CONTEMPORARY MANAGEMENT OF ABNORMAL

UTERlNE BLEEDING 0889-8545/00 $15.00 + .00

COST AND QUALITY-OF-LIFE

ISSUES ASSOCIATED WITH
DIFFERENT SURGICAL
THERAPIES FOR THE
TREATMENT OF ABNORMAL
UTERINE BLEEDING
Dennis A. Hidlebaugh, MD

Gynecologic endoscopy (Iaparoscopy and hysteroscopy) has become an

indispensable aid in the diagnosis of abnormal uterine bleeding since it was
introduced four decades ago. During the last 15 years, endoscopic procedures
have been used with increasing frequency to replace traditional surgery by
laparotomy. Operative endoscopy, appropriately used, might offer numerous
advantages, as follows":
The procedure can be performed during initial diagnostic Iaparoscopy;
Inherent complications of laparotomy are avoided.
Hospital stay is brief.
Discomfort is lessened.
Costs are reduced significantly.
Results are satisfactory.
Abnormal uterine bleeding is a common problem among women of repro-
ductive age. One fourth of middle-aged British women studied in household
surveys reported heavy menstrual bleeding (menorrhagia) that had interfered
with their lives." Menorrhagia is the presenting symptom in 20% of women
who undergo hysterectomy;" which remains the most common nonobstetric
major surgical procedure in the United States, with more than 500,000procedures
performed each year.3S, 68 The cost of hysterectomy each year is more than
$2 billion." The overall hysterectomy rate for the years 1988 to 1990 was 56.8
procedures per 10,000 women aged 15 years or older," Since Doyle2S first re-
ported that many hysterectomies might be unnecessary, numerous articles have
reported the overuse of hysterectomy.v 28,51 Pressure from patients for less radical

From the Department of Gynecology, Cleveland Clinic Florida, Naples, Florida

OBSTETRICS AND GYNECOLOGY CLINICS OF NORTH AMERICA

VOLUME 27 • NUMBER 2 • JUNE 2000 451

452 HIDLEBAUGH

methods of treatment and from insurance companies to reduce costs has focused
attention on alternatives to hysterectomy.
Until the late 1980s, the primary surgical approaches to hysterectomy for
menorrhagia were total abdominal and vaginal hysterectomy. More recently,
endoscopic approaches such as laparoscopically assisted vaginal hysterectomy
and laparoscopic myomectomy have been added to the choices of approach. I 5• I B,
26,40,66 The advent of techniques for ablating the endometrium or myomectomy
with lasers, electrocautery with roller-ball diathermy, radiofrequency ablation,
and intrauterine balloon therapy has expanded the spectrum of effective treat-
ments for menorrhagia, This article reviews the costs, quality-of-life issues, and
health care use with different medical and endoscopic therapies for the treatment
of abnormal uterine bleeding and compares them with traditional methods.

MEDICAL TREATMENT OF ABNORMAL UTERINE BLEEDING

The differential diagnosis of abnormal excessive uterine bleeding (menor-

rhagia) includes organic causes, which may be subdivided into reproductive
tract disease, iatrogenic causes, systemic disease, and dysfunctional uterine
bleeding (see Box). Excluding all organic causes leads to the diagnosis of dys-
functional uterine bleeding. Anovulatory dysfunctional uterine bleeding is most
common at either end of the reproductive years, in the postmenarcheal and the
premenopausal periods? Ovulatory dysfunctional bleeding is theorized to be
related more often to an imbalance between the vasoconstricting and aggregating
actions of prostaglandin F2a and thromboxane A2 and the vasodilating actions of
prostaglandin E2 and prostacyclin on the myometrial and endometrial vascula-
ture. Medical therapy for menorrhagia consists of prostaglandin synthetase in-
hibitors (nonsteroidal antiinflammatory drugs) or hormones (progestins, combi-
nation oral contraceptives, and gonadotropin-releasing hormone analogues).

Abnormal Uterine Bleeding

Organic causes
Reproductive tract disease
Complications of pregnancy
Malignancy
Infection
Benign pelvic lesions
Systemic disease
Coagulation disorder
Hypothyroidism
Cirrhosis
Iatrogenic causes
Steroids
Intrauterine contraceptive devices
Tranquilizers
Dysfunctional uterine bleeding
Ovulatory
Anovulatory
 COST AND QUALITY-OF-LIFE ISSUES ASSOCIATED WITH DIFFERENT THERAPIES 453

Leiomyomas and abnormal uterine bleeding account for approximately 50%

of hysterectomies." Recent questions and concerns about the appropriate use
and rates of hysterectomy have focused greater attention on medical manage-
ment. Determining the right rate of any surgical procedure depends on compar-
ing the risks and benefits of the operations with those of the alternatives." In
the case of abnormal uterine bleeding, there is little information on the outcomes
of medical management to guide clinical decision making. Dysfunctional uterine
bleeding is commonly treated with cyclic progestins or oral contraceptives. No
clinical trials have been conducted on the long-term effects of these agents on
excessive bleeding, however. Side effects associated with cyclic progestins have
not been well studied. Additionally there are no cost comparisons between
hysterectomy and medical management.
As part of the Maine Women's Health Study on the outcomes of hysterec-
tomy for abnormal uterine bleeding and leiomyomata, Carlson et aP2 performed
a prospective follow-up study on a cohort of 380 women treated nonsurgically.
The authors found that medical therapy for abdominal uterine bleeding pro-
duced statistically significant reductions in symptom levels at 3 months, which
were sustained to 1 year of follow-up. Relief of symptoms was associated with
improvements in some measures of quality of life. These findings suggest that
medical therapy for these conditions can be effective. Almost one fourth of the
patients treated medically at the onset had undergone a hysterectomy after 1
year of follow-up, and an appreciable number of women who received medical
therapy continued to be bothered by bleeding or pain. The group with leiomyo-
mas managed nonsurgically (in most cases with observation alone) had no
significant changes in symptoms and quality of life over 1 year.
Cooper et al15 at the Aberdeen Royal Infirmary performed a randomized
trial on 197 women comparing medical treatment tn = 94) with transcervical
resections of endometrium (n = 93). Progestogens (31 patients), combined oral
contraceptive pills (24 patients), tranexamic acid (22 patients), and danazol (15
patients) were used for medical treatment. Both surgical and medical treatment
significantly reduced the amount of bleeding, the number of days of heavy
bleeding, and the associated pain scores, but the patients who underwent trans-
cervical resections had significantly greater improvement (P < 0.001 for all
variables). Posttreatment mean hemoglobin counts were not affected by medical
treatment but improved significantly by surgical treatment. The patients who
underwent transcervical resections reported significantly greater levels of satis-
faction, improvement of symptoms, and acceptability of the treatment than those
who received medical treatment. There was no effect on time off from work
before and after treatment among the patients in the medical treatment group,
but a significant improvement was reported for those who underwent transcervi-
cal resections (P < 0.001).

PSYCHOLOGIC AND PHYSICAL ASPECTS OF

HYSTERECTOMY

Hysterectomy is the most common major surgical procedure in the United

States.35, 68 The procedure has wide ramifications for women when it is applied
for the treatment of abdominal uterine bleeding. In 1969, Wright90 promoted
elective hysterectomy by stating, "The uterus has but one function: reproduction.
After the last planned pregnancy it becomes a useless, bleeding, symptom
producing, potentially cancer bearing organ and therefore should be removed."
Cole and Berlin'! exposed the fallacy of prophylactic elective hysterectomy.
454 HIDLEBAUGH

The immediate and late adverse effects of elective hysterectomy, including the
morbidity and mortality from the operation, vault prolapse, sexual dysfunction,
depression, and urinary tract disorders, would affect the quality of life of an
undetermined number of women and could shift the rise of death from cancer
to other causes, diminishing the small calculated benefit. Many authors have
stated that hysterectomy is overused. 3, 25, 28, 51

Bladder and Bowel Function

Both sympathetic and parasympathetic neural innervation reach the bladder

by way of the pelvic plexus, through the cardinal ligament and, subsequently,
Frankenhauser's plexus." 52 This neural complex is potentially susceptible to
damage with the paracervical dissection associated with hysterectomy. Some
neurologic studies that evaluate subjective bladder and bowel sensations after
hysterectomy suggest a change in the integrity of the sensory nerves." Hanley"
and Vervest et aIM found that many women dated the onset of their bladder
problems to hysterectomy,
Taylor and Smith" compared a group of 75 women who had hysterectomy
for benign disease with 84 randomly matched controls and found a highly
significant association between persistently reduced bowel frequency and persis-
tently increased urinary frequency after hysterectomy. They concluded that
bowel and bladder dysfunction after hysterectomy may have a common auto-
nomic innervation. Van Dam et al B2 performed a retrospective review of 593
women who underwent hysterectomy between 1989 and 1993. A control group
consisted of 100 women who had undergone laparoscopic cholecystectomy.
Forty-one percent of hysterectomy patients had deteriorations in bowel function
compared with 9% of controls (P < 0.001). No significant difference was found
between the different types of hysterectomy. In the Maine Women's Health
Study of more than 400 women, complaints with urination occurred in 4%, and
constipation in 6% of women in the postoperative period.P

Psychosexual Function

Masters and johnson." in their pioneering studies of the female sexual

response, suggested that in at least some women, the uterus plays a role in the
physiology of the so-called vaginal orgasm. As a result, many have contended
that hysterectomy has an adverse effect in at least some women. Review of
the literature examining the relationship of hysterectomy to sexual function is
complicated by weakness in study design, including lack of baseline assessment
and absent or less-than-ideal control groups. In a retrospective cohort study,
Dennerstein et apo concluded that deterioration in sexual function after abdomi-
nal hysterectomy was related principally to preoperatively existent psychologic
factors, most notably expectations that the operations would have an adverse
effect. Contrary evidence was found in a cohort studied by Zassman et al," who
concluded that vaginal orgasms might be impaired after hysterectomy. Available
data fail to demonstrate a change in sexual function after a hysterectomy.
Various studies have shown that despite a high level of satisfaction with
the hysterectomy, a significant number of patients complain of symptoms per-
ceived as being caused or worsened by hysterectomy.w 55, 70 In one study, feelings
of loss, emptiness, and diminished femininity were reported by 16% of women. 55
In another study, a number of new symptoms were perceived to have been
 COST AND QUALITY-OF-LIFE ISSUES ASSOCIATED WITH DIFFERENT THERAPIES 455

caused or worsened by the surgery, including abdominal pain, painful sex, loss
of libido, dry vagina, weight gain, irritability, mood changes, and poor appetite."
In contrast, the Maine Women's Health Study of 418 women found the develop-
ment of new physical and psychologic symptoms to be infrequent in women
who were asymptomatic before hysterectomy." In this study, only 7% of women
reported being bothered by decreased interest in sex after hysterectomy, and
only 10% reported less enjoyment of sexual activity.

Pelvic Floor Support

The pelvic organs, including the bladder, rectum, uterus, and vagina, are
supported within the pelvis by the endopelvic fascia, a continuous layer of
connective tissue that invests each organ and spreads laterally to the pelvic
sidewalls, where it is attached to the parietal fascia. The upper portion attaches
the uterus and the lower portion connects the vagina to the pelvic walls.
Condensations of the parametrium, mainly the lateral cervical (cardinal) and
uterosacral ligaments, hold the cervix firmly in place within the pelvis. The rest
of the uterus is freely mobile. The cervix serves as an anchor of support for the
entire organ.
In total hysterectomy the cervix and a portion of the vaginal component are
severed, predisposing patients to the development of vaginal vault prolapse
and enterocoele. Improper closure of the vaginal cuff could lead to abnormal
granulation tissue, anatomic distortions, and prolapse of a preserved fallopian
tube. Vaginal vault prolapse and enterocoele are not uncommon after abdominal
or vaginal hysterectomyw " Fallopian tube prolapse occurs more commonly
after vaginal hysterectomy; however, numerous cases have been reported after
total abdominal hysterectomy.37,69 The development of abnormal cuff granulation
tissue is not unusual; in one series the incidence was 9%.1

COST OF TRADITIONAL HYSTERECTOMY (TH) VERSUS

LAPAROSCOPICALLY ASSISTED VAGINAL HYSTERECTOMY (LAVH)

Laparoscopically assisted vaginal hysterectomy (LAVH)has come into wide-

spread use to treat abnormal uterine bleeding and leiomyomata, primarily be-
cause morbidity is presumed to be less than with a large abdominal incision
and the invasive intraabdominal manipulations associated with total abdominal
hysterectomy.v 19, 42, 44, 57, 66 The laparoscopically assisted procedure has been con-
troversial, however, because of concern that it is sometimes substituted for
vaginal hysterectomy, which is generally considered to be the simplest and least
morbid method of removing the uterus. Additionally, the costs of the Iaparo-
scopic procedure may be higher than those of either alternative procedure. 22, 36, 39, 46
Distinctions between hospital costs and charges are crucial. Costs denote
the cost to the provider of the producing care. There is considerable merit in
reporting the actual costs of providing care rather than the charges for the care,
but data on cost are not always available. Hospital charges reflect the amounts
billed and do not correlate closely with costs; charges do not include physician's
fees and are not necessarily the amounts reimbursed by third-party payers. To
the hospital, charges are less important than costs, but for the insurer charges
are important because they are the amounts billed to the patient, who may be
responsible for copayments based on those amounts.
According to multiple case studies (Table 1), the average inpatient charges
456 HIDLEBAUGH

Table 1. SUMMARY OF HYSTERECTOMY OUTCOMES, CASE STUDIES

Average Average Average

Inpatient Length Inpatient Convalescent
Procedure of Stay (days) Charges ($) Period (days) Source
TAH 4.8 6300 Daniell et al'"
4.7 4550 41 Hidlebaugh et al'l2
3.4 12,440 Mushinski'"
3.9 5084 Dorsey et al 23
3.0 3946 35 Doucette and Scott'4
5723 Weber and Lee87
3.3 4926 Nezhat et al s6
VH 3.9 6300 Daniell et allO
2.7 5142 29 Hidlebaugh and Huffman"
2.5 10,500 Mushinski'"
2.9 4221 Dorsey et al2.'
2.0 3414 28 Doucette and ScotF4
5049 Weber and Lee"
3.0 4868 Nezhat et aJ56
LAVH 1.S 7623 25 Hidlebaugh and Huffman"
2.2 13,840 Mushinski'"
2.6 6116 Dorsey et al2.1
2.0 5835 21 Doucette and Scott"
8108 Weber and Lee87
2.3 7161 Nezhat et al s6

LAVH = laparoscopically assisted vaginal hysterectomy; VB = vaginal hysterectomy; TAB =

total abdominal hysterectomy.

for LAVH are greater than total abdominal hysterectomy (TAH).!9,23,24.41,42,S3,s6,87

LAVH has a shorter average inpatient length of stay than TAH but is similar to
vaginal hysterectomy (VH). VH has the lowest charges of the three procedures.
These findings often have been confounded by differences in the surgical proce-
dures performed in conjunction with hysterectomy, experience of the surgeon
with the relatively new procedure, and surgical auxiliary staff training with new
technologies. The use of nondisposable supplies with LAVH and its increased
operative time compared with TAH or VH are the main reasons for these
differences in charges.v 42, 56
Several prospective randomized studies (Table 2) have compared LAVH
with VH and with TAH.62, 77. 78,82 VH has the shortest operative time and hospital
charges of the three procedures. LAVH has a length of stay similar to VH but
less than TAH. Despite the reduced invasiveness and shorter hospitalization
associated with LAVH, the operating room time, anesthesia time, supply charges,
facility charges, and total charges for that procedure are substantially higher that
those for either TAH or VH.
Several studies have shown that the main factor leading to increased charges
with LAVH is use of disposable rather than nondisposable supplies.v 19, 23, 42, 56
Daniell et aP9compared techniques used for homeostatic separation of the uterus
and adnexal pedic1es; automatic laparoscopic stapling device versus bipolar
coagulation with sharp transaction. Hospital charges were $3083 more with the
use of stapling devices. Dorsey demonstrated an increased cost of supplies
($1496) when procedures were performed with disposable supplies." Nezhat et
als6 showed a difference of $1752 for operating room supplies when the surgeons
 COST AND QUALITY-OF-LIFE ISSUES ASSOCIATED WITH DIFFERENT THERAPIES 457

Table 2. SUMMARY OF HYSTERECTOMY OUTCOMES, PROSPECTIVE

RANDOMIZED STUDIES

Average Average Average

Inpatient Length Inpatient Convalescent
of Stay (days) Charges ($) Period (days) Source
LAVH vs VH 7905 vs 4891 Summitt et al"
LAVH vs TAH 2.1 vs 4.1 8161 vs 6974 28 vs 38 Summitt et aFa
2 vs 4 16 vs 35 Olsson et al 62
4 vs 5 .9 28 vs 49 Marana et al"

LAVH = lap aroscopically assisted vaginal hysterectomy; VH = vaginal hy sterectomy; TAH =

total abdo minal hysterectomy.

performed LAVH using linear staples versus traditional TAH performed without
disposables.
Four studies have attempted to compare the true cost (not charges) of the
laparoscopic approach compared with traditional methods of hysterectomy.ww
75,83 Dorsey et al 23 evaluated 1049 patients who underwent hysterectomy at a
community teaching hospital. They compared the cost of LAVH with TAH or
VH in clinically similar groups based on the secondary procedures (if any)
performed in conjunction w ith hysterectomy. The authors adju sted th e analysis
for age, the number of coexisting conditi ons, and u terine weight. The main
facility costs were $4914, $3954, and $3116, respectively, for LAVH, TAH, and
VH. Simon et a17S performed a retrospective study of 138 con secutive LAVHs
and compared them with 354 consecutive TAHs performed during the same
period at one community hospital. There was no cost difference between the
two procedures. The authors concluded that this finding was due to the limited
use of disposable supplies and shorter lengths of sta y, whi ch compensated
for th e higher operative room costs of time and supplies associated with the
laparos copic approach. A prospective, randomized, cost-consequence an alysis of
t otal laparoscopic hysterectomy and TAH at a Swedish University Hospital was
repo rted in 1998.30 Th e hospital costs were 1.7% higher for patients undergoing
laparos copic surgery. Van Den Eaden et al83 compared the h ospitalization costs
of LAVH with both TAH an d VH . Hosp italization costs were highest for the TAH
group ($8521), followed by the LAVH group ($7705) an d VH groups ($7000).
When performing a cost compar ison between tw o surgical procedures, one
should review direct and indirect costs. The direct costs consist of fou r compo-
nents: the surgical procedure, services purchased from other hospital depart-
ments, care during hospital stay, and hospital costs during the convalescence
pe riod. Indirect cost represents productivity lost during convalescence from
surgical treatment. It varies depending on length of recovery, annual earnings
for women in the labor force, annual value of housekeeping services for women
working at home, and perce ntage of th e female population in a given age range
working inside or outside the home. Multiple studies have shown substantial
redu ction in the convalescent period with LAVH compared with TAH. 24, 30, 41. 42,
49,62, 78 Ellstrom et al30 evaluated and compared the economic consequences and
postoperative health status of the two surgi cal procedures. The indirect costs
were 50.3% lower for patien ts undergoing laparoscopic surgery. The total costs
(direct + indirect costs) were 23.1% lower after lap aroscopic hysterectomy.
458 HIDLEBAUGH

Hidlebaugh et al42 estimated that LAVH would save an employer approximately

$1200 in wages alone. It appears that savings achieved by a shorter convales-
cence offset higher hospital costs associated with LAVH.

COST OF OPERATIVE HYSTEROSCOPY VERSUS

HYSTERECTOMY

Abnormal uterine bleeding can be debilitating, costly to trea t, and ernbar-

rassing." It often leads to a decrease in hemoglobin, hematocrit, and serum iron
levels and has been estimated to affect 9% to 14% of otherwise healthy
women.t" 81 Menorrhagia is the presenting symptom in 20% of women who
undergo a hysterectomy." The surgery's drawbacks are its cost and associated
morbidity and mortality. Pressure from women seeking less radical methods of
treatment and from insurance companies to reduce costs has focused attention
on alternatives to hysterectomy.
Hysteroscopic resection ablation of the endometrium is an accepted alterna-
tive for the treatment of menorrhagia.v->" 61,74 Hysteroscopic resection of submu-
cous leiomyomas when combined with or without endometrial ablation is also
an acceptable alternative to hysterectomy.t- 31.86 Multiple studies have shown
that hospital (direct) costs are reduced by at least 50% and savings are even
greater if the reduced morbidity and indirect costs are taken into consideration."
10, '3, 65. 72. 85 It is not as clear, however, if these benefits are durable. Many
perceived benefits would be nullified if a substantial proportion of patients
treated by endometrial ablation had to undergo repeat ablation or hysterectomy.
O'Connor and Mages" reported an extensive long-term outcomes study of
endometrial resection on 525 women. By using life-table analysis at 5 years after
the first endometrial resection, 80% of women had had no further surgery and
91 % had not had a hysterectomy. These authors found that the rate of treatment
failure reaches a plateau at 3 years. An accurate cost analysis should include
direct and indirect costs for a least 3 years when comparing operative hysteros-
copy (ablation, resection, and myomectomy) with hysterectomy.
Brumstead et al? reported on hyst eroscopic treatment of abnormal uterine
bleeding in 74 women and compared them with 229 women who had abdominal
and vaginal hysterectomies. The authors studied both direct and indirect costs.
When the initial procedure failed, the cost associated with any additional surgery
was accounted for in the determination of the direct cost per case. The mean
direct costs for endometrial ablation and for myomectomy were $5159 and
$5525, respectively. The direct cost per case was significantly less expensive than
either vaginal ($8132) or abdominal hysterectomy ($8833). The indirect costs
associated with the hysteroscopic procedures were $315 for women in the labor
force . The corresponding figures for women treated with a vaginal and abdomi-
nal hysterectomy were $2940 and $4410, respectively. What is not clear in the
study is over what period the hysteroscopy patients were followed so as to
observe failure. The authors estimated that a failure rate of 53% is required
before the economic advantage of endometrial ablation versus abdominal hyster-
ectomy is lost.
A randomized, prospective study by Sculpher et al" found costs of hysterec-
tomy to be approximately twice those of endometrial resection, but the investiga-
tors analyzed only costs of the procedure and postoperative care for only 4
months. Vilos et alas reported a mean savings of $3094 for endometrial ablation
compared with vaginal hysterectomy for treatment of menorrhagia. The authors
 COST AND QUALITY-Of-LIFEISSUES ASSOCIATED WITH DIFfERENTTIIERAPIES 459

did include the cost of convalescence (indirect cost) and additional surgeries in
their analysis and compiled only 12 months of follow-up. In another study,
Brooks et alBcalculated the total cost to the payer for 18 months after surgery.
Costs associated with hysterectomy were almost twice those of endometrial
ablation. A randomized control trial of 204 women in Scotland examined both
National Health Service (NBS) costs and costs to the patient occurring 1 year
after surgery, " The NBS costs associated with treating women with hystero-
scopic surgery were 24% less than that for hysterectomy. On average, women
undergoing hysteroscopic surgery incurred 71% less cost to themselves. The
major flaw of all these studies is a short follow-up period because failure does
not plateau until 3 years after the primary procedure.s'
A long-term economic evaluation of endometrial ablation versus hysterec-
tomy for the treatment of menorrhagia by Hidlebaugh and Orr" included both
direct and indirect costs for 3 years after a primary surgery. The endometrial
ablation failure rate for 64 patients was 12%. The analysis included costs of
additional surgery in both the hysterectomy and endometrial ablation groups.
There was a statistically significant difference in the mean total cost of endome-
trial ablation ($5959) versus hysterectomy ($11,777). A substantial portion (49%)
of the savings is due to decreased indirect costs. Sculpher et al 71 updated their
original randomized control trial extending out to a mean of 2.2 years follow-up.
The mean total cost of endometrial resection was 71% of that of hysterectomy.

OPERATIVE HYSTEROSCOPY VERSUS HYSTERECTOMY:

LONG·TERM QUALITY-OF-LiFE OUTCOMES

Initial studies of endometrial ablation showed high success rates with sub-
stantial alleviation of menstrual symptoms and avoidance of hysterectomy in
most patients.21• 74 Later, large-scale surveys were less favorable; success rates fell
as the number of participating centers increased.w 61, 71 The Royal College of
Obstetricians and Gynecologists in London, for example, reported on more than
10,000 procedures." The discrepancies in outcome can be explained to some
extent by differences in patient selection, operator experience, operative tech-
niques, and length of follow-up."
Two prospective, randomized trials have compared the short-term outcome
of endometrial resection or laser endometrial ablation with hysterectomy.27, 63
Both revealed a faster return to work and normal activity, but patients were
followed for only 12 months. Hysteroscopic treatment failure can occur beyond
this time period, which could lead to adverse physical and psychologic effects.
O'Conner et al60 performed a multicenter, randomized, controlled trial com-
paring endometrial resection with hysterectomy in 202 women. The primary
endpoints of the study were women's satisfaction and the need for further
gynecologic surgery within 3 years of endoscopic management. The patient's
psychologic and social state was monitored before surgery, then annually. The
median follow-up for the study was 2 years. Menstrual symptoms improved
consistently in more than 80% of patients during the 3-year follow-up period
after endometrial resection; 22% had further surgery. Five percent of patients in
the hysterectomy group had further surgery. There were significant differences
in favor of endometrial resection as to the resumption of normal domestic
activities (1.9 versus 4.6 weeks), work (2.9 versus 7.4 weeks), and sexual activity
(3.9 versus 5.9 weeks). The satisfaction rate was progressively higher after
hysterectomy and lower with endometrial resection, but none of the differences
460 HIDLEBAUGH

was statistically significant, even at 3 years (96% versus 85%; P = 0.16). All
psychologic and social scores improved after endometrial resection and hysterec-
tomy for the duration of the study, but there was not a significant d ifference
between the treatment groups.
A prosp ective, randomized, controlled trial of 204 wom en with dysfunc-
tional bleeding comparing psychiatric and ps ychosocial aspects after hysterec-
tomy versus endometrial ablation w as reported by Alexander et aJ.2 Both treat-
ments significantly reduced the anxiety and depression experienced by women
before the operation, and there were no differences in mental health assessment
between the two groups at 12 months after surgery. Sexual interes t did not vary
with treatment and marital relationships were unaffected by surgery.
Nagele et al5-1 performed an observational study based on postal question-
naires to determine why women choose endometrial ablation rather than hyster-
ectomy for the treatment of menorrhagia. The average postoperative follow-up
period was 45 months. Of 180 randomly selected endometrial ablation patients,
106 reported complete satisfaction. More than half the women indica ted that
they would find endometrial ablation accep table even if there was no chance of
amenorrhea, if the probability of menstruation becoming lighter was 2:4:101 if
the likelihood of menstrual pain decreasing was :2:3:10, if the chance of requiring
repeated endometrial ablation or hysterectomy was $1 :4, and if the risk of
uterine cancer after surgery was $ 1:200. According to the authors, patients
found three important advantages of endometrial ablation over hysterectomy:
(1) avoidance of majo r surgery, (2) fast return to normal functioning, and (3)
short hospitalization.

COST AND QUALITY OF LIFE WITH MYOMECTOMY: OPEN

VERSUS LAPAROSCOPIC TECHNIQUES

Leiomyomas are the most comm on uterine neoplasm. Approximately 15%

of women require surgery for symp tomatic myomas between the ages of 25 and
64, with a peak incidence around the age of 45 years." Abnormal uterine
bleeding is the most common symptom of uterine leiomyomata. Abdominal
myomectomy has been shown to be highly successful with low morbidity. A
large series of 622 myomectomies demonstrated a cumulative 10-year recurrence
rate of more than 20%.11 The use of laparoscopy for myomectomy was pioneered
in 1980 by Semm." Multiple studies have suggested the advantages of laparos-
copic surgery over laparotomy in the management of uterine my omas.w 26. 40. 58
Little has been published about the cost and long-term quality-of-life issues of
laparoscopic versus abdominal myomectomies.
Only one study has compared the two techniques in a prospective random-
ized trial." Convalescence was complete in 18 of 20 patients in the laparoscopy
group by day IS, whereas only 1 of 20 patients in the laparotomy group had
complete recovery by day 15. The authors suggested that this might lead to
economic benefits for the hospital and the community. In a retrospective review
of 1167 laparoscopic myomectomies in Italy, Cittadini'" reported that 90% of
patients were fully recuperated by day 15. Abnormal uterine bleeding recurred
in 15% of women and pain in 25%. Nezhat et a159 found the cumulative risk of
myoma recurrence was 10.6% after 1 year, 31.7% after 3 years, and 51.4% after
5 years after laparoscopic su rgery. This reoccurrence risk was higher than that
reported with laparotomy," The au thors suggested that this mi ght be due to
difficulty in laparoscopically visuali zing smaller intramural myoma. In a retro-
 COST AND QUALlTY-OF-LIFE ISSUES ASSOCIATED WITH DIFFERENT THERAPIES 461

spective review of 49 laparoscopic and 49 open myomectomies performed by a

single senior surgeon, Stringer et aF6 compared the cost of the two techniques.
Estimated average cost of each procedure, expressed in April 1995 dollars, using
the consumer price index was $14A61 for open myomectomies and $13,814 for
laparoscopies (P = 0.65). The authors used linear regression analysis to show
that the cost of laparoscopic myomectomy was not increased compared with
that of open myomectomy, which increased at a rate of $868 per year.

SUMMARY

Abnormal uterine bleeding is a common problem among women of repro-

ductive age and can be treated medically or surgically. When medical therapy
fails to cure menorrhagia, many women undergo hysterectomy. Over the past
15 years, operative laparoscopy and hysteroscopy increasingly have replaced
traditional surgery (i.e., abdominal and vaginal hysterectomy). An endoscopic
approach such as LAVH has been added to the therapeutic choices of patient
and physician. Additionally, hysterectomy alternatives such as endometrial re-
section and ablation and myomectomy have been offered to women with sig-
nificant menorrhagia. This article reviewed the cost and quality-of-life issues of
endoscopic treatment versus traditional surgical methods.
Vaginal hysterectomy is the least costly of all hysterectomy techniques.
Studies have shown that for LAVH direct costs are higher that abdominal
hysterectomy. However, this difference decreases with additional operator expe-
rience and with the use of nondisposable instrumentation. The indirect cost of
LAVH is significantly less than abdominal hysterectomy because of the more
rapid convalescence. With endometrial resection and ablation, direct and indirect
costs are significantly less than those of hysterectomy even when high failure
rates are factored. Women choose this procedure over hysterectomy because it
avoids major surgery, allows for a fast return to normal functioning, and entails
short hospitalization. Hysterectomy can lead to many psychologic and physical
changes for a woman. It continues to provide a high satisfaction rate because it
is a guaranteed cure for abnormal bleeding.

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Address reprint requests to

Dennis A. Hidlebaugh, MD
Department of Gynecology
Cleveland Clinic Florida
6101 Pine Ridge Road
Naples, FL 34119