William H. Parker, MD

The American College of Obstetricians and Gynecologists (ACOG) recently published an updated committee opinion regarding morcellation of presumed uterine leiomyoma.

The key points included in the recommendations are careful preoperative patient evaluation; patient counseling regarding risks and benefits of manual or electromechanical morcellation; the increased morbidity associated with open procedures; and, importantly, the recommendation for shared decision-making with each patient based on their individual medical condition, goals of treatment, risk of malignancy, and personal preferences.

Parker is an ob-gyn specializing in the evaluation and treatment of women with uterine fibroids. He is an expert in surgery for myomectomy using minimally invasive surgery or through open abdominal incisions. He is affiliated with the University of California San Diego Health.

The best estimate of the risk of a leiomyosarcoma (LMS) being found at surgery for a presumed fibroid comes from a thorough and sophisticated analysis of 156,726 women published by the Agency for Healthcare Research and Quality (AHRQ).

 AHRQ is a division of the US Department of Health & Human Services with core competencies in data and analytics. 

Although the overall estimate based on these studies showed a range from 1 in 770 to 1 in 10,000, analysis of the best evidence using prospective studies found the risk to be approximately 1 in 3000 women having surgery for fibroid-related symptoms.

Currently, we do not have reliable preoperative diagnostic testing to identify LMS. However, risk stratification can be improved using a patient’s age, history, tamoxifen use, imaging, cervical cancer screening, endometrial tissue sampling, and lactate dehydrogenase (LDH) blood test (

Studies show that women who are screened with a careful history (including age, bleeding pattern, and tamoxifen exposure) and clinical evaluation (endometrial biopsy/dilation and curettage, serum LDH, and MRI) are at very low risk of having a LMS morcellated.

Although LMS can occur in younger women, the average age of women who receive a diagnosis of LMS is approximately 60 years. Advancing age is a risk factor; however, no sudden increase in risk occurs after aged 50 years. 

Restricting access to a treatment option based on age alone is uncommon, and older women have greater morbidity from open procedures.

 Heavy menstrual bleeding is common among women with fibroids, but irregular menstrual bleeding and postmenopausal bleeding should be investigated with an assessment of the endometrium with imaging and/or endometrial sampling. Atypical or malignant cells can be found with endometrial sampling in as many as 60% of women with LMS.

MRI with and without contrast enhancement is the most accurate imaging modality to assess LMS. Solitary large masses, irregular borders, the presence of hemorrhage, increased contrast enhancement, and restricted diffusion all raise suspicion of LMS. 

LDH is an enzyme commonly found in cells but made in greater amounts by malignant cells. Total LDH and isoenzyme 3 have been found to be increased in some women with LMS.

Morcellation describes a variety of techniques to cut tissue into smaller fragments that allow the tissue's removal from the abdominal cavity through small incisions. 

Morcellation can be done manually with a scalpel through the vagina or abdominal incision or with an electromechanical device through a laparoscopic port site. All types of morcellation may disseminate cells throughout the pelvic and abdominal cavities. 

Notably, uterine muscle spindle cells have been found in the abdomen prior to morcellation during open and laparoscopic myomectomy and laparoscopic hysterectomy.

 The use of a containment system to limit tissue dissemination has been cleared by the FDA. Containment systems have been shown to leak and have not been shown to limit spread of LMS or influence survival for women found to have LMS.

Minimally invasive surgery has less morbidity and risk of death than open abdominal surgeries. Following the FDA’s initial advisory for morcellation procedures, studies showed a decrease in minimally invasive surgery, a corresponding increase in open abdominal procedures, and an associated increase in complications, hospital readmissions, and patient deaths.

All medical decisions are based on an assessment of risks and benefits for an individual patient. 

Shared decision-making is a collaborative process of understanding the risks and benefits of treatment options (including no treatment), open and minimally invasive approaches to surgery, and morcellation and contained morcellation. 

The appropriate option differs from patient to patient and depends on the patient’s specific medical issues, assessment of risks, and the patient’s preferences. These conversations take time, but important guidance can come from patient-centered discussions.

Unfortunately for women with fibroids, the FDA analysis and warnings regarding morcellation are restrictive, not evidence-based, and will commit many women to more morbid open procedures. Thank you to ACOG for suggesting a reasoned and reasonable patient-centered approach. 

Uterine morcellation for presumed leiomyomas: ACOG Committee opinion summary, number 822. 

. 2021;137(3):552-553. doi:10.1097/AOG.0000000000004292

Hartmann KE, Fonnesbeck C, Surawicz T, et al. 

. Agency for Healthcare Research and Quality (US); 2017.

Lieng M, Berner E, Busund B. Risk of morcellation of uterine leiomyosacomas in laparoscopic supracervical hysterectomy and laparoscopic myomectomy, a retrospective trial including 4791 women. 

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Jorgensen EM, Li A, Modest AM, Leung K, Moore Simas TA, Hur HC. Incidence of venous thromboembolism after different modes of gynecologic surgery. 

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Hinchcliff EM, Esselen KM, Watkins JC, et al. The role of endometrial biopsy in the preoperative detection of uterine leiomyosarcoma. 

. 2016;23(4):567-572. doi:10.1016/j.jmig.2016.01.022

Goto A, Takeuchi S, Sugimura K, Maruo T. Usefulness of Gd-DTPA contrast-enhanced dynamic MRI and serum determination of LDH and its isozymes in the differential diagnosis of leiomyosarcoma from degenerated leiomyoma of the uterus. 

. 2002;12(4):354-361. doi:10.1046/j.1525-1438.2002.01086.x

Sandberg EM, van den Haak L, Bosse T, Jansen FW. Disseminated leiomyoma cells can be identified following conventional myomectomy. 

. 2016;123(13):2183-2187. doi:10.1111/1471-0528.14265

Toubia T, Moulder JK, Schiff LD, Clarke-Pearson D, O’Connor SM, Siedhoff MT. Peritoneal washings after power morcellation in laparoscopic myomectomy: a pilot study. 

. 2016;23(4):578-581. doi:10.1016/j.jmig.2016.02.001

Chen J, Wield A, Bose S, et al. Smooth muscle cells in pelvic washings at time of benign hysterectomy. 

 2019;26(6):1144-1148. doi:10.1016/j.jmig.2018.11.008

Cohen SL, Greenberg JA, Wang KC, et al. Risk of leakage and tissue dissemination with various contained tissue extraction (CTE) techniques: an in vitro pilot study. 

. 2014;21(5):935-939. doi:10.1016/j.jmig.2014.06.004

Harris A, Swenson CW, Uppal S, et al. Practice patterns and postoperative complications before and after US Food and Drug Administration safety communication on power morcellation. 

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Multinu F, Casarin J, Hanson KT, et al. Practice patterns and complications of benign hysterectomy following the FDA statement warning against the use of power morcellation. 

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Rabi DM, Kunneman M, Montori VM. When guidelines recommend shared decision-making. 

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Articles

The American College of Obstetricians and Gynecologists (ACOG) recently published an updated committee opinion regarding morcellation of presumed uterine leiomyoma. Here are the key points. 

Morcellation, ACOG, and shared decision-making

What Are the Treatment Options for         Fibroids?

If you need treatment for fibroids, there are a number of         options available to you. Your choices should be guided by the medical         problems the fibroids are causing, your desire to have children, and         your feelings and thoughts about surgery or other options. I think it is         important for you to know all the options available. Even if some         treatments do not apply at the current time, your condition or symptoms         may change. If you understand the potential for future symptoms and         problems, as well as the alternative means of treatment available, much         of the mystery of fibroids will disappear.  
 

Although most women will have fibroids during their lifetime,         only a small number of them will ever need treatment. The vast majority         of women with fibroids are unaware of them until their doctor feels them         at the time of a routine exam. Some women have very minor symptoms,         which are not bothersome at all. If that is the case for you, then no         treatment is necessary. I consider careful observation to be the primary         treatment option.  

The cause of the growth of fibroids is not well understood, and the         rate of growth is unpredictable. Most fibroids never grow; others grow         gradually over the course of many years; and some seem to go through         growth spurts and then may stop growing entirely. The only way to know         what is happening is to have a pelvic examination on a regular basis. I         usually examine women with fibroids every three to six months. If the         fibroid grows during that time period, the growth will be discovered         early, and a number of options, short of hysterectomy, should still be         available. If the fibroid seems to be growing, I usually do exams more         frequently, generally every month, until the growth stops.         Ultrasonography, a simple test that uses sound waves to make a picture,         may also be used to determine the size of the fibroids.

On the other hand, fibroids may sometimes grow large enough to cause         constant discomfort, pressure, and even pain. And, while not dangerous,         the discomfort may lead you to choose surgery as treatment for fibroids.         One added note: very large fibroids may partially block blood flowing         from the legs back to the heart. This can lead to swelling of the legs         and some discomfort. Very rarely, it can also lead to formation of blood         clots in the legs that can be dangerous. If you have very large         fibroids, it is important that you not sit for prolonged periods of time         so that clots have less chance to form.

Doctors have been taught that if a woman has fibroids the size         of a large grapefruit (or a twelve-week pregnant uterus) or larger, she         would be at risk for other health problems. This reason-the future         possibility of problems-simply does not make sense to me. If you have a         large fibroid and you are feeling fine, I can't see the need for you to         undergo surgery. It is actually likely that your large fibroid will         never go on to cause you any bothersome symptoms.  

Doctors also feel that large fibroids make it very difficult to         perform a thorough pelvic examination and fear that a less than optimum         pelvic examination can result in missing an early diagnosis of ovarian         cancer. Unfortunately, ovarian cancer is extremely difficult to diagnose         in the early stages, with or without fibroids, even with the most         sophisticated and expensive testing (see 

This is a frustrating and difficult reality for us all. Usually, by         the time a gynecologist can feel an abnormality of the ovary during the         pelvic exam, the disease has already spread. It is also common for         gynecologists to not be able to feel every patient's ovaries because of         the size of the ovaries, the position of the ovaries, or the weight of         the patient. It would make no sense to recommend a hysterectomy to every         woman whose ovaries were unable to be felt by her gynecologist. And no         study has ever shown that removal of a uterus enlarged with fibroids         will make any difference in the early detection of ovarian cancer.

Another argument for aggressive surgery relates to the belief that         the risks and complications of surgery are greater if the surgery is         delayed and the uterus grows larger. As shown in a recent study by Dr.         Robert Reiter of the University of Iowa College of Medicine, the         complication rate for women who have hysterectomies for large fibroids         is no different from that for women with small fibroids. A myomectomy         may be safely performed on a woman with large fibroids.

Dr Stanley West, Dr. Reginald Ruiz and I just submitted an article         for publication reviewing the results of 91 women with uterine fibroids         larger than a four month sized pregnant uterus operated on by Dr. West         between 3/1/98 and 2/28/03 . The results compare very favourably to         other studies of women who had a hysterectomy for large fibroids.

Therefore, surgery is only reasonable if you have symptoms that truly         warrant the risk, time, stress, and money that an operation entails.         Many patients with uterine fibroids need no treatment.

Unfortunately, there are no medications currently available         that are able to prevent the formation of fibroids or permanently shrink         them once they are present. Medicines are often used to buy time or         reduce symptoms. For some women, a reduction in discomfort is enough to         indefinitely postpone surgery. For others, medication allows a more         relaxed time period to prepare emotionally and physically for an         inevitable surgery. Medications may also temporarily reduce the size of         the fibroids enough to allow for a less invasive surgery with a quicker         recovery. For some women who are approaching menopause, the "bought         time" may lead them right into menopause, when the natural loss of         estrogen and progesterone

Lupron and Synarel are two of the medications that work by temporarily         shutting off the ovaries' ability to make estrogen and progesterone, and         menstrual periods temporarily cease. Since estrogen and progesterone are         necessary for fibroids to grow, the lack of hormones causes fibroids to         shrink. Because these medications are destroyed by digestive fluids in         the stomach, they must be given in a non-pill form. Lupron is given by         injection, and Synarel is administered by nasal spray.  

These medications take about two weeks to begin shrinking the         fibroids, and the full effect is seen after three months. At that time,         most fibroids will decrease in size by about 50 percent of their volume.         The shrinking effect is maintained for as long as you use the         medication, but there is rarely any further shrinkage after the third         month of treatment. If the medication is stopped, the ovaries begin to         produce hormones again and the fibroids return to their original size         within three months. Therefore, the medication has no permanent effect         and is primarily used to reduce symptoms and allow time to correct         anemia and plan surgery. In addition, long-term use of these medications         is limited by their side effects and the risk of osteoporosis.

Two medications used to treat uterine fibroids are now in clinical         trials. Both drugs act by blocking the growth-promoting action of         progesterone on fibroids. The first drug is RU-486, also known as the         abortion pill. This medication is being studied in Rochester , NY and         the researchers have found about a 50% reduction in fibroid size after         taking this oral medication. Because the drug blocks progesterone but         not estrogen, the estrogen from the ovaries can stimulate the lining         cells of the uterus without any counter action by the progesterone.         After a year of treatment, about 5% of women had overgrowth of these         lining cells, although no one developed pre-cancer or cancer. There is         some concern that continued use of this medication might eventually lead         to pre-cancer or cancer, but again, this has not been found so far.         Other side-effects include hot flashes

Low-dose mifepristone for uterine leiomyomata.
 Authors: Eisinger SH, Meldrum S, Fiscella K, le Roux HD, Guzick                 DS.


 
 OBJECTIVE: To compare the effect of 5 and 10 mg of mifepristone                 on uterine leiomyoma size and symptoms, and to measure side                 effects.

METHODS: Forty premenopausal women with large,                 symptomatic leiomyomata were randomized to receive either 5 or                 10 mg of mifepristone daily for 6 months in an open-label study.                 Uterine volume was measured at bimonthly intervals by sonography.                 Serum concentrations of hemoglobin levels, follicle-stimulating                 hormone, and liver enzymes were obtained, and endometrial                 samples, symptoms, and menstrual bleeding were also assessed.

RESULTS: Nineteen of 20 subjects taking 5 mg and all 20                 subjects taking 10 mg completed all 6 months of the study. Mean                 uterine volume shrank by 48% (P <.001) in the 5-mg group and                 49% (P <.001) in the 10-mg group, a nonsignificant                 difference. Leiomyoma-related symptoms were comparably reduced                 in both groups. Amenorrhea occurred in 60-65% of both groups.                 Hemoglobin levels increased by 2.5 g/dL in anemic subjects. The                 incidence of hot flashes increased significantly over baseline                 in the 10-mg group but not in the 5-mg group. Simple endometrial                 hyperplasia occurred in 28% of all subjects, with no difference                 between groups. No atypical hyperplasia was noted.

CONCLUSION: Mifepristone in doses of 5 mg or 10 mg                 results in comparable leiomyoma regression, improvement in                 symptoms, and few side effects. Further study is needed to                 assess the long-term safety and efficacy of low-dose                 mifepristone.

The other progesterone blocking drug is Asoprisnil. Early results         also show about a 50% shrinkage in fibroid size.

I am including the only published abstract so far (funded by TAP the         company that makes the drug):

Asoprisnil (J867): a selective progesterone receptor                 modulator for gynecological therapy.
             
             Authors: DeManno D, Elger W, Garg R, Lee R, Schneider B, Hess-Stumpp                 H, Schubert G, Chwalisz K.

Steroids. 2003 Nov;68(10-13):1019-32.
             
             TAP Pharmaceutical Products Inc., 675 N. Field Drive , 600452,                 Lake Forest , IL , USA
             
             Asoprisnil is a novel selective steroid receptor modulator that                 shows unique pharmacodynamic effects in animal models and                 humans. Asoprisnil, its major metabolite J912, and structurally                 related compounds represent a new class of progesterone receptor                 (PR) ligands that exhibit partial agonist and antagonist                 activities in vivo. Asoprisnil demonstrates a high degree of                 receptor and tissue selectivity, with high-binding affinity for                 PR, moderate affinity for glucocorticoid receptor (GR), low                 affinity for androgen receptor (AR), and no binding affinity for                 estrogen or mineralocorticoid receptors. In the rabbit                 endometrium, both asoprisnil and J912 induce partial agonist and                 antagonist effects. Asoprisnil induces mucification of the                 guinea pig vagina and has pronounced anti-uterotrophic effects                 in normal and ovariectomized guinea pigs. Unlike antiprogestins,                 asoprisnil shows only marginal labor-inducing activity during                 mid-pregnancy and is completely ineffective in inducing preterm                 parturition in the guinea pig. Asoprisnil exhibits only marginal                 antiglucocorticoid activity in transactivation in vitro assays                 and animal models. In male rats, asoprisnil showed weak                 androgenic and anti-androgenic properties. In toxicological                 studies in female cynomolgus monkeys, asoprisnil treatment                 abolished menstrual cyclicity and endometrial atrophy. Early                 clinical studies of asoprisnil in normal volunteers demonstrated                 a dose-dependent suppression of menstruation irrespective of the                 effects on ovulation, with no change in basal estrogen                 concentrations and no antiglucocorticoid effects. Unlike                 progestins, asoprisnil does not induce breakthrough bleeding.                 With favorable safety and tolerability profiles thus far,                 asoprisnil appears promising as a novel treatment of                 gynecological disorders, such as uterine fibroids and                 endometriosis.

Can Lupron Be Used for Women Approaching         Menopause?

A woman with fibroids who is approaching menopause can use         Lupron or Synarel until menopause begins. Then the natural supply of         estrogen will cease, and the fibroids will remain small without any         medication. However, because the exact age of natural menopause is         unpredictable, this can turn into an expensive proposition-$2,000 per         year-and is usually not covered by medical insurance. But, for some         women, this treatment plan may be useful.  

Are There Any Other Promising         Medications on the Horizon?

Pirfenidone is a new, not yet available, medication that blocks         the growth of existing fibroids and may stop the formation of new         fibroids. Although the exact mechanism of action is not known,         pirfenidone affects the production of collagen, a major component of         fibroids. Other effects of pirfenidone on cell growth factors may also         be important. Studies are now under way to evaluate how fibroids respond         to this new drug and to evaluate its side effects. In the future, women         with small fibroids may be able to take pirfenidone, or a medication         like it, to prevent fibroid growth and avoid any other need for         treatment.

Can Focused Ultrasound Be Used to Treat         Fibroids?

Ultrasound is a form of energy, and when used at high intensity         and focused on an object, the energy can be used to destroy that object.         This principle has recently been used in experiments for the treatment         of fibroids. The ultrasound energy is generated outside the body but         focused on a fibroid in the uterus. The procedure presently takes a few         hours to treat each fibroid. The size of the fibroid that can be         successfully treated is limited to about a two-inch (5cm) diameter. This         procedure is in its early development. We hope these techniques can be         refined so that the procedure time will be shorter, and the size of the         treated fibroid can be larger.

If you need treatment for fibroids, there are a number of options available to you. Your choices should be guided by the medical problems the fibroids are causing, your desire to have children, and your feelings and thoughts about surgery or other options. I think it is important for you to know all the options available.

Conservative Treatment for Fibroids

Throughout history, menstruation has been associated with myth and         superstition. Menstrual blood was felt to cure leprosy, warts,         birthmarks, gout, worms and epilepsy. It has been used to ward off         demons and evil spirits. Menstruating women have been separated from         their tribes in order to prevent a bad influence on the crops or the         hunt. As recently as 1930, the cause of abnormal menstrual bleeding was         felt to be an undue exposure to cold or wet just prior to the beginning         of the period.  

In modern times we have learned that menstruation is the end of the         monthly cycle a woman's body goes through if conception has not occured,         allowing the uterine lining to start over again for the next cycle. We         have made quantum leaps towards understanding the role menstruation         plays in preparing a woman's body for reproduction. And we have learned         a great deal about the treatment of many of the problems of abnormal         periods. Science has thankfully dispelled the myths and superstitions         that surrounded menstruation and sexuality, but the mystery and wonder         of these processes stays with us still. 

Since the days that I studied the female hormone system in medical         school, new research has revealed an astonishingly complex system of         hormones and nerve transmitter proteins that interplay to regulate the         monthly menstrual cycle

. The system is balanced, but in certain         situations - such as times of stress, when body weight changes, when         taking medications - it is easily upset. Once the balance is upset,         bleeding can occur that is outside of the normal pattern. Also, cells         that form abnormal growths within the uterine lining - polyps,         hyperplasia, cancer- can cause bleeding as they develop. In the first         part of this chapter, we will deal with the circumstances and solutions         for problems with your periods. The second part of the chapter will deal         with painful periods and the new ideas and treatments for this common,         bothersome and, sometimes, incapacitating problem. 


 The onset of menstrual periods occurs between the ages of 9-17 with the         average age being 13. Adolescents tend to have periods that are far         apart and then establish more regularity over the subsequent few years.         Most adult women will have a menstrual cycle, measured from the first         day of any bleeding to the next episode of bleeding, about every 21-35         days. Although women expect to bleed every 28 days, only 15% of women         actually have cycles that length. Bleeding usually lasts 4-6 days with         some women bleeding a few days longer or shorter. Most women lose about         6 teaspoons of blood each month. Interestingly, the number of days         between periods changes over time, with periods becoming further apart         as women reach their forties. 

Abnormal bleeding is said to occur if you have a period more often         than every 21 days, less often than every 35 days, or if you have         bleeding or spotting in between periods. Very heavy bleeding, saturating         a pad or tampon every hour or two for more than a few hours, is also         abnormal. There are a number of causes of abnormal bleeding, and the         good news is that almost all of them are benign and easily treatable.         The most common causes are hormonal changes, ovarian cysts, uterine or         cervical polyps, overgrowth of the uterine lining cells (hyperplasia),         fibroids, and, rarely, precancer or cancer of the uterus. The following         sections will explain each of these problems in detail. 

WHAT SHOULD BE DONE IF YOU HAVE ABNORMAL BLEEDING DURING         PERIMENOPAUSE OR AFTER MENOPAUSE?
 

As menopause approaches, most women will experience lighter and less         frequent periods. However, the likelihood of bleeding from other causes         such as hyperplasia (lining overgrowth), polyps, or precancer or cancer         of the uterus increases at this time of your life. Bleeding that is         irregular, very heavy (need to change a pad every hour or two) or         prolonged (more than seven days) is abnormal and it is important to         establish the cause. The best way to accomplish this is with a sampling         of the cells from the uterine lining. The diagnostic methods available         include hysteroscopy, endometrial biopsy, and D&C. These methods are         fully described in this chapter.

This test allows the doctor to look inside the uterus by placing the         hysteroscope, a small telescope, through the vagina and into the opening         in the cervix. Once inside the uterus, the lining cells can be         inspected. Polyps, fibroids, hyperplasia and cancer can all be seen with         the hysteroscope. The procedure, called hysteroscopy, can be done in the         office in about 5 minutes and usually does not require any anesthesia.         The information the doctor can get from this procedure is invaluable.         Because many problems can be clearly seen, the diagnosis is often         certain. A number of studies have shown that the diagnosis made by         hysteroscopy followed by scraping the visualized abnormal area of lining         cells is more accurate than when a D&C is performed blindly without         the hysteroscope. 


 Endometrial ablation is an outpatient surgical procedure used to stop or         decrease bleeding from the uterus. The traditional method of performing         endometrial ablation uses electrical energy passed into the uterus at         the end of a telescope in order to burn and destroy the lining of the         uterus The uterus is filled with fluid and the doctor is able to look         through the telescope and watch to make sure the entire lining is         destroyed. This technique is very effective, but does require special         training and skill on the part of the doctor. As a result, many doctors         never learned how to perform endometrial ablation and do not offer the         procedure to their patients as an alternative to hysterectomy. 

Newer methods of ablation have recently been developed that should         allow most gynecologists to perform the procedure without involved         special training. Some of these devices may even be able to be used in a         doctor?s office, avoiding anesthesia and the added costs of a hospital.         In addition, neither of the new methods uses fluid to hold the uterus         open during surgery and thus avoids the extremely rare chance that extra         fluid might get absorbed into the bloodstream and cause complications.         One of these methods uses an expandable metal device that is inserted         into the uterus like an IUD, Once the device is expanded inside the         uterus, a gentle suction pulls the uterine lining close to the         instrument and an electrical current burns the lining cells. This         procedure only takes 90 seconds and the results have been excellent.         Another device circulates hot water inside the uterus to burn the lining         cells. This device has been specially engineered to keep the water at a         low pressure so that it cannot escape through the tubes. If the device         senses a leak it automatically shuts off. Because the water circulates         freely throughout the entire uterine cavity, the shape of the cavity         will not affect the results. As a result, the device is very effective         for women with fibroids, enlarged or abnormally shaped uterine cavities.         This procedure takes about 10 minutes and results have been comparable         to the other methods. Other devices are in development and, hopefully,         endometrial ablation will become more available to women as an         alternative to hysterectomy for heavy bleeding.
 
 

HOW WELL DOES ENDOMETRIAL ABLATION WORK? 


 After endometrial ablation, the ovaries continue to make normal amounts         of hormone, but without lining cells, bleeding cannot occur. In 50%         percent of patients, all the lining cells have been destroyed, and these         women never have another menstrual period again. In an additional 40%         percent of women, a few lining cells have been left behind, and these         women will experience a light flow for a few days each month. For 10% of         women, no improvement is noted. Still, 90% of the women who have this         procedure are extremely happy not to have to tolerate the severe and         debilitating monthly bleeding they had previously had. Women who have         had an endometrial ablation are among the most satisfied patients in my         practice. After surgery, they are able to return to normal activity and         life unencumbered by the fatigue and inconvenience associated with heavy         bleeding. 

Endometrial ablation may only be performed on women who do not wish         to have any, or any more, children. Once the lining cells of the uterus         are destroyed by the procedure, there is no place for a developing fetus         to attach within the uterus. Despite this, it is best to use some form         of contraception after the procedure. If some cells remain following         endometrial ablation, there exists the rare possibility of pregnancy. In         the few cases where pregnancy has occurred, termination of the pregnancy         has been recommended. Doctors have been concerned that without adequate         cells lining the inside of the uterus, the placenta would grow         abnormally, directly into the muscle wall of the uterus and take hold         like the roots of a tree. As a result, the placenta would not be able to         separate at the time of delivery, and hemorrhage could occur. 

WHAT ARE THE CAUSES OF PAINFUL PERIODS (DYSMENORRHEA)?
 

Dysmenorrhea refers to the pain accompanying a period. Most         menstruating women have uterine contractions of moderate strength that         each last for less than thirty seconds and occur about every 3 to 5         minutes. However, women who experience severe dysmenorrhea have cramps         that last up to 90 seconds with only a few seconds of rest in between.         And, the strength of the contraction may be up to 5 times greater than         normal. 

We now know that dysmenorrhea results from the release of a chemical         substance, called prostaglandin, from the lining cells of the uterus at         the time of the menstrual period. The prostaglandin causes contractions         of the muscle wall of the uterus, "menstrual cramps". In fact,         if you give prostaglandin to a woman by injection, severe menstrual         cramps result. Along the same lines, prostaglandin is now used to help         start the contractions of labor in women who, for medical reasons, need         to deliver their babies promptly. 

Women who have dysmenorrhea have been found to produce more         prostaglandin in the lining cells of the uterus than woman who do not         have cramps. And, when the increased amount of prostaglandin is released         at the time of the period, stronger uterine contractions are the result.         As we will discuss, new medications are now available that prevent the         formation of prostaglandins in the uterus and thus can prevent or         decrease menstrual cramps. 

The following questions and answers can be found in         our 

ARE ADOLESCENTS PRONE TO ABNORMAL             BLEEDING? 

CAN STRESS INTERFERE WITH YOUR             PERIODS? 

CAN CHANGES IN THE AMOUNT OF             EXERCISE YOU DO CAUSE ABNORMAL BLEEDING? 

CAN ANOREXIA NERVOSA INTERFERE WITH             YOUR PERIODS? 

CAN ANY MEDICATIONS INTERFERE WITH             THE MENSTRUAL CYCLE? 

CAN DRUG OR NARCOTIC USE CAUSE             ABNORMAL PERIODS? 

CAN PROBLEMS WITH YOUR THYROID GLAND             INTERFERE WITH YOUR PERIODS? 

CAN OTHER HORMONAL PROBLEMS             INTERFERE WITH YOUR PERIODS? 

CAN OVARIAN CYSTS CAUSE IRREGULAR             PERIODS? 

CAN MISSING PERIODS LEAD TO ANY             OTHER PROBLEMS?

WHAT IS THE TREATMENT FOR ABNORMAL             PERIODS?

WHAT IS THE TREATMENT IF IRREGULAR             BLEEDING IS DUE TO MISSED OVULATION?

WHEN IS A D&C NECCESARY FOR             ABNORMAL HORMONAL BLEEDING?

ARE THERE HOMEOPATHIC REMEDIES FOR             ABNORMAL BLEEDING DUE TO HORMONAL CAUSES?

WHAT IS POLYCYSTIC OVARIAN DISEASE (PCO)?

WHAT KIND OF BLEEDING PROBLEMS MAY             DEVELOP IN MENOPAUSE?

WHAT SHOULD BE DONE IF YOU HAVE             ABNORMAL BLEEDING DURING PERIMENOPAUSE OR AFTER MENOPAUSE?

WHAT IF YOU ARE BLEEDING WHILE YOU             ARE ON HORMONE REPLACEMENT THERAPY FOR MENOPAUSE?

POLYPS, FIBROIDS, HYPERPLASIA AND           CANCER

WHAT KIND OF BLEEDING PROBLEMS CAN             FIBROIDS CAUSE? 

WHAT IS THE BEST TREATMENT IF THE             CAUSE OF BLEEDING IS FIBROIDS?

Throughout history, menstruation has been associated with myth and superstition. Menstrual blood was felt to cure leprosy, warts, birthmarks, gout, worms and epilepsy. It has been used to ward off demons and evil spirits. Menstruating women have been separated from their tribes in order to prevent a bad influence on the crops or the hunt. As recently as 1930, the cause of abnormal menstrual bleeding was felt to be an undue exposure to cold or wet just prior to the beginning of the period.

Problems with your Periods

Of the 600,000 hysterectomies performed yearly in the U.S., approximately  300,000 are accompanied by prophylactic bilateral oophorectomy, traditionally  suggested as the best strategy to decrease the rate of ovarian cancer. However,  excluding women from high-risk families, ovarian cancer is a relatively uncommon  malignancy. At age 50, only about one in 1,500 women will be diagnosed with  ovarian cancer and at age 70, the age of peak incidence, only 1 in 400 will be  found to have ovarian cancer. In fact, while 16,000 women die of ovarian cancer  every year, 70,000 die of lung cancer, 28,000 die of colon cancer and 40,000 die  of breast cancer. Notably, 490,000 women die of heart disease every year and  about 48,000 women die within one year following hip fracture. 
 
 


 Premenopausal oophorectomy causes an immediate loss of all ovarian hormones.  Following menopause, the ovary continues to produce androstenedione and  testosterone in significant amounts until age 80 and these androgens are  converted in fat, muscle and skin into estrone. Following oophorectomy,  menopausal women have significantly lower levels of androstenedione and  testosterone than naturally menopausal women. 
 
 Oophorectomy has been shown to increase the risk of cardiovascular disease, the  major cause of death for women. Oophorectomy after age 50 increases the risk of  developing a first MI by 40% (RR 1.4, CI 1.0-2.0). Both estrogens and androgens  inhibit bone resorption, and androgens increase bone formation. One study found  that after 16 years of follow-up, women who were postmenopausal at the time of  oophorectomy had 54% more osteoporotic fractures than women with intact ovaries.  And, women older than 60 have a twofold increase in mortality (OR 2.18, CI  2.03-2.32) within a year following a hip fracture. 
 
 

 
 The ideal way to study risks and benefits of oophorectomy would be with a  prospective, randomized trial. However, that study would require 8,000 women to  be randomized to oophorectomy or ovarian conservation and then followed for 40  years to ascertain causes of mortality. It is unlikely that this kind of study  will ever be performed.
 
 Therefore, in order to study the risks and benefits of prophylactic oophorectomy,  we used a Markov computer model that can help to make complex medical decisions.  We reviewed the literature for studies that examine the incidence of disease and  mortality from 5 conditions that appear to be related to ovarian hormones:  coronary heart disease (CHD), ovarian cancer, breast cancer, stroke and hip  fracture, as well as data for death from all other causes. We then found data  for the relative risk of developing these five conditions for women having  either oophorectomy or ovarian conservation between the ages of 40 and 75. Next,  we calculated risk estimates for these conditions for every 5-year interval  until women in our model either died or reached the age of 80. We deliberately  chose to measure mortality because good data for quantifying morbidity or  quality of life is not available. 
 
 


 For women who have a hysterectomy with ovarian conservation at ages 50-54 and  who are not at high risk of ovarian cancer, coronary heart disease,  osteoporosis, breast cancer, or stroke, the probability of surviving to age 80  was 62.46%, compared to 53.88% if oophorectomy was performed. This 8.58%  difference in survival is primarily due to fewer women dying of CHD and hip  fracture, far outweighing the 0.47% mortality rate from ovarian cancer. If  surgery occurs at ages 55-59, the survival advantage is 3.92%, but after age 64  there was no significant difference in survival. (see graph)
 
 For a hypothetical group of 4,000 women ages 50 to 54 undergoing hysterectomy  with oophorectomy, our analysis predicts 343 excess deaths (mostly from CHD).  For the risk of ovarian cancer to outweigh the risks of CHD and hip fracture  following oophorectomy, CHD deaths would need to be 95% lower than what the  rates among women are currently.
 
 Although quality of life issues are of great importance to women, data were not  available to include these in our model. Premenopausal, and for some  post-menopausal women, oophorectomy may lead to the onset of hot flushes and  mood disturbances, a decline in a sense of well-being, a decline in cognitive  functioning, poor sleep quality, depression and a decline in sexual desire and  frequency. While estrogen therapy may reduce both these symptoms, only 17% of  women have continued hormone therapy after the WHI and fewer now start hormones  at the time of menopause. Also, the number of patients still taking either  statins or Bisphosphanates after 1 year is less than 20%. Therefore, any  assumption that medical treatment can decrease risks following oophorectomy is  questionable. 
 
 The results of our model suggest that the decision to perform prophylactic  oophorectomy should be approached with great caution for the majority of women  who are at average risk of developing ovarian cancer and who are under the age  of 65. The American College of Obstetricians and Gynecologists recommends that  “the decision to perform prophylactic oophorectomy should be based not only on  the patient’s age but also on other factors that weigh individual risk for  developing ovarian cancer against loss of ovarian function”. Hopefully, our  results will encourage a dialogue between doctors and women who are considering  ovarian conservation or oophorectomy.
 
 

Ovarian Conservation at the Time of Hysterectomy for Benign Disease


 
 William H. Parker, MD, Michael S. Broder, MD MPH, Zhimei Liu, PhD, Donna Shoupe,  MD, Cindy Farquhar, MD, Jonathan S. Berek, MD, MMSc. 
 
 

Obstetrics and Gynecology 2005;106:219-26.

 Prophylactic oophorectomy is often recommended concurrent with  hysterectomy for benign disease. The optimal age for this recommendation in  women not at high risk for ovarian cancer has not been determined.
 
 

 Using published age-specific data for absolute and relative  risk, both with and without oophorectomy, for ovarian cancer, coronary heart  disease (CHD), hip fracture, breast cancer, and stroke, a Markov decision  analysis model was used to determine the optimal strategy to maximize survival  for women not at high risk of ovarian cancer. For each 5-year age group from  40-80, four strategies were compared: ovarian conservation or oophorectomy; and  use of ERT or non-use. Outcomes as proportion of women alive at age 80 were  measured. Sensitivity analyses were performed varying both relative and absolute  risk estimates across the range of reported values. 
 
 

 Ovarian conservation until age 65 benefits long-term survival  for women undergoing hysterectomy for benign disease; women with oophorectomy  before age 55 have 8.38% excess mortality by age 80 and before age 59 have 3.92%  excess mortality. There is sustained, but decreasing, benefit until the age of  75, when excess mortality for oophorectomy is less than 1%. These results were  unchanged following multiple sensitivity analyses and were most sensitive to the  risk of coronary heart disease.
 
 

 Ovarian conservation until at least age 65 benefits long-term  survival for women not at high risk of ovarian cancer when undergoing  hysterectomy for benign disease.

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Of the 600,000 hysterectomies performed yearly in the U.S., approximately 300,000 are accompanied by prophylactic bilateral oophorectomy, traditionally suggested as the best strategy to decrease the rate of ovarian cancer.

William H. Parker, MD

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