Key content
Heavy menstrual bleeding affects one in five premenopausalbwomen and can significantly impair quality of life.
Management options for heavy menstrual bleeding are diverse andbinclude a variety of medical, radiological and surgical treatments.
Surgical treatment options are endometrial ablation, hysterectomy and myomectomy.
Treatment choice for heavy menstrual bleeding should take into account underlying pathology, and the woman’s preferences and fertility needs.
Learning objectives
To understand the efficacy, patient-centred outcomes, risk profile and cost-effectiveness of various surgical modalities for the treatment of heavy menstrual bleeding in premenopausal women.
To evaluate differing surgical approaches and techniques for hysterectomy and myomectomy, and their advantages and limitations.
To be able to undertake informed counselling about the different surgical treatment modalities for heavy menstrual bleeding.
Ethical issues
Is it justified to offer hysterectomy as a first choice surgical option
that entails increased morbidity but has higher satisfaction rates
and is more cost-effective?
How can the continuing high rates of open abdominal
hysterectomy be justified for a benign condition when the evidence
clearly supports alternative routes?
Keywords: heavy menstrual bleeding / hysterectomy / myomectomy
Introduction
Myomectomy
Hysteroscopic myomectomy
Abdominal myomectomy
Hysterectomy
Surgical approach: which route to choose?
Abdominal hysterectomy
Laparoscopic hysterectomy
Vaginal hysterectomy
Robot-assisted hysterectomy
Risks and complications of hysterectomy
Conclusion
Heavy menstrual loss exerts a significant burden on society
and NHS resources. It is important that women are offered
the most effective treatments and involved in the decisionmaking
process. There is good evidence to support the use
of both endometrial ablation and hysterectomy for women
with HMB as both achieve high satisfaction rates and
significantly improve quality of life. There is poor evidence
to support myomectomy to normalise menstrual loss, unless
intracavity, and further research is needed here. It is
disappointing that rates of abdominal hysterectomy remain
above 60% in the UK, when the evidence and
recommendations support vaginal and laparoscopic
approaches. Complications from surgery are reported as
more commonplace when laparoscopic hysterectomy is
undertaken, but the evidence is cited from potentially
outdated trials. Advances in equipment, surgical technique
and better training programmes should reduce complication
rates. Consideration should be given to laparoscopic
subtotal hysterectomy, which has low major complication
rates, a short hospital stay and a quick return to normal
activities for the woman, although results from the
HEALTH trial should be awaited before routine
introduction.