2015 Update on abnormal uterine bleeding

Surgery involves a certain degree of risk. The risk could be in the form of a complication, or it could be surgical failure. When I was a resident, gynecologic oncologist Gary Johnson, MD, used to say: “If you don’t want complications, don’t do surgery.” I was never sure whether he was trying to make me feel better when complications occurred, or was just stating the facts. Maybe both. It could be argued that one should consider offering medical options before exposing a patient to surgical risks.

In this article, I review three recent studies that shed some light on patient selection for surgical intervention—more specifically, on surgical and counseling ­failures ­associated with surgical management of abnormal uterine bleeding (AUB):

In the PALM-COEIN classification system for causes of abnormal uterine bleeding, PALM represents polyps, adenomyosis, leiomyomata, and malignancy/hyperplasia—lesions that can be seen but may not necessarily be the cause of bleeding. Some of these causes may or may not make endometrial ablation an optimal option.

Don’t resort to surgery until alternative treatments have been exhausted

Corona LE, Swenson CW, Sheetz KH, et al. Use of other treatments before hysterectomy for benign conditions in a statewide hospital collaborative [published online ahead of print December 23, 2014]. Am J Obstet Gynecol. pii: S0002-9378(14)02355-2. doi: 10.1016/j.ajog.2014.11.031.

In this analysis, Corona and colleagues evaluated the use of alternative treatments among women who underwent hysterectomy for uterine fibroids, AUB, endometriosis, or pelvic pain at 52 hospitals participating in the Michigan Surgical Quality Collabo­rative in 2013. They also determined whether the pathology was “supportive” or “unsupportive” of the surgical indication.

A significant percentage of hysterectomies were performed with an indication of AUB or fibroids, or both (49.1%). A combination of pain, AUB, and/or fibroids was the indication in 48.1% of hysterectomies, and endometriosis and/or pain was listed in 9.2%.

In 37.7% of cases (n = 1,281), no offering of alternative treatments was documented.

Although endometrial ablation was offered to 44.1% of women younger than age 40, to 48.3% of women aged 40 to 50 years, and to 31.6% of women older than age 50, the conservative, nonsurgical option of a levonorgestrel intrauterine system (LNG-IUS) was offered in only 12.7%, 12.4%, and 9.3% of these cases, respectively.

Overall, the rate of unsupportive pathology was 18.3% (n = 621). That rate was higher in women younger than age 40, compared with those aged 40 to 50 and older than age 50 (37.8% vs 12.0% and 7.5%, respectively; P<.001).

These data suggest that a significant number of women with AUB associated with ovulatory dysfunction (AUB-O) undergo hysterectomy. The authors point out that the American College of Obstetricians and Gynecologists (ACOG) recommends medical therapy as a first-line therapy for AUB-O rather than surgical therapy.

What this EVIDENCE means for practice
Although AUB is a common indication for hysterectomy, conservative alternative therapies should be offered when appropriate. A particularly cost-effective and effective conservative therapy—the LNG-IUS—is underutilized and should be considered more often.

How to determine who is most likely to benefit from endometrial ablation

Wishall KM, Price J, Pereira N, et al. Postablation risk factors for pain and subsequent hysterectomy. Obstet Gynecol. 2014;124(5):904–910.

Smithling KR, Savella G, Raker CA, et al. Preoperative uterine bleeding pattern and risk of endometrial ablation failure. Am J Obstet Gynecol. 2014;211(5):556.e1–e6.

Endometrial ablation has been around a long time—likely since the 1930s. However, it was not until the 1980s that operative hysteroscopy and endometrial ablation became commonplace. As a result of new, more “automated” technology, five nonresectoscopic endometrial ablation techniques were introduced, starting with FDA approval of the thermal balloon device in 1997.

Initially, information on the feasibility of endometrial ablation was presented in the form of case reports. Efficacy and safety were studied through FDA trials, which yielded variable amenorrhea rates but relatively high satisfaction rates in the range of 85% to 95%. In the interim, we have learned more refined details about endometrial ablation as case reports of unintended consequences have cropped up and as this technology has reached a broader physician base. After almost two decades of experience with nonresectoscopic endometrial ablation devices, information on “failure”—ie, the need for additional treatment—is surfacing.