WHAT THIS EVIDENCE MEANS FOR PRACTICE
Use of the FIGO-recommended terms, definitions, and classification of AUB will lead to higher-quality clinical research and thorough clinical investigation into the causes of AUB, with improved management of patients.
How hysterectomy for AUB compares with less invasive treatment options
Matteson KA, Abed H, Wheeler TL II, et al; Society of Gynecologic Surgeons Systematic Review Group. A systematic review comparing hysterectomy with less invasive treatments for abnormal uterine bleeding. J Minim Invasive Gynecol. 2012;19(1):13–28.
To create reliable treatment recommendations for AUB, as defined by the FIGO classification system just described, in women with ovulatory disorders, endometrial hemostatic dysfunction, and concomitant leiomyoma, the Systematic Review Group (SRG) of the Society of Gynecologic Surgeons performed a systematic review of treatments. The analysis was intended to compare hysterectomy with less invasive treatment modalities. The SRG reviewed randomized, controlled trials of AUB treatment that compared hysterectomy with:
- endometrial ablation by resectoscopic loop, rollerball, or thermal balloon
- the LNG-IUS
- medical therapy.
This comprehensive review of literature published between 1950 and January 14, 2011 led the SRG to create seven categories of clinical outcomes:
- bleeding control
- quality of life
- pain
- sexual health
- patient satisfaction
- need for additional treatment
- adverse events.
Of the initial 5,503 titles identified, only 18 articles, representing nine clinical trials, contained data of adequate quality to meet criteria for review. Seven of the trials compared hysterectomy with ablation, one compared hysterectomy with the LNG-IUS, and one compared hysterectomy with medical therapy. As FIGO has pointed out, the lack of homogeneity of terminology used to describe AUB and classification of its causes prevented clinically applicable comparative analyses of treatment outcomes.
Here are some of the SRG’s findings:
- Control of bleeding. Only data regarding amenorrhea were sufficient for comparative analysis. The SRG was able to conclude only that there was moderate strength of evidence supporting the statement that bleeding is better controlled following hysterectomy than following ablation.
- Quality of life. Overall, studies that evaluated quality of life showed improvement after ablation and hysterectomy. The strength of evidence demonstrating no difference between hysterectomy and ablation in postoperative quality of life was moderate.
- Pain, general health, vitality, and social function. Three studies found statistically significant differences in validated dimensions of the SF-36 questionnaire favoring hysterectomy for pain, general health, vitality, and social function. Two of these three studies evaluated minimally invasive hysterectomy by the laparoscopic supracervical or vaginal approach. The strength of evidence on pain beyond the postoperative time period was low and favored hysterectomy over ablation.
- Sexual health. The strength of evidence related to sexual health was low and revealed no differences between hysterectomy and ablation.
- Patient satisfaction. Overall, the quality of evidence was very low, showing no difference between hysterectomy and ablation.
- Need for additional treatment. The quality of evidence was moderate and favored hysterectomy over ablation.
- Adverse events. Evidence of moderate quality favored ablation and the LNG-IUS over hysterectomy, and low-quality evidence favored medical therapy over hysterectomy (TABLES 1, 2).
TABLE 1
What the data reveal about hysterectomy versus ablation
| Parameter | Strength of evidence (comparison) | |
|---|---|---|
| Hysterectomy | Ablation | |
| Bleeding control | Moderate (F) | — |
| Quality of life | Moderate (S) | Moderate (S) |
| Lower pain | Low (F) | — |
| Sexual health | Low (S) | Low (S) |
| Patient satisfaction | Very low (S) | Very low (S) |
| Need for additional treatment | Moderate (F) | — |
| Adverse events | — | Moderate (F) |
| F=Evidence favors comparator; S=no difference between comparators | ||
TABLE 2
What the data reveal about hysterectomy versus the levonorgestrel-releasing intrauterine system (LNG-IUS)
| Parameter | Strength of evidence (comparison) | |
|---|---|---|
| Hysterectomy | LNG-IUS | |
| Bleeding control | Moderate (F) | — |
| Quality of life | Moderate (S) | Moderate (S) |
| Lower pain | Moderate (S) | Moderate (S) |
| Sexual health | Moderate (S) | Moderate (S) |
| Patient satisfaction | Moderate (S) | Moderate (S) |
| Need for additional treatment | Moderate (F) | — |
| Adverse events | — | Moderate (F) |
| F=Evidence favors comparator; S=no difference between comparators | ||
The SRG concluded that there are tradeoffs between treatment effectiveness and the risk of serious adverse events between hysterectomy, ablation, and the LNG-IUS. It recommended that clinicians be educated about the relative advantages and disadvantages of each option so that they can discuss them with patients.
The SRG developed clinical practice guidelines for the treatment of ovulatory disorders and endometrial hemostatic dysfunction associated with AUB (see below).
WHAT THIS EVIDENCE MEANS FOR PRACTICE
Gynecologists should educate each patient about the efficacy and risks of options available for the management of AUB in the context of specific symptoms to facilitate an informed choice.
Wheeler TL II, Murphy M, Rogers RG, et al; Society of Gynecologic Surgeons Systematic Review Group. Clinical practice guidelines for abnormal uterine bleeding: hysterectomy versus alternative therapy. J Minim Invasive Gynecol. 2012;19(1):81–87.
The SRG used the results of the systematic review just summarized to formulate clinical guidelines for the treatment of AUB related to ovulatory disorders and endometrial hemostatic dysfunction. Recommendations were assigned a grade for their strength on the basis of the quality of supporting evidence, the size of the net medical benefit, and other considerations, including values and preferences applied in judgments. The strength of the clinical recommendation is either “strong” or “weak” and indicates the degree to which one can be confident that adherence to the recommendation will do more good than harm. All of the clinical recommendations described below received a grade of “weak.”