Surgical Option: Hysterectomy may top drugs for women with heavy bleeding

Women who chronically have heavy menstrual periods face a difficult choice. Many cases of abnormal bleeding stem from a hormone imbalance, and drugs containing progesterone and estrogen often alleviate the problem. Medications don’t always work, however. Another option is a hysterectomy, or removal of the uterus, which stops menstrual bleeding. But it is major surgery and ends a woman’s reproductive life.

A U.S. study now finds that women who fail to improve after taking a hormone-based drug do better if they undergo a hysterectomy than do women in similar circumstances who try other drugs instead. A separate but similar study by Finnish researchers finds little difference between surgery and extended drug therapy.

In both studies, however, many of the women assigned to receive drugs chose to abandon medication at some point and have a hysterectomy, suggesting that the drugs weren’t working adequately. The studies appear in the March 24/31 Journal of the American Medical Association (JAMA).

The U.S. researchers recruited women between ages 30 and 50 who had reported either heavy menstrual bleeding for at least 7 days per month or anemia because of heavy bleeding. Each of the recruits had failed to improve while taking medroxyprogesterone acetate, a first-line hormonal treatment, and was willing to have a hysterectomy, says study coauthor Miriam Kuppermann, an epidemiologist at the University of California, San Francisco (UCSF).

Kuppermann and her colleagues randomly assigned 29 women to undergo hysterectomy and 30 to receive orally one of several combinations of hormones or a hormone-regulating drug.

After 6 months, the women who had undergone hysterectomies reported more improvement in mental health, sexual desire, and sleeping patterns than the women getting only drugs did.

After 2 years, the improvements held up for women who had hysterectomies. Within that time, 16 of the women assigned to drug-only therapy requested and got a hysterectomy and subsequently improved in overall health. The 14 women who stayed on medication reported better physical and mental health at the 2-year mark than they did before the study.

In the Finnish research, gynecologist Ritva Hurskainen of Helsinki University Hospital and her team randomly assigned 115 women to get a hysterectomy and 117 others to receive an intrauterine device that discharged the hormone-based drug levonorgestrel directly to the uterus.

After 5 years, volunteers in the hysterectomy group showed clear improvements in an overall index of physical and mental health. Among the women receiving medication via the intrauterine device, 50 requested a hysterectomy during the trial. The remaining 67 women taking drugs reported health improvements equal to those in the hysterectomy group.

Notable in both trials is that roughly half of the women assigned to receive drugs ultimately opted for a hysterectomy, physicians Roy M. Pitkin of the University of California, Los Angeles and James R. Scott of the University of Utah in Salt Lake City say in an editorial in JAMA accompanying the two reports. These women were those who hadn’t done well on the drugs.

If this switch rate is true of the general population, Pitkin and Scott note, then doctors counseling women who have heavy bleeding can point out that half of those who pursue hormonal therapy eventually choose to have a hysterectomy.

On the other hand, says Lee A. Learman, an obstetric gynecologist at UCSF and a coauthor of the U.S. study, the finding that about half the women stay with the drug therapy indicates that it can provide some women—probably those well into their 40s—with a “bridge therapy” to menopause and let them avoid surgery.

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