The effect of hysterectomy or levonorgestrel‐releasing intrauterine system on lower urinary tract symptoms: a 10‐year follow‐up study of a randomised trial

Abstract

Objective To evaluate the effect of hysterectomy and levonorgestrel-releasing intrauterine system (LNG-IUS) on lower urinary tract symptoms (LUTS) among women treated for menorrhagia.Design Randomised controlled trial analysed by actual treatment.Setting Five university hospitals in Finland.Sample A cohort of 236 women, aged 35-49 years, referred for menorrhagia between 1994 and 1997.Methods Women were randomly assigned to treatment by hysterectomy (n = 117) or LNG-IUS (n = 119).Main outcome measures Lower urinary tract symptoms were evaluated by questionnaires at baseline, and after 6, 12 months, 5, and 10 years. Medications and operations for urinary incontinence were confirmed from medical records and national registries.Results Overall, 221 (94%) women took part in the 10-year follow-up evaluation. As 55 (46%) women originally randomised to the LNG-IUS group underwent hysterectomy, the results were analysed by actual treatment. Women treated by hysterectomy used more medication for urinary incontinence than LNG-IUS users (12% versus 1%) (OR 9.45, 95% CI 1.24-71.87, P = 0.006). Three hysterectomised women and one LNG-IUS user underwent surgery for stress urinary incontinence (SUI). Women treated by hysterectomy had more urinary tract infections (UTIs) than LNG-IUS users (OR 3.20, 95% CI 1.47-6.96, P = 0.002). Feeling of incomplete emptying (OR 3.00, 95% CI 1.00-9.05, P = 0.04) and SUI (OR 1.83, 95% CI 1.01-3.32, P = 0.04) were more common among women treated by hysterectomy. No differences between the study arms were noted in urge urinary incontinence or by the Urinary Incontinence Severity Score. A multivariate model showed that UTIs were associated with hysterectomy (P = 0.004).Conclusions Hysterectomy increases the risks for incomplete emptying, lower UTIs and SUI.Keywords Hysterectomy, LNG-IUS, lower urinary tract symptoms, menorrhagia, urinary incontinence, urinary tract infection.Please cite this paper as: Heliövaara-Peippo S, Halmesmäki K, Hurskainen R, Teperi J, Grenman S, Kivelä A, Tomas E, Tuppurainen M, Paavonen J. The effect of hysterectomy or levonorgestrel-releasing intrauterine system on lower urinary tract symptoms: a 10-year follow-up study of a randomised trial.

Clinical Practice Guideline for Abnormal Uterine Bleeding: Hysterectomy versus Alternative Therapy

“…The systematic review yielded 18 articles from 9 trials that directly compared hysterectomy with another intervention and met our eligibility criteria [10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27]. In women with predominately AUB-O or AUB-E, there were 7 studies comparing endometrial ablation against hysterectomy, 1 study comparing a variety of different systemically administered medical treatments versus hysterectomy, and 1 study comparing LNG-IUS versus hysterectomy.…”

“…One randomized trial of 236 women with heavy menstrual bleeding compared LNG-IUS and hysterectomy for patients with AUB without intrauterine pathology (presumed AUB-O or AUB-E) [20][21][22][23][24][25]. This study has resulted in a series of publications including a 10-year follow-up report (Table 4).…”

A Systematic Review Comparing Hysterectomy with Less-Invasive Treatments for Abnormal Uterine Bleeding

“…(27–32) A total of 236 women with heavy menstrual bleeding were followed for 6 months to 10 years after treatment. In the hysterectomy group 20% (n=21) had a TAH, 28% (n=30) had a TVH, and 52% (n=56) had a laparoscopic approach to hysterectomy.…”

“… a Note: we included in the hysterectomy numbers the 50 patients in the LNG-IUS vs. hysterectomy studies (28–32) who were randomized to LNG-IUS and underwent subsequent hysterectomy because complications specifically after hysterectomy were presented. We did not include the 16 patients in the Learman study (33,34) who were randomized to medications and underwent subsequent hysterectomy in the hysterectomy numbers because whether or not they had complications secondary to hysterectomy was not specifically reported.…”

“…Percent/proportion not presented because one patient could have multiple complications and this distinction was not clear in the papers. Dividing the number of major complications by the number of patients would provide an inflated complication rate. c Included unplanned intra-operative surgical procedures (not treatment failure) such as conversion to laparotomy if laparoscopic or vaginal hysterectomy, laparoscopy if vaginal hysterectomy, laparoscopy if ablation, hysterectomy if ablation, urgent post-operative laparotomy d Cystotomy includes 1 vesicovaginal fistula (28–32) e No deaths, MIs, stroke, pulmonary embolus, or admission to the ICU were specifically reported. One study reported 3 “cardiorespiratory events” and 2 “thromboembolic events” which were classified as such.…”