Hysterectomy for Dysfunctional Uterine Bleeding
Jose P. Noronha
Rina Maria Dias
This article has been reproduced from the August 1984 issue, Vol. 48 , No. 8, “ The Clinician”. Permission has been obtained from Dr. Elvira Dias for reprint of the article.
The prevalence of dysfunctional uterine bleeding (DUB) requiring a hysterectomy was 9.44%, the highest incidence occurring in the age group of 40-44 years (40.63%). Majority of the patients (97.66%) were parous, out of which 57.04% were grand multipara. Menorrhagia, polymenorrhagia and menometrorrhagia were the commonest menstrual irregularities encountered. A history of sterilization by the Modiﬁed Pomeroy’s method was given by 18.75% of patients. Abdominal hysterectomy was carried out in 65.63% and vaginal hysterectomy in 33.59%.
The incidence of ovulatory endometrium was 20.31%, anovulatory endometrium was 61.71% and an atrophic endometrium was 1.56%. In the study group, subsequent histopathological examination of the uterine specimens revealed ﬁbromyomas and adenomyosis in 21 cases (16.41%). Thus, hysterectomy has a deﬁnite place in the management of DUB, particularly in the age group above 40 years, decision being based upon the nature of the endometrium, particularly in view of the progressive nature of the endometrial hyperplasias.
Irregular or excessive bleeding from the uterus is one of the most common symptoms the gynaecologist is called upon to diagnose and treat. When it occurs in the pre-menopausal age group, it may assume a sinister signiﬁcance always requiring close analysis to diﬀerentiate it from the more serious bleeding of uterine malignancy, with or without associated ﬁbroids, often met with at this age. The term dysfunctional uterine bleeding (DUB) is deﬁned as abnormal endometrial bleeding in which organic lesions cannot be demonstrated. It embraces all types of abnormal menstruation and uterine bleeding, provided infection, neoplasm and pregnancy have been excluded. There have been many modalities of management that have been resorted to in the last decade. Hysterectomy has a major role to play in pre-menopausal women and older women where the need to preserve reproductive function is minimal, more so when the other forms of treatment like hormonal and anti-ﬁbrinolytic therapy, and dilatation and curettage, may have been used without any beneﬁcial eﬀect. This is a review of hysterectomies carried out for DUB during a three-year period from July 1979 to June 1982.
Material and Methods :
All the patients admitted in the gynaecological ward during this period for hysterectomy for DUB were screened and data referring to the age of the patient, parity, type of menstrual irregularity, associated symptoms, and previous operative procedures was compiled. In addition, the incidence of patients with DUB amongst all the hospital admissions was evaluated along with the incidence of hysterectomy for the same.
Observation and Results :
- During the study period, 13,561 gynaecological admissions were made, of these 1,356 cases of DUB were admitted, thus giving an incidence of 10%. During this same period, of the total of 1,356 cases of DUB, a total of 128 patients were admitted for hysterectomy thus the incidence of hysterectomy was 9.44%.
- Out of the cases subjected to hysterectomy, the prevalence of DUB was highest in the age group of 40-44 years. There were no cases below the age of 30 years, the youngest patient being 30 years old while the oldest was 50 years old.
- Out of 128 cases studied, only three cases (2.34%) were nulliparous, thus showing that it was more common in multiparae (97.66%). The incidence of grand multiparae was 57.04%.
- A variety of menstrual irregularities were encountered, with some patients having more than one irregularity. Menorrhagia was the commonest menstrual irregularity encountered (37.5%) followed by polymenorrhagia (23.44%). The diﬀerent menstrual irregularities are shown in Table 1.
- All the patients were subjected to a routine dilatation and curettage and a cervix biopsy was carried out on a clinically suspicious cervix. A special note was made of previous puerperal and vaginal ligations. 25.78% of our patients underwent a cervix biopsy, 15.63% underwent a puerperal ligation whereas 3.12% a vaginal ligation. All sterilizations were performed by Modiﬁed Pomeroy’s method. Table 2 indicates the endometrial pattern of the patients in the study group.
- Abdominal hysterectomy was the commonest surgical procedure performed for DUB, carried out in 65.63% of cases. 33.59% underwent a vaginal hysterectomy whereas 0.78% had an abdominal hysterectomy with an anterior- posterior repair for DUB with cystocoele and rectocoele and no descent of cervix. Two patients (1.56%) were given a Kelly’s stitch for stress incontinence, during the vaginal hysterectomy.
- There was no post-operative mortality, the most common problem encountered was febrile morbidity due to either urinary tract infection, respiratory tract infection or coincident viral fever. We had one case each of pelvic abscess, vault haematoma and intestinal obstruction.
- It is interesting to note that of the 128 patients that were subject to hysterectomy, 21 patients were found to have signiﬁcant pathology of leiomyoma and adenomyosis, which were missed clinically, thus giving a percentage of 16.41% of missed pathology.
DUB is an all-inclusive term or “Rag-Bag” comprising of a group of menstrual disorders of diﬀerent aetiologies and it is not a single disease entity. The diagnosis of DUB is at present made by excluding organic disease of the genital tract.
The incidence of dysfunctional uterine bleeding at the Boston Hospital for women (Kistner, 1980) was approximately 5% of all admissions; in addition, this process accounts for about 60% of all diagnostic curettages. Taylor (1965) reports DUB as a ﬁrst diagnosis in at least 10% of all new out-patients seen both privately and at hospital.
DUB may occur at any age between puberty and menopause, but it is most frequently encountered at the two extremes of menstrual life, when disturbances of ovarian function are most common. Israel (1967) has observed that two-thirds of the patients treated in the hospital for DUB were over 40 years of age and only 3% were under 20 years. Similarly, Sutherland (1953) found that fewer than 4% of his patients subjected to curettage for DUB were less than 20 years of age. In our study, no patients below 30 years of age were admitted for hysterectomy, 20.32% of the patients were from the age group of 30-39 years, whereas 72.56% of cases were from the group of 40-49 years. Only 7.03% of cases were 50 years and above. This very well proves Sir John Dewhurst’s (1981) dictum that hysterectomy should be the ﬁrst resort in patients in the age group of 40 years and above, if bleeding is persistent after dilatation and curettage and hormone therapy, seldom in the age group of 20-40 years, only to be done if bleeding is persistent or severe after dilatation and curettage and hormone therapy. Dewhurst, (1981) includes abnormalities of the thyroid and haemopoietic system under DUB but not a single case in our study had any such abnormalities.
Since a suspicion was raised in the past by many authors regarding the eﬀect of sterilization and subsequent development of DUB, all patients who underwent sterilization were reviewed regarding the mode, the method and the route of sterilization. In a study of 1101 post-partum tubal ligations report by Jacob et al (1979), 561 were carried out by Modiﬁed Pomeroy’s method, 135 by the Uchida’s method and 405 were done vaginally. The diﬀerence in immediate complications of the two groups was not very signiﬁcant. However, the incidence of DUB, a late complication, was 13% in the Modiﬁed Pomeroy’s method, while it was only 2% in the Uchida group. The development of menorrhagia after tubal sterilization using Modiﬁed Pomeroy’s method is perhaps related to the interruption of the terminal branch of the uterine artery to the ovary, thus resulting in a cystic degeneration of that structure. Some hold the view that the utero-tubal circulation is impaired by the tubal sterilization, causing engorgement of the venous circulation of the uterus, with subsequent menorrhagia. Uchida’s method has a sparing eﬀect on the ovarian blood supply and hence the incidence of subsequent menorrhagia is much less. Jacob et al (1979) advocate the routine use of Uchida’s method of tubal ligation.
As mentioned before, 21 patients (16.41%) were found to have a pathology like ﬁbromyoma and adenomyosis and had to be excluded from the ﬁnal list.
We thank Dr. G.J.S. Abraham, Dean, Goa Medical College for permitting us to publish hospital records.
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