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Hysterectomy versus hysterectomy plus ovary removal for premenopausal women

Review question: Cochrane authors reviewed the evidence on the risks and benefits of the removal or conservation of ovaries at the time of hysterectomy for benign gynaecological disease in premenopausal women.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Subtotal versus total hysterectomy

When hysterectomy is required for non‐cancerous conditions, either the uterus alone (subtotal hysterectomy) or the uterus and the cervix (total hysterectomy) are removed. It has been suggested that not removing the cervix (subtotal hysterectomy) would reduce the chances of sexual difficulties or problems with passing urine or stools. This review has found no evidence of a difference between these two different operations for these outcomes. Surgery is faster with subtotal hysterectomy and there is less blood loss during or just after surgery, although these benefits are not large. With subtotal hysterectomy, women are less likely to experience fever during or just after surgery but are more likely to have long term ongoing menstrual bleeding when compared with total hysterectomy.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Surgical approach to hysterectomy for benign gynaecological diseases

Abdominal hysterectomy involves removal of the uterus through an incision on the lower abdomen. Vaginal hysterectomy involves removal of the uterus via the vagina, with no abdominal incision. Laparoscopic hysterectomy involves 'keyhole surgery' with small incisions on the abdomen. In laparoscopic hysterectomy, the uterus is removed with the aid of a surgical telescope (laparoscope) inserted through the umbilicus (belly button) and instruments inserted through two or three further keyholes. Laparoscopic hysterectomy may be further subdivided depending on the extent of the surgery performed laparoscopically compared to that performed vaginally. More recently, laparoscopic hysterectomy can be performed with the use of a so‐called robot which is operated from a distance by the surgeon.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2011

Pre‐operative GnRH analogue therapy before hysterectomy or myomectomy for uterine fibroids

Smooth muscle tumours of the uterus (uterine fibroids)are usually asymptomatic, however up to 50% cause symptoms severe enough to warrant therapy, and surgery is the standard treatment. Fibroid growth is stimulated by the hormone oestrogen and gonadotropin releasing hormone agonists (GnRHa). GnRHa treatment causes fibroids to shrink but cannot be used long term because of side effects and bone loss.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2011

The effect of chemotherapy on survival from early womb cancer after hysterectomy

Womb (uterine/endometrial) cancer is a fairly common disease affecting approximately 1 in 70 women. A hysterectomy is usually curative because most cancers have a low risk of spreading (metastasising) to other sites which may result in a later recurrence. Microscopic examination of the hysterectomy specimen can tell doctors if there is a high risk of the cancer returning and this allows women to decide if they want further preventative treatment (adjuvant therapy) to reduce the risk. Chemotherapy can increase cure rates for other types of high‐risk cancer after initial surgery and this review examines the effectiveness of chemotherapy for primary womb cancer after hysterectomy. Data from nine high quality randomised clinical trials involving up to 2197 women were subjected to systematic statistical modelling. This shows that chemotherapy reduces the risk of recurrent disease, lengthens the duration women have before a metastasis is diagnosed and improves survival rates. There are many ways to examine the data. The subset analysis that excluded old fashioned drug regimens suggests that chemotherapy reduces the risk of being dead at any nominated time by a quarter. The number of women who would need to have need chemotherapy to prevent one death depends on the type of cancer. In these trials, one woman was cured for every 25 women treated with high dose platinum based chemotherapy after hysterectomy. This is an absolute risk reduction of 4%. Chemotherapy is associated with a greater survival advantage than radiotherapy and has added value when used with radiotherapy. It also appears to reduce the absolute risk of developing a recurrence outside the pelvis by about 5%. This would benefit one woman in every 20 treated. However, chemotherapy has side effects, risks and temporarily reduces a woman's quality of life. In many cases, the small reduction in the cancer recurrence risk may not be worth the side effects of adjuvant treatment.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Key hole‐assisted vaginal extended (radical) hysterectomy versus open radical hysterectomy for the treatment of early cervical cancer

Cervical cancer is the second most common cancer among women. A woman's risk of developing cervical cancer by 65 years of age ranges from 0.69% in developed countries to 1.38% in developing countries. In Europe, about 60% of women with cervical cancer are alive five years after diagnosis. Standard treatment for selected early cervical cancer is radical hysterectomy, involving removal of the cervix, uterus (womb) and supporting tissues (parametrium), together with the pelvic lymph glands (nodes) and a top part of the vagina (cuff). Traditionally, radical hysterectomy has been performed as open surgery for more than a century. In recent years this operation has also been performed laparoscopically (key hole surgery) to reduce the size of the abdominal incision.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2015

Hysterectomy with medical management for cervical cancer that has spread to nearby tissues only

Cancer of the neck of the womb (cervical cancer) is the commonest cancer among women up to 65 years of age. A high proportion of women in developing countries are diagnosed with locally advanced disease (spread to nearby tissues, but no obvious distant spread). They are usually treated with radiotherapy, with or without chemotherapy (medical treatment). Hysterectomy (surgery to remove the womb and the cervix) with medical treatment is also used, especially in developing countries where access to radiotherapy is limited.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2015

Radiotherapy, or a combination of radiotherapy and chemotherapy, after surgery for early‐stage cervical cancer

At present, doctors are not sure whether women with early cervical cancer who have had their womb and pelvic lymph nodes removed should be given radiotherapy. If the woman has a combination of certain risk factors that put her at high risk of having a recurrence of her cancer, doctors often think that it would be a good idea to give her radiotherapy. However, radiotherapy has never been shown to improve overall survival for these women and the combination of surgery and radiotherapy increases the risk of side effects and complications. We searched for all the available randomised controlled trials (RCTs) that assessed whether radiotherapy (with or without chemotherapy) could improve survival in these women.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Treatment for excessive bleeding after childbirth

After a woman gives birth, womb muscles contract, clamping down on the blood vessels and helping to limit bleeding when the placenta has detached. If the muscles do not contract strongly enough, very heavy bleeding (postpartum haemorrhage) can occur, which can be life threatening. These situations are common in resource‐poor countries, and maternal mortality is about 100 times higher than in resource‐rich countries. It is a very serious problem that requires effective treatments that might avoid the use of surgery to remove the womb (hysterectomy). This is often the last treatment option and leaves the woman unable to have more children. In most settings, women are given a drug at the time of birth (before excessive bleeding occurs) to reduce the likelihood of excessive blood loss. However, despite this intervention, some women bleed excessively, and this review looked to see what interventions might be used to reduce the amount of blood lost by these women. Treatment options include drugs to increase muscles contractions (such as oxytocin, ergometrine and prostaglandins like misoprostol), drugs to help with blood clotting (haemostatic drugs such as tranexamic acid and recombinant activated factor VII), surgical techniques (such as tying off or blocking of the uterine artery) and radiological interventions (to assist in blocking the main artery to the womb by using gel foams).

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Surgical removal of fibroids does not improve fertility outcomes

Fibroids are the most common benign tumours of the female genital tract and commonly affect women of reproductive age. Fibroids occur in different parts of the womb and can vary in size and shape. Fibroids can lead to a variety of symptoms including heavy periods, pain, difficulty to conceive, or problems with pregnancy such as miscarriage and premature labour. In women wishing to preserve their fertility, it is possible to remove the fibroid while preserving the womb, an operation known as myomectomy. This procedure can be performed by open surgery, laparoscopic surgery (a key‐hole through the abdomen) or hysteroscopic surgery (a key‐hole through the neck of the womb) depending on the site and size of the fibroid. This review included three studies with 474 participants and aimed to answer two questions. Firstly, whether myomectomy led to an improvement in fertility; and secondly, if the procedure is beneficial, what is the ideal surgical approach. Only one study was found that examined the effect of myomectomy on fertility and it found no significant benefit. However, there are some concerns regarding how the data were analysed and therefore the evidence cannot be considered to be conclusive until further studies are available. Regarding the choice of the surgical approach to the myomectomy, only two studies were identified. They compared open versus laparoscopic myomectomy and found no difference in fertility outcomes. Therefore, again more studies are needed before a strong conclusion can be reached.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Surgery versus long‐term hormone treatment for heavy menstrual bleeding

Various types of surgery or an intrauterine hormone‐releasing device are effective in reducing heavy menstrual bleeding (menorrhagia). These suit most women better than oral medication.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2010

Uterine fibroids: Fibroid embolization

In fibroid embolization, the blood supply to the fibroid is cut off in order to reduce its size. It is an alternative to operations to remove the fibroids (myomectomy) or the uterus (hysterectomy)The aim of fibroid embolization (transcatheter embolization) is to stop symptoms caused by fibroids such as heavy menstrual bleeding, period pain or pressure on the bladder or bowel. The recovery time after embolization is faster than after myomectomy or hysterectomy, but the procedure is not suitable for all women. It is also very common for further treatments to be required at a later stage.

Informed Health Online [Internet] - Institute for Quality and Efficiency in Health Care (IQWiG).

Version: October 22, 2014

Laparoscopy versus laparotomy for the management of presumed early stage endometrial cancer

Worldwide, cancer of the womb 'endometrial cancer' is the fifth commonest cancer among women up to 65 years of age and has a higher incidence in developed countries than developing countries. For women with cancer of the womb, removal of the womb (hysterectomy) and removal of both fallopian tubes and ovaries is considered current standard treatment. Other treatments include radiotherapy and chemotherapy. Traditionally, surgery for cancer of the womb is performed through a laparotomy (open cut in abdomen).

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2015

Adjuvant (supplementary treatment after initial treatment) platinum‐based anti‐cancer drugs for early stage cervical cancer

Cervical cancer is the second most common cancer among women. Most women with early stage cervical cancer (stages I to IIA) are cured with surgery or , radiotherapy, or both. Radiotherapy uses high energy x‐rays to damage tumour cells. Chemotherapy (anti‐cancer) drugs use different ways to stop tumour cells dividing so they stop growing or die.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Uterine fibroids: Surgery

Using medication to treat fibroid symptoms usually only helps for as long as it is taken. Many women who have more severe pain and heavy menstrual bleeding end up considering surgery as an option. There are a number of different types of surgical treatments, each with its own pros and cons.Surgery is done in the hope that it can permanently stop the symptoms of uterine fibroids, and some women do experience long-term relief. But as with any other type of surgery, there are always benefits and risks. What you think about the different advantages and disadvantages will determine whether surgery could be an option, and if so, what kind. The size, number and location of the fibroids will also influence which type of treatment should be used. Not all types of surgery are suitable for women who still want to conceive.Your doctor may recommend taking hormones such as GnRH analogues several weeks before having surgery. These kinds of hormone analogues are used to shrink the fibroids, minimizing the strain put on the uterus and making the procedure as gentle as possible. This is the same reason that the drug ulipristal acetate is sometimes used.Removing individual fibroids is not a good idea if it might cause too much scarring on the uterus or if the risk of bleeding during or after surgery is too great. Plus, it is not always absolutely clear that the symptoms will improve after surgery. In these cases a hysterectomy (surgical removal of the uterus) is an option – or possibly another non-surgical treatment option such as fibroid embolization. Fibroid embolization cuts off the blood supply to the fibroid, causing it to shrink.

Informed Health Online [Internet] - Institute for Quality and Efficiency in Health Care (IQWiG).

Version: October 22, 2014

Adjuvant radiotherapy for stage I endometrial cancer

Women with stage I (early) endometrial cancer have a low risk of recurrence of their disease. Less than 10% of women treated with surgery alone have a recurrence after surgery. This risk is significantly higher (and may be double) for some women with high risk factors including aggressive cell types (grade 3) and deep invasion of the muscle (stage IC). External beam radiotherapy (EBRT) after surgery reduces the risk that the cancer will initially recur in the pelvis by around two‐thirds compared to surgery alone, but does not reduce the risk of death.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2015

Early versus delayed feeding for reducing complications after gynaecologic surgery

Physicians often delay giving food and drink to women after abdominal gynaecologic surgery (uterine fibroids, endometriosis, ovarian cysts, uterine and ovarian cancer) until bowel function recommences (typically 24 hours after surgery). This is to reduce the risk of complications such as vomiting, gastrointestinal disruptions and wound rupturing or leakage. However, it has been suggested that some women may recover more quickly if food is introduced earlier. We reviewed evidence from randomised controlled trials of early and delayed feeding after abdominal gynaecologic surgery.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2015

A comparison of the effectiveness and safety of two different surgical treatments for heavy menstrual bleeding

This Cochrane review concerns women with heavy menstrual bleeding (HMB), which is menstrual blood loss that a woman feels to be excessive and that often interferes with her quality of life. Researchers from The Cochrane Collaboration compared endometrial resection or ablation versus hysterectomy for women with HMB. The main factors (thought to be of greatest importance) were how well each operation was able to treat the symptoms of HMB, how women felt about undergoing each operation and what the complication rates were. Additional factors studied were how long each operation took to perform, how long women took to recover from the operation and how much the operation cost the hospital and the woman herself.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

Heavy periods: How effective are the different types of surgery?

Removing the whole womb (hysterectomy) provides more relief from heavy menstrual bleeding than surgically removing the lining of the womb does. The risk of adverse effects is lower if only the lining is removed, but further surgery is sometimes needed.

Informed Health Online [Internet] - Institute for Quality and Efficiency in Health Care (IQWiG).

Version: June 20, 2013

Treatment options for heavy periods

Women with very heavy periods (menorrhagia) have various pharmaceutical and surgical treatment options. Knowing about the advantages and disadvantages of each can help make it easier to choose an appropriate therapy.The possible treatment options and the timing of treatment will depend on whether a woman wants to have a (further) child or not. The most effective treatments all affect the ability to get pregnant – either temporarily, like the pill, or permanently, like the surgical removal of the womb (hysterectomy).There are also procedures that do not involve removing the womb. Hormonal medications are not the only pharmaceutical option. There are also non-hormonal drugs that aim to reduce menstrual bleeding and help with the associated problems. If one kind of medication is not working, it is usually possible to try out other kinds of medicines or combine them.As long as the heavy periods have not caused anemia, it is possible to deal with the “heavier” days without having any treatment.

Informed Health Online [Internet] - Institute for Quality and Efficiency in Health Care (IQWiG).

Version: June 20, 2013

Systematic Reviews in PubMed

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