Bilateral uterine artery ligation via minilaparotomy for heavy menstrual bleeding

1. Introduction 

Heavy menstrual bleeding (HMB) is a common gynecologic problem that affects 1 in 3 women worldwide [1]. The management of HMB is tailored to the severity of bleeding, its impact on the woman's health and health-related quality of life, as well as her future fertility wishes [2]. Another important determinant in the selection of HMB treatment is the presence of other pathology such as fibroids, which affect the uterine cavity, or pathology such as adenomyosis, which may affect the response to treatment. Current available methods include medical treatment, surgical treatment, and minimally invasive alternatives to surgery [3]. The inconsistent efficacy, adverse effects, and low patient compliance with medical treatments hamper their long-term use [4]. Hysterectomy remains the definitive treatment for HMB, particularly in women who do not wish to conceive. However, hysterectomy has potential short- and long-term negative effects, both on psychological and psychosexual functions. This requires a comprehensive re-evaluation of its use in benign indications [5], [6]. Hysterectomy can be followed by depression and immediate postoperative anxiety that can significantly affect a woman's quality of life [7]. In Egyptian women, conserving the uterus may be important for gender identity, sexuality, marital relations, and self-esteem [8]. Preoperative anxiety in these women has been related to an increased chance of postoperative anxiety and depression [8].

In women who wish to preserve their fertility the surgical options are limited [9]. Over the past 2 decades, uterine artery embolization (UAE) has become an established method to treat life-threatening postpartum hemorrhage, bleeding after gynecologic surgery, pelvic arteriovenous malformation, and cervical pregnancy [10]. Reported adverse effects included impairment of ovarian function and premature ovarian failure. These reports limit its use as a treatment for fibroids in women who wish to preserve their fertility [11].

Uterine artery ligation (UAL) is an effective, minimally invasive procedure that directly reduces uterine blood supply and menstrual blood flow. Indirectly it acts through reducing prostaglandin levels in the endometrium [9]. Despite its successful use to control postpartum hemorrhage, its efficacy in the treatment of HMB is, to date, still unclear. The procedure can be performed using minilaparotomy with basic laparotomy instruments. It can be performed with local anesthesia or light sedation [12], [13]. These factors lower the cost, reduce anesthesia-related complications, and make UAL an appealing procedure in low-income settings. The objective of the present study was to investigate the safety and short-term efficacy of bilateral UAL using minilaparotomy for the management of HMB.

3. Results 

Between August 2006 and May 2007, 30 women with heavy menstrual bleeding were included in the study. The mean age of the women was 41.5±3.6 years with a median parity of 5.0 (range, 2–9) (Table 1). The procedure time was 32.3±4.5 minutes (95% CI, 30.5–34.0 minutes; range 26–50 minutes). Hospital stay in days was 1.2±0.4 (95% CI 1.1–1.4 days; range, 1.0–2.0 days). Only 8 patients (26.7%) had to stay overnight after the procedure (95% CI, 14.2%–44.4%).

Table 1. Clinical data for the study participants (n=30) a

	Variable	Data	95% Confidence Interval
	Age, y	41.5±3.6	40.2–42.8
		40 (37–48)
	Parity	5.0±1.7	4.3–5.6
		5.0 (2–9)
	Previous medical treatment
	Estrogen/progestins, %	17 (57)	39–73
	Progestins, %	13 (43)	27–61
	Pattern of bleeding
	Regular, %	17 (57)	39–73
	Irregular, %	13 (43)	27–61
	Amount of bleeding
	Excessive, %	24 (80)	62.7–90.4
	Spotting, %	6 (20)	9.5–37.3
	Duration of bleeding, days	17±7.1	14.3–19.7
		15 (8–30)
	Hemoglobin, g/dL	8.3±0.6	8.1–8.5
		8.3 (7–9.3)
	Pathology
	No abnormality, %	24 (80)	62.7–90.4
	Simple hyperplasia, %	6 (20)	9.5–37.3
	Follow-up, mo.	12.5±4.0	11.0–14.0
		13.2 (3.1–17.3)

a Values are given as mean±SD or median (range) for continuous variables, and number (percentage) for categorical variables.

The median follow-up was 13.2 months (range, 3.1–17.3 months). At 12 months, 6 women had undergone hysterectomy for bleeding. The total cumulative failure at 12 months was 20% (95% CI, 9%–38%). Women with irregular bleeding (menometrorrhagia and spotting) were more likely to undergo hysterectomy after the procedure compared with those who had regular bleeding, with a hazard ratio of 7.5 (95% CI, 2.3–15.6; P=0.027); while women with spotting were more likely to undergo hysterectomy after the procedure, with a hazard ratio of 9.8 (95% CI, 4.3–12.4; P=0.007) (Fig. 2). The study included 7 patients with symmetrically enlarged uteri where the uterine cavity ranged between 8.5 cm and 10.0 cm. None of these 7 patients needed further treatment during the follow-up period.

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Figure 2. Failure rate of UAL in various subgroups: (A) women with regular compared with irregular bleeding; (B) women with excessive bleeding compared with spotting.

Significant improvement in the duration of bleeding was reported, with a reduction of 11.9±1.5 days (95% CI, 8.9–14.9; P<0.001. Bleeding days decreased from 17±7.1 days (range, 8–30 days) before the procedure to 5.1±3.3 days (range, 2.0–15.0) after the procedure (P<0.001).

In addition, significant increases in hemoglobin levels of 1.3±0.15 g/dL (95% CI, 1.0–1.6; P<0.001) were observed after the procedure. Hemoglobin levels increased from 8.3±0.6 g/dL (range, 7–9.3 g/dL) before the procedure to 9.6±0.8 g/dL (range, 7.4–10.8 g/dL) after the procedure (P<0.001).

Of the 30 patients, 24 (80%) expressed their satisfaction with the results of the procedure. No major complications were reported during the procedure or during follow-up.

4. Discussion 

The present study assessed the safety and efficacy of a bilateral uterine artery ligation procedure carried out via minilaparotomy for management of heavy uterine bleeding. We included 30 women older than 35 years who had had unsuccessful medical treatment for at least 6 months. UAL was found to be safe and with a success rate of 80%. In addition, UAL significantly reduced the days of bleeding from 17±7.1 days preoperatively to 5.1±3.3 days postoperatively (P<0.001). Hemoglobin level also improved from 8.3±0.6 g/dL to 9.6±0.8 g/dL within 3 months postoperatively.

UAL via minilaparotomy proved to have a high safety profile, high feasibility, and low cost in our setting. These represent advantages over hysterectomy and other minimally invasive procedures, including endometrial ablation and uterine artery embolization techniques for the management of HMB. The procedure has relatively lower cost, requires average surgical skills, and is suitable for settings in low-income countries. UAL has the potential to treat women with chronic symmetrically enlarged uteri larger than 10 cm in size, for which endometrial ablation would be less effective [14], [15]. We included 7 patients with symmetrically enlarged uteri, none of whom required further treatment.

Previous studies have suggested the benefits of UAL to treat HMB in women with larger uteri and those with adenomyosis. Aziz [13] suggested that the increase in cavity surface of a hypertrophic uterus and diffuse intramural fibrosis may be treated by uterine vessel ligation. That study included women of high parity with symmetrical enlargement of the uterus, manifested by menorrhagia [13]. The suggested mechanism was a decrease in blood perfusion per unit volume and decrease in menstrual blood loss. Impaired uterine perfusion via UAL might induce a decline in the level of prostaglandins during menstruation, decrease blood loss, and relieve pain [16], [17]. Chin et al. [9] reported good control of menstrual bleeding and adequate relief of dysmenorrhea following laparoscopic UAL for treatment of symptomatic adenomyosis [9].

The uterus has a dual extrinsic blood supply. Uterine arteries supply approximately 42% of blood flow, while ovarian and vaginal arteries supply approximately 58% [18]. Stepwise uterine devascularization including uterine, ovarian arteries, and round ligament ligation, allows good control of postpartum hemorrhage [19], [20]. Vascular occlusion is temporary because recanalization and subsequent normal uterine circulation are expected [19]. We propose the same etiology for failures in the current cohort. Ligation of the anastomotic branches of uterine and ovarian arteries in all women undergoing UAL is strongly indicated in women older than 45 years [5], [12]. Retrospective series and case reports have shown that arterial ligation harms neither uterine nor ovarian function [19], [21]. In addition, Bradley et al. [10] and Hurst et al. [17] have shown that UAL results in a 40% to 60% reduction in uterine volume within 2–4 months post operatively. Less diffuse uterine necrosis and sepsis are expected to occur after UAL compared with women treated with uterine artery embolization [10], [17], [22], [23].

Despite the relatively small sample size in the present study it appears that women with regular bleeding benefit the most from UAL. Women with menometrorrhagia and spotting were more likely to undergo hysterectomy after the procedure. The advantages of the procedure are the reductions in postoperative pain, use of analgesia, hospital stay, and recovery time, along with the potential psychological benefits from the preservation of the uterus [24], [25].

The limitations of the present study include the short follow-up period, the small sample size, and inclusion of 2 different types of medical treatments to control bleeding before UAL. Other limitations include the lack of objective evaluation of menstrual blood loss and health-related quality of life assessment following the procedure. We believe that the present study provides initial evidence supporting the efficacy and safety of UAL as a therapy for heavy menstrual bleeding. Further studies are needed to compare UAL via minilaparotomy with transvaginal UAL, laparoscopic UAL, Doppler-assisted transvaginal uterine artery clamping, and hysterectomy (laparoscopy, laparotomy, and transvaginal approaches.