South Tyneside & Sunderland NHS Foundation Trust,, Harton Lane, South Shields, NE34 0PL, United Kingdom
Corresponding author details:
Shamma Al-Inizi, Consultant obstetrician and gynaecologist
South Tyneside and Sunderland NHS Foundation Trust
United Kingdom
Copyright: © 2023 Shamma Al-Inizi. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 international License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.
Objectives: Heavy menstrual bleeding (HMB) is one of the commonest referrals to hospital-based gynaecological services from primary care in the UK. Several medical and surgical uterine sparing modalities are currently performed in modern gynaecology for women presenting with HMB. This has led into much less women needing hysterectomy for this indication. In order to identify the reasons which led to hysterectomy in women referred with HMB, this study was conducted.
Study design: A retrospective electronic case record review study for women referred with HMB and needed hysterectomy.
Material and Methods: A retrospective study was conducted at South Tyneside and Sunderland hospitals between January 2016 and December 2018.All women who had hysterectomy during this period were reviewed and those who had it for HMB were included in the study. Data was collected electronically on an excel spread sheet. Reasons for hysterectomy and histological findings of the removed uterus were identified.Results were analyzed using a simple statistical tool.
Results: 935 women had hysterectomy during the period of the study and only 145 women had hysterectomy for HMB and were included in the study. The commonest cause for hysterectomy was failure of the intrauterine system (IUS) followed by women`s choice for definitive treatment (complete amenorrhoea).Other causes such as failed endometrial ablation (EA), history of chronic pelvic pain or known endometriosis & the presence of uterine fibroid/adenomyosis on ultrasound scan were also identified. The commonest histological finding at hysterectomy was benign leiomyoma with or without adenomyosis.
Conclusions: HMB is more likely to lead to hysterectomy when women have fibroids, adenomyosis, chronic pelvic pain or known to have endometriosis where other uterine medical and surgical sparing modalities might fail. Woman`s preference for complete amenorrhea was found to be the second common factor leading to hysterectomyfollowing failed IUS. These factors should be considered when counselling women with HMB to reduce their length of suffering prior to definitive treatment.
• One of the common gynaecological referrals to secondary care hospitals from GPs in the
UK is heavy menstrual bleeding (HMB).
• HMB can cause physical, emotional and social issues affecting the woman`s quality of
life and wellbeing.
• Many women undergo different medical and surgical uterine sparing modalities prior to
hysterectomy which can cause increased suffering and cost, by prolonging the treatment
journey
• Certain gynaecological pathologies can predispose to hysterectomy in HMB such as
fibroids, adenomyosis and endometriosis
• Correlation between symptoms, investigations and histological findings at hysterectomy
could aid the clinician to identify the reasons which might lead to hysterectomy in order
to support the counselling process in the future towards hysterectomy in women with
HMB.
Heavy Menstrual Bleeding; Hysterectomy
I confirm that I have designed the study, completed the data collection with colleagues, prepared the paper and completely wrote it.
HMB is a common condition in women of reproductive age group,
accounts to 20% of referrals to outpatient Gynecology in the UK.The
National Institute for Health and Care Excellence in the UK (NICE)
defines HMB as excessive menstrual blood loss, which interferes with
a woman’s physical, social, emotional and/or material quality of life
occurring alone or in combination with other symptoms [1].
In modern gynaecology, women with HMB are usually offered
uterine sparing medical and surgical modalities to avoid hysterectomy,
such as EA and the Mirena intrauterine system (IUS) (Levonorgestrel
20 mcg/24 hours, Bayer Healthcare Pharmaceuticals). Most women
treated with the IUS do not require a hysterectomy according to the
ECLIPSE trial [2]; where only 1:5 women would need a hysterectomy
after 5 years of treatment. The same applies to endometrial ablation
(EA) which has changed the management of HMB significantly
mainly by the development of second-generation ablation techniques
which can achieve a very high success rate avoiding hysterectomy
[3,4].
The most frequently performed procedure in gynaecology is hysterectomy [5]. It is more invasive than theMirena IUS (Levonorgestrel IUS 20 micrograms/24 hours IUS, Bayer Health Care Pharmaceuticals) and EA, but it represents the most definitive treatment for HMB [6]. Hysterectomy being a more invasive intervention, it has been suggested that it should be reserved for women where other interventions have failed or contraindicated [5].
Hysterectomy can be associated with physical and emotional complications as well as social and economic costs. In the 1980s, 60% of referrals for HMB ended with hysterectomy [5]. Most cases of HMB are benign, with much less incidence of endometrial hyperplasia with atypia or endometrial cancer [5].
Despite the recent advances in modern gynaecology aiming to treat women with HMB without needing hysterectomy, several women still end their HMB journey with hysterectomy. We aim to understand the reasons which led to hysterectomy and correlate this to the presenting symptoms, investigations & histology of the removed uterus.
All women referred to South Tyneside and Sunderland hospitals from January 2016 till December 2020 with HMB who needed hysterectomy were reviewed& data was collected electronically on an excel spread sheet. Reasons for hysterectomy were identified by reviewing symptoms at presentation, investigations &histology of the removed uterus in addition to the medical and surgical uterine sparing modalities offered. Results were analysed using a simple statistical tool.
Ethical approval was not required for this study being a retrospective case review study.
All hysterectomies during the period of the study were reviewed (935 cases). 145 women had hysterectomy for HMB and were included in the study. Hysterectomy for other reasons such as prolapse, ovarian masses and premalignant or malignant conditions were excluded.
Age ranged between 31-56 with a mean of 45. The duration of HMB ranged between 10 months and 11 years with a mean of 3years. The majority of hysterectomies were performed laparoscopically (72/145, 50%), whereas 56/145 women had abdominal hysterectomy (38%) and the rest had vaginal hysterectomy (17/145, 12%). 53 women had symptoms suggestive of endometriosis including chronic pelvic pain, dysmenorrhoea, and dyspareunia. 80 women had uterine fibroids >3 cm size on ultrasound scan and only 6 women were found to have adenomyosis prior hysterectomy (Table 1).
101 women (70%) had combination of different options of medical treatment prior to hysterectomy (Table 2) with failed IUS in 57% of patients,43%of women had failed EA& 9% had failed both options. The commonest performed EA was the Novasure (Bioplar Radiofrequency ablation-Hologic) (Table 1). The commonest Indication for hysterectomy was found to be failed IUS/EA followed by women`s choice for complete amenorrhoea (definitive surgery) which was identified in 62% of cases (Table 1). Histology of the removed uterus confirmed the majority of women had a benign fibroid with or without adenomyosis (Table 3).
Many women are referred annually to secondary care hospitals
in the UK with HMB. Most of them are usually offered medical and
surgical uterine sparing modalities prior to offering hysterectomy.
Medical and surgical uterine sparing modalities to treat HMB
have proven to be very effective including the Levonorgestrel IUS and
different types of endometrial ablation [2-4].
Hysterectomy is a major gynaecological surgical procedure and
is still practised in the context of HMB despite the high success
rate of uterine sparing medical and surgical modalities. In order to
understand the reasons which led those patients to have hysterectomy
for HMB, we conducted this study.
Women`s symptoms of chronic pelvic pain, dysmenorrhoea and
dyspareunia or known endometriosis & adenomyosis can predict
that the surgical and medical uterine sparing modalities for HMB
might not completely settle these symptoms and hysterectomy can
provide significant and long-lasting reduction in pain symptoms [7].
In addition, dysmenorrhoea was identified as one of the factors which
might predict failure of EA [8].
EA might not improve pelvicpain related to endometriosis and can
even make chronic pelvic pain worse if it was caused by adenomyosis
especially when the adenomyosis is deep [9]. We identified that
more than half of the women who underwent hysterectomy for
HMB had symptoms suggestive of endometriosis/adenomyosis and
they were offered medical and surgical uterine sparing modalities
prior to hysterectomy. In fact, 46 women (32%) had adenomyosis/
endometriosis on histology of the removed uterus (Table 3).
On the other hand, the presence of uterine fibroid(s) >3 cm on ultrasound scan (80/145, 53%) was found to be associated with women needing hysterectomy for HMB where nearly 60% of the identified women had histological evidence of fibroid with or without adenomyosis (Table 3). The presence of uterine fibroids with or without adenomyosis can present a risk to the success of endometrial ablation [8-11].
In addition, the Levonorgestrel IUS may not help to treat fibroids associated with HMB and it has been reported that most hysterectomies performed after failed Levonorgestrel IUS used to treat HMB, contained uterine fibroids [12]. We had 82 cases of failed IUS, 63 cases of failed endometrial ablation and 13 cases where both modalities failed (Table 1).
We identified that women`s choice for definitive treatment was one
of the commonest indications for hysterectomy where 62% of women
asked for hysterectomy aiming for complete amenorrhoea (Table
1). We should keep in mind that other medical and surgical uterine
sparing modalities might not guarantee complete amenorrhoea. The
HEALTH study; a randomisation trial which compared laparoscopic
supracervical hysterectomy (LASH) and EA for the management
of HMB concluded that LASH resulted in significantly higher
satisfaction and better quality of life compared with EA [13].
LASH led to a greater improvement in menstrual blood loss,
cyclical period-like pain, and dyspareunia, without incurring a higher
risk of postoperative complications or [13].
Women still need hysterectomy for HMB despite the high effectiveness of modern medical and surgical uterine sparing modalities. The commonest pathology identified in women needing hysterectomy is benign uterine fibroid with or without adenomyosis. Failed IUS followed by women`s choice for complete amenorrhoea were the leading indications for hysterectomy in this series. Other causes such as chronic pelvic pain, dysmenorrhoea or known endometriosis and failed EA were also identified. These parameters when present in women with HMB, should be considered as indicators for increased likelihood of hysterectomy in order to direct the counselling process towards hysterectomy rather than uterine sparing modalities to reduce women`s suffering where uterine sparing modalities might fail.
I declare that I did not receive any funding to conduct this retrospective study.
I would like to thank Miss Claire Challoner, Dr.NazorahMalek, Dr. Sandeep Kaur, Dr. Ala Abdullah, Dr.Neelam Agrawal and Dr Sheena Johns in helping us to collect the data.
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