Does medical debulking with gonadotrophin-releasing hormone agonist facilitate vaginal hysterectomy with a moderate enlarged uterus? A randomized control study.

Background: Vaginal hysterectomy is considered the method of choice for removal of the uterus but most gynecologists still prefer the abdominal route for removal of benign uteri >14 weeks in size. Conversion of an abdominal to a potential vaginal hysterectomy by uterine size reduction would be advantageous. Gonadotrophin-releasing hormone (GnRH) agonists can reduce uterine bulk by up to 50%.

Objective: To evaluate the efficacy of the preoperative administration of a GnRH agonist for women with enlarged non-prolapsing uteri in order to facilitate vaginal hysterectomy, in comparison with patients with enlarged uteri who underwent direct total abdominal hysterectomy (TAH) for the same indication (menorrhagia).

Study Design: Randomized controlled study. Women scheduled for hysterectomy for menorrhagia with a non-prolapsing uterus of ≥14 weeks size (by clinical and sonographic assessments) were offered a trial of vaginal hysterectomy after pre-treatment with a GnRH agonist (goserelin) for 3 months (study group=Group 1=40). A group of women with uteri of comparable size who underwent abdominal hysterectomy for similar indications served as controls (Group 2=40). Pre- and post-operative data such as hemoglobin, myoma size, uterine weight, duration of procedure and complications, pain score and length of hospital stay were collected prospectively.

Results: The weight of the uterine specimen was significantly lower in Group 1 (511.7±217g) compared to Group 2 (736.8±212g); P<0.001. The mean objective decrease in clinical uterine bulk preoperatively in Group 1 was 20.1%. The duration of surgery was nearly 1.5 times as long in vaginal (119.6±41.7min) compared to abdominal hysterectomy (81.1±34.1min), P<0.001, but analgesia use and the length of inpatient stay were significantly lower in Group 1 (2.6±1.3 days) compared to Group 2 (4.12±1.7 days), P<0.001. There was no significant difference between the two groups as regards the rate of occurrence of surgical complications.

Conclusions: In women with ≥14 week size uteri, treatment with a GnRH agonist reduces uterine size sufficiently to allow safe vaginal hysterectomy. Although duration of surgery was longer, women who underwent vaginal hysterectomy required less analgesia and had a shorter inpatient stay.