ALTERNATIVES TO HYSTERECTOMY.
Uterine fibroids and DUB affects millions of women for which total abdominal hysterectomy (TAH) is performed by gynaecologists. It is a fact that all surgery carries risks. Before deciding in favour of hysterectomy, both the surgeons and patients should consider the treatment options or alternatives for the ailment that
In recent years, there has been a trend towards medical treatment of symptomatic fibroids largely because of changing attitudes of women towards child-bearing and uterine conservation. In this era of evidence-based medicine, a thorough assessment of available research data is necessary to determine the place of new therapies in clinical practice.
1. Non Aggressive Management –
Wait and watch policy without doing any harm is a good norm in the management of some fibroids. Asymptomatic women or whose symptoms do not influence their general health or lifestyle may be kept under surveillance. Regular/periodic clinical follow-up and ultrasound scans need be done to detect any deterioration of symptoms or increase in fibroid size or volume so that proper timely care can be provided.
2. Antifibrinolytics —
Epsilon aminocaproic acid (EACA) and tranexamic acid as well as ethamsylate decrease blood loss by 50% in menorrhagic women. Although ethamsylate reduces capillary fragility, the exact mode of action is not clear. Caution is advised by Shaw10 before prescribing these drugs to women with history of, or risk factors from, thrombic disorders.
3. Non-steriodal anti-inflammatory drugs (NSAIDs) —
Administration of prostaglandin synthatase inhibitors ie, NSAIDs can reduce bleeding in menorrhagic women11. NSAIDs decrease menstrual blood loss by an average of 30% when given to women complaining of heavy periods. These are most effective in reducing blood loss in ovulatory patients, specially when used with oral contraceptives, or they can be used alone in women with DUB who wish to conceive.
4. Progestogens, oestrogen-progestogen combination and combined oral contraceptive pills —
Hormones play a major role in the treatment of DUB in reproductive age. Norethisterone is preferred for cyclical therapy in younger women for its better effect. It serves to reduce blood loss and act as a contraceptive as well.
5. Danazol —
A synthetic derivative of ethisterone is more effective than norethisterone in controlling menorrhagia. There is a substantial reduction in menstrual blood loss and it provides time for consideration to patients awaiting hysterectomy. But, danazol has significant side-effects, expensive and its effect is temporary.
6. Laevonorgestrel releasing intra-uterine system / device —
It is used as a contraceptive and in conservative treatment of menorrhagia with considerable success. It can also be used in carefully selected women with menorrhagia caused by fibroids. It should only be offered to women whose uterus does not exceed 12 weeks in size without any distortion of the cavity. The results appear to be promising showing a reduction in blood loss as well as fibroid shrinkage12.
7. GnRH analogues —
These are commonly used to control fibroid-related menorrhagia. Used pre-operatively, they reduce fibroid volume and control excessive bleeding. Their use is normally limited to a maximum of six months because long term use is associated with menopausal adverse effects and bone density loss. GnRH agonists are valuable for short term use in DUB, particularly if the patient is infertile and keen to conceive. A combination of depot GnRH agonist and cyclical hormone therapy is a successful and acceptable treatment of DUB13.
S N Mukherjee
DGO, MD, FACS, FAMS, FICOG, FICMCH, Senior Consultant Obstetrician and Gynaecologist, New Delhi 110092 and Ex-Professor and Head of the Department of Obstetrics and Gynaecology, JIPMER, Pondicherry 605006, Indira Gandhi Medical College, Simla 171001, UCMS and Safdarjung Hospiral, New Delhi 110095, Maulana Azad Medical College and LNJPN Hospital, New Delhi 110002
Dr. Ashok Koparday
MBBS, FC SEPI
Center for Therapy, Education, Research in
Sex, Marriage, Relationships
Ex. Teaching Faculty
Seth G. S. Medical College and K. E. M. Hospital and
Grant Medical College and Sir J. J. Group of Hospitals
University of Mumbai, India