Alternatives to Abdominal Hysterectomy for Excessive Menstruation

Dysfunctional uterine bleeding is an important problem in perimenopausal women and is the commonest indication for hysterectomy, usually performed abdominally. Three articles in this issue are concerned with alternatives to abdominal hysterectomy. The advantages of laparoscopic hysterectomy include a shorter hospital stay and a quicker long term recovery, but there are anxieties concerning its safety. On page 345 Jan-Henrik Olsson and his colleagues describe a randomised comparison of abdominal and laparoscopic hysterectomy in which there were no differences in the number of complications associated with either operation. These results are in the main reassuring, although the most serious complication, vesico–vaginal fistula, occurred in a woman who had undergone laparoscopic hysterectomy. Further randomised trials are required to compare the risks of rare complications of laparoscopic and abdominal hysterectomy. Another alternative to abdominal hysterectomy is endometrial ablation which should be performed after inducing endometrial atrophy pharmacologically, usually using either danazol or a gonadotrophin-releasing hormone analogue. Hitherto the relative effectiveness of these treatments as endometrial thinning agents was unknown, but on page 339 Ray Garry and his colleagues report a randomised trial which addresses this issue. Goserelin was more effective and better tolerated than danazol; and eight weeks of treatment with goserelin produced better operating conditions than four weeks of treatment, albeit with more side effects. One disadvantage of goserelin is that because it induces a hypo-oestrogenic state it increases cervical resistance prior to endometrial ablation, as shown by K.G. Cooper and colleagues on page 375, and this increase in resistance was not reversed by vaginal misoprostol. The search is on for an effective cervical relaxant where gonadotrophin-releasing hormone analogues have been administered in preparation for endometrial ablation.