliferative or secretory endometrium, but levels did not differ from those in menstrual-phase endometrium.

CONCLUSION(S)

The mean (+/-SD) levels of t-PA mRNA and PAI-1 mRNA in the endometrium of women with and without menorrhagia did not differ, suggesting that the PA system is not the major determinant of menstrual blood loss. However, continuous induction of PAI-1 may contribute to the therapeutic effect of LNG-IUS in treating menorrhagia.

Menorrhagia and uterine artery blood flow

Menorrhagia is a significant problem in women of reproductive age. In half of the cases no specific aetiology is known. Vascular factors play a role but remain poorly understood. We chose to study whether any association exists between the flow impedance of uterine arteries and the amount of menstrual blood loss. The study population consisted of 60 spontaneously menstruating 35- to 49-year-old women without endometrial hyperplasia, polyps, or submucous fibroids. The pulsatility index (PI) from uterine arteries, arcuate arteries, and radial arteries was measured by transvaginal colour Doppler. Menstrual blood loss was measured by the alkaline haematin method. A significant inverse correlation was found between uterine artery PI and the amount of menstrual blood loss, suggesting that women with lower uterine flow impedance bleed more. A regression model confirmed that this association was specific and not explained by uterine size, fibroids or any other of the 11 potential confounders included in the model. The correlation between uterine artery PI and amount of menstrual blood loss suggests that vascular factors may be involved in the pathogenesis of menorrhagia.

Hysterectomy trends in Finland in 1987-1995--a register based analysis

BACKGROUND

The study objective was to identify trends in the use of hysterectomy by nationwide register based analysis in Finland.

METHODS

All women (n=89,069) undergoing hysterectomy in 1987-1995 according to the Finnish Hospital Discharge Register were the numerator. The annual denominator data were obtained from the population database of Statistics Finland.

RESULTS

From 1987 to 1992 the hysterectomy rate increased by 22%, from 340 to 414 per 100,000 females, almost half of this being attributable to the changing age structure. From 1993 on, ambiguity in coding laparoscopically assisted vaginal hysterectomies prohibited detailed analyses. However, the overall trend continued at least among women 50 years and over until 1995. The age-adjusted 12% increase from 1987 to 1992 coincided with a rapid increase in operation rates in postmenopausal groups (60% or more among women aged 55 59 and 70-79 years). Among women aged 55-64 years, operations for fibroids and uterine bleeding more than doubled, suggesting an influence of increased use of estrogen replacement therapy. Among all women, operations due to bleeding disorders and genital prolapse showed the largest increase (41% and 42% respectively). Bilateral oophorectomy became more common in all age groups over 46 years.

CONCLUSIONS

There was a modest increase in the overall hysterectomy rate. However, the operation became far more common in postmenopausal women, possibly due to the growing use of estrogen replacement therapy. Register data can be used for describing changes in clinical practice, but other methods are needed to confirm the causal relationships underlying the changes.

Combined laboratory and diary method for objective assessment of menstrual blood loss

BACKGROUND

To develop an objective measurement system for menstrual blood loss applicable in clinical practice.

METHODS

One hundred and fifty-six patients were enrolled in a randomized trial of the treatment of menorrhagia in all five gynecology departments of the university teaching hospitals in Finland. Correlation between venous blood hemoglobin concentration (Hb) and absorbance at 564 nm (A564) was investigated in experiments with blood samples. Amount of collected menstrual blood and menstrual diary data were analyzed.

RESULT

Hb concentration and A564 of the blood were linearly correlated (r=0.99). One hundred and fifty-four women (99%) returned used sanitary protection and menstrual diaries. On average, 12% (range 0-57%) of menstrual blood was lost during collection. The median amount of blood recovered from sanitary protection was 89 ml (range 14-724 ml), with 58% (n=90) of the women exceeding 80 ml per cycle. When the spilled blood was taken into account, the corresponding figures were 104 ml (range 15-724 ml) and 66% (n= 101).

CONCLUSIONS

The spectrophotometric measurement of venous blood in the conventional alkaline hematin method can be replaced by measurement of Hb concentration. All blood incompletely collected should be recorded. Objective measurement of menstrual blood loss can be applied in routine clinical practice.