Date Published: June 11, 2019
Publisher: Public Library of Science
Author(s): Lucie de Léotoing, Gwendoline Chaize, Jérôme Fernandes, Dusan Toth, Philippe Descamps, Gil Dubernard, Thomas Lafon, Ludovic Lamarsalle, Hervé Fernandez, Simone Garzon.
The objective of the study was to compare success rates, complications and management costs of different surgical techniques for abnormal uterine bleeding (AUB).
This was a retrospective analysis of the French national hospital discharge database. All hospital stays with a diagnostic code for AUB and an appropriate surgical procedure code between 2009 and 2015 inclusive were identified, concerning 109,884 women overall. Outcomes were compared between second generation procedures (2G surgery), first-generation procedures (1G surgery), curettage and hysterectomy. Clinical outcomes were treatment failure and complications during the follow-up period. Costs were attributed using standard French hospital tariffs.
7,863 women underwent a 2G procedure (7.2%), 39,935 a 1G procedure, (36.3%), 38,923 curettage (35.4%) and 23,163 hysterectomy (21.1%). Failure rates at 18 months were 9.9% for 2G surgery, 12.7% for 1G surgery, 20.6% for curettage and 2.8% for hysterectomy. Complication rates at 18 months were 1.9% for 2G surgery, 1.5% for 1G surgery, 1.4% for curettage and 5.3% for hysterectomy. Median 18-month costs were € 1 173 for 2G surgery, € 1 059 for 1G surgery, € 782 for curettage and € 3 090 for hysterectomy.
Curettage has the highest failure rate. Hysterectomy has the lowest failure rate but the highest complication rate and is also the most expensive. Despite good clinical outcomes and relatively low cost, 1G and 2G procedures are not widely used. Current guidelines for treatment of AUB are not respected, the recommended 2G procedures being only used in <10% of cases.
Abnormal uterine bleeding (AUB) is defined as at least one of the following three conditions (1) menstrual periods lasting more than seven days, (2) periods involving blood loss greater than 80 ml or (3) a PBAC (pictorial menstrual blood loss assessment chart) score ≥ 100. It is thought that between twenty and thirty percent of women of reproductive age present with AUB at some time.[1, 2] A recent survey in the general population of five European countries reported that 27.2% had experienced two or more symptoms of AUB within the previous year. The prevalence of AUB increases with age up until the menopause. Although AUB may occur secondary to another underlying pathology, frequently leiomyoma, malignancies or coagulopathies, in many cases no underlying cause can be identified and it is considered idiopathic. [3, 4]
In this study, 109,884 women between 35 and 55 years old undergoing surgery for uncomplicated idiopathic AUB between 2009 and 2015 were identified, which is the largest cohort of surgically treated idiopathic AUB patients ever reported. With respect to the type of surgical procedure used, current practice does not follow the French guidelines . Curettage and hysterectomy, neither of which is recommended as first-line treatment options, account for over half the surgical procedures performed, in spite of the fact that hysterectomy is over twice as expensive as other procedures and curettage has a two-fold higher failure rate. Second-generation procedures are the least frequently used, accounting for nor more than ten percent of all procedures. The number of women undergoing surgery for idiopathic AUB decreased by 13% between 2009 and 2015. This was essentially driven by a decrease in the number of women undergoing curettage, which decreased by 37%. A concomitant doubling in the number of 2G procedures over the same period was insufficient to compensate for the fall in the number of curettages. In addition, sales of IUD in France decreased over the same period , which means that a shift to non-surgical interventions cannot account for the fall in the number of women undergoing surgery for idiopathic AUB.