Dysfunctional uterine bleeding--place of hysterectomy in its management.
With better understanding of the endocrine control of menstruation, the etiopathology and management of dysfunctional uterine bleeding has changed from an extreme conservatism to minimal radical surgery. Hysterectomy in the perimenopausal women remains as a last resort approach to this problem, Dysfunctional uterine bleeding associated with prolapse, and previous sterilisation often tempts the surgeon towards hysterectomy. It does remain a mode of management in such cases.
The present review summarises 357 cases of hysterectomies done for dysfunctional uterine bleeding alone or associated with other causes.
This work comprises 357 cases admitted to the K. E. M. Hospital, Bombay, during a period of 1 year from January to December 1983 with a provisional diagnosis of dysfunctional uterine bleeding alone or associated with the other symptoms. They were subjected to hysterectomies later.
All these patients were broadly divided into three groups according to their menstrual complaints: (i) menorrhagia (ii) polymenorrhoea (iii) meno-metrorrhagia. These patients were subjected to dilatation and curettage and/or hormonal therapy before hysterectomy. Routine, preoperative evaluation of these patients was done.
As a matter of policy decision for the route of hysterectomy, vaginal hysterectomy was undertaken only when the uterus was mobile with a descent and the size was not greater than twelve weeks. Associated symptoms like prolapse also formed an indication for vaginal hysterectomy.
There were a total of 719 cases of hysterectomies carried out for benign conditions of the uterus, at K.E.M. Hospital in the year 1983. Out of them, 357 hysterectomies were performed for dysfunctional uterine bleeding alone or associated with other causes, thereby forming an incidence of 49.65%.
[Table - 1] shows the age and parity-wise distribution of these patients. Out of total 357 patients, 51.26%, patients had menorrhagia, 36.7% patients had polymenorrhoea and 12.04% patients had meno-metrorrhagia. Associated symptoms like prolapse occurred in 8.12% of the patients.
All these patients were subjected to curettage once or twice before hysterectomy. [Table - 2] depicts the number of patients subjected to the therapy before hysterectomy for dysfunctional uterine bleeding.
Pre-operatively, 200 patients (56.02%) were anaemic, amongst whom 38 patients required one and 19 patients required two blood transfusions followed by parenteral iron therapy and the remaining 143 patients required only parenteral iron therapy. Forty nine and 29 patients were hypertensive and diabetic respectively. These patients were stabilised before surgery.
Out of total 357 cases, 336 hysterectomies (305 simple, 29 with A.P. repair and 2 with Kelly's stitch) were performed per vaginum whereas 21 were done per abdomen. Histopathological examination of the uteri removed at surgery showed proliferative endometrium in 226 patients, typical hyperplastic endometrium in 74, atypical hyperplastic endometrium in 30 and secretory endometrium in 27 patients, Myometrium was normal in 349 patients, whereas adenomyosis and myohyperplasia were found in 5 and 3 patients respectively. Squamous metaplasia of the cervix was found in 24 cases. These findings are consistent with those of Das and Chugh.
[Table - 3] depicts the mortality and morbidity of these patients. Twenty-three patients had pre-operative and 5 had post-operative haemorrhage requiring blood transfusion, Post-operative pyrexia (defined as two oral temperatures of 38°C on two separate occasions, post-operatively, excluding the first 24 hours) occurred in 80 patients (22.4%).
Dysfunctional uterine bleeding is the bleeding from uterus, abnormal either in amount or duration or in its regularity or frequency or in its relation to menstruation in the absence of any palpable or detectable pelvic pathology, but yet due to disturbed corticohypothalamic-hypophyseal utero-ovarian axis relationship.
Dysfunctional uterine bleeding is more commonly seen in perimenopausal and reproductive age groups. Although it is frequently found in the adolescent age group, being self limiting it seldom requires hospitalisation.
It is essential to take all appropriate steps to exclude organic disease, if necessary by repeated and/or special investigations and to make a Positive diagnosis of the endocrinological or functional defect underlying the dysfunctional bleeding. Treatment should be individualised according to (a) age, parity, emotional and social background of the patients, (b) the severi-61, pattern and duration of bleeding and general disturbance of the Patients and (c) the nature of underlying defect, the prognosis and the likelihood of organic disease.
The aims of treatment of dysfunctional uterine bleeding are: (i) to control abnormal loss of blood, (ii) to establish regular menstruation and (iii) to prevent recurrent bleeding.
In the perimenopausal age groups, it is better to do curettage first (i) to rule out neoplasm (ii) to provide enough tissue for diagnostic evaluation and (iii) to assure quick control of haemorrhage. In 60% of the patients of perimenopausal age group, the symptoms recur after one curettage. In these patients, who do not respond to curettage or hormonal therapy, hysterectomy5 either by vaginal or abdominal route remains a last resort of cure.
The operative mortality of hysterectomy is as low as 0.2% or even less in well equipped centres. The substantial disagreement persists over the appropriate indications for hysterectomy6 as compared with these for conservative surgery or alternative therapy because despite advances in operative gynaecology, hysterectomy today carries a substantial risk of morbidity. Hence, the operation should be elective and the patients must be prepared properly to reduce post-operative mortality and morbidity