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Sir,

The aim of any ethical randomised controlled trial of any therapy is to compare the new (test) therapy with an accepted gold standard therapy. For many years the traditionally accepted standard therapy for dysfunctional uterine bleeding was to perform a curette of the uterus and then start medical therapy (hormonal or NSAID) as the combination of the two gave the best results. Garry4 (Vol 104 December 1997) calls endometrial ablation/ resection an “entirely new surgical procedure” and a “revolutionary technique”, but alternatively it could be described as a much more thorough and complete form of uterine curettage under direct vision. Copper et al.2 compare combined medical (gosere-lin) plus surgical (endometrial resection) therapy with any one of a mixed bag of medical therapies alone. They found, after a single assessment at only four months, that the patients with combined therapy were more satisfied–surprise surprise! Surely, in the assessment of managements of dysfunctional uterine bleeding, uterine curettage (including inspection of the uterine cavity hys-teroscopically or ultrasonically) with single best medical therapy (eg, tranexamic acid4) is what should be compared with endometrial ablatiodresection in a randomised controlled trial and the results assessed over at least one year and not just a few months.

Garry muddies the waters when he compares endometrial ablationhesection with hysterectomy (abdominal and vaginal)1, as the latter is hardly first line treatment for dysfunctional uterine bleeding. He states that endometrial ablationhesection has reduced the need for hysterectomy in 80% of patients and yet acknowledges that Bridgemad found that the extensive performance of endometrial ablatiodresection did not reduce the hysterectomy rate.

With risk factors in medicine a crude rule of thumb is that high risk is 10% or greater, low risk is ≤ 1% and in-between is medium risk. On this scale the perioperative complication rate for endometrial ablatiodresection for significant complications of 4.44%3 is not ‘low’3 and the techniques should not be described as ‘extraordinarily safe’1. I find it difficult to concur with the data presented in the December 1997 issue of the Journal that either endometrial ablation should now form part of the therapeutic repertoire of all gynaecological surgeons1, or that endometrial ablation and resection have been “validated”1.

References

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  2. References
  • 1
    Garry R. Endometrial ablation and resection: validation of a new surgical concept. Br J Obstet Gynaecol 1997; 104: 13291331.
  • 2
    Overton C, Hargreaves J, Maresh M. A national survey of the complications of endometrial destruction for menstrual disorders: the Mistletoe study. Br J Obstet Gynaecol 1997; 104: 13511359.
  • 3
    Cooper KG, Parkin DE, Garratt AM, Grant AM. A randomised comparison of medical and hysteroscopic management in women consulting a gynaecologist for treatment of heavy menstrual loss. Br J Obsret Gynaecol 1997; 104: 13601366.
  • 4
    Preston JT, Cameron IT, Adams EJ, Smith SK. Comparative study of tranexamic acid and norehisterone in the treatment of ovulatory menorrhagia. Br J Obstet Gynaecol 1997; 102: 40146.
  • 5
    Bridgeman SA. Increasing operative rates for dysfunctional uterine bleeding after endometrial ablation. Lancet 1994; 344: 893.