Cost effective management of heavy uterine bleeding: ablative methods versus hysterectomy.

The treatment of menorrhagia in the twentieth century changed after 1960 with the introduction of hormonal therapy as well as an array of laboratory, imaging and minimal access tests for more accurate diagnosis. Since 1981, hysteroscopy has been used for diagnosis as well as the control of thermoablative treatments of bleeding non-malignant endometrium, including laser, electrocoagulation and electroresection. The success rates, complications, intermediate range outcome and cost comparisons with hysterectomy favor hysteroscopic methods. But the long term data on both hysteroscopic ablation and hysterectomy are not yet complete. In an effort to simplify techniques, reduce costs, and reduce complications, a variety of non-hysteroscopic methods and devices have appeared. Only two balloon devices have satisfactory success data as well as sufficient field experience to provide some degree of reliability regarding complications, which appear to be very low. Most of the devices have had clinical trials, which suggest equivalence to hysteroscopic endometrial ablation, but the determination of clinical safety requires at least several thousand cases. However, the levels of effectiveness for most of these devices make them candidates for commercial use. Hysterectomy may move from a primary surgical treatment of menorrhagia to a second-line treatment after ablation, particularly if some of the non-hysteroscopic methods become well accepted. If they are found to be safe, the costs and ease of use for the gynecologist and patient will make them attractive as a first-line surgical option. Hysterectomy, whether abdominal, vaginal, or laparoscopic will then be applied to ablation failures or non-candidates. This has the potential to change gynecological training and practice significantly in the future.