Hysteroscopic Endometrial Destruction, Optimum Method for Preoperative Endometrial Preparation: A Prospective, Randomized, Multicenter Evaluation

OBJECTIVE To compare the outcome and cost-effectiveness of various forms of preoperative endometrial preparation prior to hysteroscopic endometrial destruction for abnormal uterine bleeding. METHODS This was a multicenter, prospective, comparative, randomized study conducted in a tertiary care hospital in Cairo, Egypt and 2 academic tertiary care teaching hospitals in the United States. One hundred thirty-one premenopausal women, who had completed childbearing, mean age of 45.7 years, with abnormal uterine bleeding refractory to medical management without histologic evidence of endometrial neoplasia were studied. The 131 patients were randomized for preoperative preparation for hysteroscopic endometrial destruction into 1 of 5 groups as follows: Group I, dilation and curettage (D & C) (39); Group II, gonadotropin-releasing hormone analogue (GnRHa) for 1 month (23); Group III, GnRHa for 3 months (26); Group IV, danazol for 3 months (26); and Group V, medroxyprogesterone acetate (MPA) 15 mg for 3 months (27). The choice of endometrial ablation or endometrial resection was left to the surgeon. RESULTS Improvement in bleeding patterns, amenorrhea, operative times, complications, and relative cost were the measured outcomes. The mean follow-up time was 1 year from the time of the procedure. Overall, in Group I, 39/39 (100%) improved and 7/39 (18.0%) experienced amenorrhea; in Group II, 21/23 (91.3%) improved and 9/23 (39.1%) experienced amenorrhea; in Group III, 24/26 (92.3%) improved and 10/26 (38.5%) experienced amenorrhea; in Group IV, 24/26 (92.3%) improved and 9/26 (34.6%) experienced amenorrhea; and in Group V, 23/27 (85.1%) improved and 7/27 (25.9%) experienced amenorrhea. CONCLUSION Endometrial destruction whether by the ablation or resection technique, regardless of the type of surgical pretreatment is a safe and effective surgical approach for treating abnormal uterine bleeding. D & C or MPA appear to be the most cost-effective pretreatment regimens. MPA pretreatment may confer the added advantage of decreasing blood flow and allowing better hysteroscopic visualization than D & C pretreatment.