2016 Update on abnormal uterine bleeding

A total of 118 pathologies were removed in 74 patients. Forty-two women were treated in the office setting; 32 were treated in the OR setting. Among the 118 pathologies removed, 53 were removed in the office (28 myomas and 25 polyps), and 55 were removed in the OR (14 myomas and 41 polyps).

The percentage of patients who reported being satisfied or highly satisfied was higher in the OR cohort (96.5%) compared with the office cohort (83.3%), although this difference was not statistically significant (P = .06). The percentage of patients who had 100% of their pathology removed was significantly higher in those with polyps compared with patients with myomas (96.0% vs 63.6%, respectively; P<.01).

These findings indicate that there were several cases in which the majority of a myoma was removed but a small residual portion remained. This disparity was especially pronounced in the office setting, where 96% of polyps were completely removed, compared with 52% of fibroids. There was no statistically significant difference in health-related quality of life between patients with complete removal and those with residual pathology, and there was no difference in satisfaction rates between patients who were treated in the office and those treated in the OR.

What this EVIDENCE means for practice
In general, office-based hysteroscopic myomectomy and polypectomy using morcellation for small- to medium-size lesions was associated with low rates of adverse events, high physician acceptance, and significant durable health-related quality-of-life improvements for up to 12 months post­‑ procedure. Partial removal of myomas did not seem to be a significant factor in patients’ perceived outcomes.

Endometrial ablation for AUB costs less, has fewer complications at 1 year than hysterectomy

Miller JD, Lenhart GM, Bonafede MM, Lukes AS, Laughlin-Tommaso SK. Cost-effectiveness of global endometrial ablation vs hysterectomy for treatment of abnormal uterine bleeding: US commercial and Medicaid payer perspectives. Popul Health Manag. 2015;18(5):373–382.

Endometrial ablation often is performed in the office for AUB management. Miller and colleagues suggested that cost-effectiveness modeling studies of endometrial ablation for AUB treatment from a US perspective are lacking. They therefore designed a study to model the cost-effectiveness of endometrial ablation versus hysterectomy for treatment of AUB from both commercial and Medicaid payer perspectives.

They developed a decision-tree, state-transition (semi-Markov) model to simulate 2 hypothetical patient cohorts of women with AUB: one treated with endometrial ablation and the other with hysterectomy. Twenty-one health states were included in the model of intervention with endometrial ablation or hysterectomy; these comprised postablation reintervention with secondary ablation, tranexamic acid, or a levonorgestrel-containing IUD due to AUB, use of adjunctive pharmacotherapy following ablation, and a small probability of death from hysterectomy or actuarial death from all other causes.

The 1-year direct costs of endometrial ablation were $7,352 and $6,306 in the commercial payer and Medicaid payer perspectives, respectively; these were about half the costs of hysterectomy. The cost differential between the 2 treatments narrowed over time but, even at 5 years, endometrial ablation costs were still one-third less than hysterectomy costs.

In the first year, 35.6% of patients who had a hysterectomy and only 17.1% of patients undergoing ablation had complications. Short-term results were similar under the Medicaid perspective. By 5 years intervention/reintervention, however, complications of endometrial ablation were higher than those for hysterectomy by about 1.6%.

Over a 5-year time frame, direct costs of endometrial ablation were lower than those of hysterectomy from both the commercial payer and Medicaid perspectives. In the commercial payer analysis, the indirect costs of endometrial ablation were also lower than for hysterectomy, with 38.5 workdays lost for endometrial ablation compared with 55.3 days lost for hysterectomy, resulting in indirect costs of $8,976 versus $13,087.

What this EVIDENCE means for practice
Costs and cost-effectiveness of endometrial ablation from a US perspective are understudied. This model estimates a financial advantage for endometrial ablation over hysterectomy from both the commercial payer and Medicaid payer perspectives. Over a variety of time frames, endometrial ablation may save costs while reducing treatment complications and lost workdays. From the patient perspective, this model suggests better quality of life in the short term after endometrial ablation. It will be interesting to see whether longer term impacts show this model to be predictive.

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