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OBJECTIVE: To compare endometrial laser ablation (ELA) with transcervical resection of the endometrium (TCRE) in the treatment of menorrhagia. DESIGN: Randomised controlled trial. SETTING: Gynaecology department of a large teaching hospital. PARTICIPANTS: Women with menorrhagia due to dysfunctional uterine bleeding (n = 372) were randomly allocated to ELA (n = 188) or TCRE (n = 184). MAIN OUTCOME MEASURES: Operative complications, post-operative recovery, relief of menstrual and other symptoms, need for further surgical treatment, satisfaction with treatment after 6 and 12 months, and differential resource use. RESULTS: TCRE was significantly quicker, with lower rates of fluid overload. Perioperative morbidity was low and similar in both groups. Outcome at 12 months was also similar: 72 women (45%) had either amenorrhoea or brown discharge in the ELA group compared with 71 (49%) in the TCRE group; 79 (49%) versus 68 (46%) had lighter periods. Thirty (16%) versus 36 (20%) had received further surgical treatment: 9 (5%) compared with 25 (14%) had had a hysterectomy and 21 (11%) versus 11 (6%) had received repeat ablation. Anxiety and depression, dysmenorrhoea and pre-menstrual symptoms were improved by both procedures and bladder symptoms were affected by neither. At 12 months 148 (90%) women in the ELA group and 140 (91%) women in the TCRE group were satisfied with their treatment. The estimated additional cost of ELA was Pound 145 per procedure. CONCLUSIONS: At one year there was no clear difference in clinical outcome between ELA and TCRE. Both procedures were associated with low morbidity. ELA was the more costly procedure. Despite the need for further surgery for about one in six women, satisfaction rates were high following both ELA and TCRE.

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OBJECTIVES: To estimate and compare the costs of treating women with menorrhagia by hysterectomy or hysteroscopic surgery, in the form of transcervical resection of the endometrium (TCRE) or endometrial laser ablation (ELA). STUDY DESIGN: Randomised controlled trial set in the gynaecological department of a large British teaching hospital. Under usual circumstances, 204 women who would have undergone hysterectomy for menorrhagia were randomly allocated to either hysterectomy (n = 99) or hysteroscopic surgery in the form of TCRE (n = 52) or ELA (n = 53). National Health Service (NHS) costs and costs to patients per patient occurring up to 1 year following surgery were estimated. Theatre times and length of hospital stay were recorded during the trial. Costs were obtained from the health board finance department and relevant suppliers of technical equipment. One year after treatment patients completed questionnaires on personal costs incurred. RESULTS: The NHS costs of treating women with hysteroscopic surgery were 24% (TCRE) or 20% (ELA) less than treating women by hysterectomy (1001 pounds/1046 pounds vs. 1315 pounds). On average, women undergoing hysteroscopic surgery incurred 71% less costs to themselves than those who underwent hysterectomy (21 pounds vs. 73.40 pounds). CONCLUSIONS: Hysteroscopic endometrial ablation incurs less costs than hysterectomy both to the National Health Service and to women alike, up to 1 year after surgery.

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OBJECTIVE: To compare in psychiatric and psychosocial terms the outcome of hysterectomy and endometrial ablation for the treatment of dysfunctional uterine bleeding. DESIGN: Prospective randomised controlled trial. SETTING--Obstetrics and gynaecology department of a large teaching hospital. SUBJECTS: 204 women with dysfunctional bleeding for whom hysterectomy would have been the preferred treatment were recruited over 24 months and randomly allocated to hysterectomy (99 women) or to hysteroscopic surgery (transcervical resection (52 women) or laser ablation (53 women). MAIN OUTCOME MEASURES: Mental state, martial relationship, psychosocial and sexual adjustment in assessments conducted before the operation and one month, six months, and 12 months later. RESULTS: Both treatments significantly reduced the anxiety and depression present before the operation, and there were no differences in mental health between the groups at 12 months. Hysterectomy did not lead to postoperative psychiatric illness. Sexual interest after the operation did not vary with treatment. Overall, 46 out of 185 (25%) women reported a loss sexual interest and 50 out of 185 (27%) reported increased sexual interest. Marital relationships were unaffected by surgery. Personality and duration of dysfunctional uterine bleeding played no significant part in determining outcome. CONCLUSIONS: Hysteroscopic surgery and hysterectomy have a similar effect on psychiatric and psychosocial outcomes. There is no evidence that hysterectomy leads to postoperative psychiatric illness.

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OBJECTIVE: To evaluate the effectiveness and safety of endometrial laser ablation and transcervical resection of the endometrium compared with hysterectomy in the surgical treatment of women with dysfunctional uterine bleeding. DESIGN: Prospective randomised controlled trial. SETTING: Gynaecology department of a large teaching hospital. SUBJECTS: 204 women who would otherwise have been undergoing hysterectomy for menorrhagia were recruited between August 1990 and March 1992 and randomly allocated to hysterectomy (n = 99) or conservative (hysteroscopic) surgery (transcervical resection (n = 52) and laser ablation (n = 53)). MAIN OUTCOME MEASURES: Operative complications, postoperative recovery, relief of menstrual and other symptoms, patient satisfaction with treatment after six and 12 months. RESULTS: Women treated by hysteroscopic surgery had less early morbidity and a significantly shorter recovery period than those treated by hysterectomy (median time to full recovery 2-4 weeks v 2-3 months, P < 0.001). Twelve months later 17 women in the hysteroscopy group had had a hysterectomy, 11 for continuing symptoms; 11 women had had a repeat hysteroscopic procedure; 45 were amenorrhoeic or had only a brown discharge; and 35 had light periods. Dysmenorrhoea and premenstrual symptoms improved in most women in both groups. After 12 months 89% (79/89) in the hysterectomy group and 78% (75/96) in the hysteroscopy group were very satisfied with the effect of surgery (P < 0.05); 95% (85/89) and 90% (86/96) thought that there had been an acceptable improvement in symptoms, and 72% (64/89) and 71% (68/96) would recommend the same operation to others. CONCLUSIONS: Hysteroscopic endometrial ablation was superior to hysterectomy in terms of operative complications and postoperative recovery. Satisfaction after hysterectomy was significantly higher, but between 70% and 90% of the women were satisfied with the outcome of hysteroscopic surgery. Hysteroscopic surgery can be recommended as an alternative to hysterectomy for dysfunctional uterine bleeding.

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Sixty-three patients under the age of 50 years who were long-term survivors following radiotherapy for cervical cancer and had been placed on hormone replacement therapy (HRT) were identified. The median age at treatment was 37 years and the mean delay from treatment to the initiation of HRT was over 15 months. Fifteen of the 63 patients had experienced vaginal bleeding attributable to the effects of HRT on persisting endometrial tissue. The significance of this is discussed.

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Expression of the oncogenes Ha-RAS, c-MYC, and ERB-2 was investigated with an automated image analysis system in 12 specimens of normal cervix, 10 of cervical intraepithelial neoplasia (CIN) grade 1, 24 of CIN 3, and 10 of invasive cancer of the cervix. There was amplification of all three oncogenes in CIN 3 and invasive cancer compared with normal cervix and CIN 1. The difference was most pronounced with an antibody to the RAS p21 protein, with no overlap between CIN 3 and the normal range. This method might be useful in screening for cervical neoplasia, and for the determination of which CIN lesions require treatment.

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A retrospective study of 1921 caesarean sections at Rutherglen Maternity Hospital in Glasgow during the years 1979-1983, inclusive, showed that 229 (12%) were performed at less than 37 weeks gestation. Of these 229 preterm caesarean sections 41% were elective, 21% were for antepartum haemorrhage and 38% took place during labour. Of the 254 babies born 18 (7%) died in the neonatal period. These deaths comprised 31% of all neonatal deaths during the study period in this hospital. The neonatal death rate was 70% for babies weighing less than 1000 g (7 of 10) and 23% for babies weighing 1000-1500 g (6 of 26), but only 3% for babies heavier than this (7 of 217). Of the 75 women with a subsequent pregnancy after the preterm caesarean section 56% were again delivered by caesarean section. In view of the maternal morbidity associated with caesarean section and the poor neonatal outcome at birthweights of less than 1500 g, the use of operative delivery for very low birthweight infants deserves further scrutiny.

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