To reduce uterine size before hysterectomy, patients with large leiomyomas may be pretreated with a gonadotropin-releasing hormone (GnRH) agonist (8,9). In many cases, the reduction of uterine size is sufficient to permit vaginal hysterectomy when an abdominal hysterectomy would otherwise be necessary. In one prospective trial, premenopausal patients with leiomyomas the size of 14 to 18 weeks’ gestation were randomized to receive either 2 months of preoperative depot GnRH agonist or no GnRH agonist (8). Treatment with a short course (8 weeks) of leuprolide acetate before surgery enabled the procedures to be converted safely from an abdominal hysterectomy to a vaginal hysterectomy (9). This preoperative regimen was associated with a rise in hematocrit before surgery and a shorter hospital stay and convalescent period because patients were more likely to have a vaginal rather than an abdominal hysterectomy.
Excessive uterine bleeding is the indication for about 20% of hysterectomies. Dysfunctional uterine bleeding assumes abnormal bleeding without an obvious anatomic cause (see Chapter 14). Anovulatory uterine bleeding is typically associated with polycystic ovary syndrome (PCOS), a condition in which anovulatory cycles are common. The bleeding can be controlled by medical intervention with progestin, estrogen, or a combination of progestin and estrogen given as oral contraceptives. Ovulatory abnormal uterine bleeding can be controlled by nonsteroidal anti-inﬂammatory agents, hormonal intervention, tranexamic acid, or the levonorgestrel intrauterine device. In these patients, endometrial sampling should be performed before hysterectomy (10). Dilation and curettage is not an effective means of controlling bleeding and is not necessary before hysterectomy. Hysterectomy should be reserved for
Table 24.1 Indications for Hysterectomy (Percentage): United States 2000–2004
Endometriosis 17.7
Other 15.2 (includes cervical dysplasia and menstrual disorders)
Uterine prolapse 14.5
Cancer 9.2
From Whiteman MK, Hillis SD, Jamieson DJ, et al. Inpatient hysterectomy surveillance in the United States, 2000–2004. Obstet Gynecol 2008;34.e1–e7, with permission.
patients who do not respond to or cannot tolerate medical therapy. Alternatives to hysterectomy (e.g., endometrial ablation or resection) should be considered in selected patients because these operations may be cost-effective and have a lower morbidity rate. However, in a clinical trial that randomized endometrial ablation to hysterectomy, 29% of patients assigned to the ablation underwent hysterectomy by 60 months (11).
About 10% of adult women are incapacitated for up to 3 days per month as a result of dysmenorrhea (see Chapter 16) (12). Dysmenorrhea can be treated with nonsteroidal anti-inﬂammatory agents used alone or in combination with oral contraceptives or other hormone agents to reduce or ablate menstrual ﬂow (12). The levonorgestrel intrauterine device effectively reduces dysmenorrhea symptoms. Hysterectomy is rarely required for the treatment of primary dysmenorrhea. In patients with secondary dysmenorrhea, the underlying condition (e.g., leiomyomas, endometriosis) should be treated primarily. Hysterectomy should be considered only if medical therapy fails or if the patient does not want to preserve fertility (12).