Effect of hysterectomy versus medical treatment on health-related quality of life and sexual functioning

In this study, 63 women with a history of at least 4 years of abnormal bleeding who had failed treatment with cyclic medroxyprogesterone were randomized to treatment with expanded medical treatment or hysterectomy. The recommended medical regimen was 21 days of low-dose oral contraceptive followed by 5 days of prostaglandin synthetase inhibitor starting on day 1 of the menstrual cycle. Some patients received continuous oral contraceptives, alternative progestogens, oral or intramuscular, or cyclic estrogen-progestin, accordingly. The type and route of hysterectomy were selected by the surgeon. At enrollment, each patient underwent evaluation for sociodemographic, clinical, and health-related quality-of-life variables. Four weeks after surgery or the start of expanded medical therapy, reassessment was made by telephone interview. In addition, patients were seen in the clinic every 6 months for 2 years, and further telephone interviews were conducted at 3, 9, 15, and 21 months after enrollment. Measures for quality-of-life variables were made using modifications of the Medical Outcomes Study (MOS), including MOS SF-36, the Mental Component Summary (MCS), and the Physical Component Summary (PCS). At enrollment, most participants reported symptoms of pelvic pain and pressure and had fibroids on pelvic examination. Their mean MCS and PCS scores were 45 and 42, respectively (compared to U.S. norms of 49 and 51); the mean body mass index was 32. Of 31 women randomized to hysterectomy, 10 had an abdominal and 18 had a vaginal procedure. Most of the 32 participants randomized to expanded medical treatment received hormonal treatment with or without prostaglandin inhibitor (29 of 32, 91%). Three others were treated with prostaglandin inhibitor only. After 4 weeks of follow up, the PCS scores of women who had undergone hysterectomy were lower than at baseline, whereas women receiving medical treatment showed some improvement. However, the MCS score of women in the hysterectomy group improved relative to baseline and were higher than those for women in the medical group (P = 0.004 and P = 0.03 for differences, respectively). After 6 months of follow up, the PCS scores of those who had hysterectomy had improved and were significantly higher than those in the medicine group (8 vs. 2; P = 0.04). Compared with those receiving expanded medical treatment, the hysterectomy group also reported greater sexual desire (P = 0.01), less interference with sex (P = 0.003), less health distress (P = 0.009), fewer sleep problems (P = 0.03), greater overall health (P = 0.006), and greater satisfaction with health (P = 0.01). Fourteen women (43%) in the medicine group requested hysterectomy in the first year of follow up, and, within 2 years, an additional 3 crossed over from medical treatment to hysterectomy. After surgery, these women reported improvements similar to those who had initial hysterectomy. Women who continued with expanded medical treatment did not improve significantly in their MCS score. After 2 years of follow up, women who had hysterectomy continued to report improvement in all outcome measures. The secondary symptoms of women receiving medical treatment also improved. At 2 years, the only difference in symptoms was that women in the hysterectomy group continued to report a significantly greater increase in sexual desire than women in the medical group.