Coming from a large university teaching hospital, the paper by Weeks et al. (Vol 107, March 2000)1 provides an unfortunate legitimacy to an extremely low vaginal rate (30%) as hysterectomy treatment of dysfunctional menorrhagia. The primary aim of this investigation was apparently to determine a way of reducing morbidity associated with hysterectomy using intra-operative blood loss as a surrogate measure. As the authors acknowledge a higher proportion of women having a vaginal hysterectomy in the treatment group could account for the lower blood loss found in the treatment group. While a decrease in uterine volume by one third may be critical to the success of a vaginal hysterectomy for uterine fibroids, I do not think this applies to a bulky uterus. When the indication for hysterectomy has been dysfunctional menorrhagia, in the past six years I have never listed anyone for abdominal hysterectomy. Some would argue that oophorectomy can be safely carried out vaginally in the majority of women2 and the option of laparoscopic assisted vaginal hysterectomy with salpingo-oophorectomy is available if difficulty is envisaged. The unnecessary costs of disposable stapling equipment can be avoided by using a suture technique3.
The cost of a training course in vaginal hysterectomy for the surgeons involved would have been recouped after about six patients treated by vaginal rather than abdominal hysterectomy with two months of leuprorelin. It will be a travesty if the failure to demonstrate a significant reduction in blood loss in the treatment arm due to lack of power in this publication encourages others to repeat a similar but larger series. It might be helpful to repeat the study in a series of vaginal hysterectomies. More effort needs to be concentrated on ways of increasing the use of vaginal rather than abdominal hysterectomy in dysfunctional menorrhagia