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Home , Hysterectomy, Tubal ligation

Journal of Rawalpindi Medical College (JRMC); 2015;19(2):168-170

Original Article

Is Incidence of Increased in Post Tubal Ligated Patients due to Dysfunctional Uterine Bleeding?

Iram Munawar, Nadia Zahid, Amna Aslam Department of /Obstetrics, Avicenna Medical College, Lahore

Abstract patients, one important cause is . Bilateral tubal ligation (BTL) is a known and effective method Background: To determine if previous bilateral of among women, particularly those tubal ligation (BTL) increases the risk of undergoing cesarean section. But like any other hysterectomy due to dysfunctional uterine bleeding surgical procedure, it has variable outcomes. The (DUB). complications any woman has to face post-ligation are Methods: In this case-control study female patients termed as Post-tubal ligation syndrome which include with bilateral tubal ligation, undergoing increased incidence of irregular and heavy menstrual hysterectomy due to abnormal uterine bleeding were bleeding and subsequent .2 included. These patients were divided into two Hysterectomy is among most commonly performed groups. Group A (study group) were those who had gynaecological procedures. Since a long time, this undergone BTL in past and group B (control group) procedure is being performed for a variety of causes were those not having history of tubal ligation. and pathologies including DUB,, Hysterectomy was done in all these patients and malignancies, and . It is second demographic data including age, hemoglobin (Hb) most commonly performed procedure among adult level and parity were recorded. The incidence of females after cesarean section (CS).3 Recently a hysterectomy in patients with DUB was compared in question has been raised among researchers that both groups. Frequencies and percentages were whether this procedure is being done logically and calculated for qualitative variables like number of judicially. According to Magon et al. hysterectomy is a patients undergoing hysterectomy in both groups using chi-square test. The Odd’s Risk (OR) and its surgery which has been used and misused, underused, 4 95% Confidence Interval (CI) was calculated and p- and abused at different times in gynaecology. So it is value ≤ 0.05 was considered as significant. important to search for risk factors of hysterectomy and it is topic of debate with various studies Results: A total of 313 patients underwent concluding contradictory results. Specifically focusing hysterectomy during this period. Among them, 89 on BTL being a risk factor of hysterectomy, the relative patients were operated due to DUB. Of these 89 risk of hysterectomy because of DUB subsequent to patients, 28 (31.4%) had history of BTL (Case group) tubal sterilization is increased.5 while 61 (68.5) had no history of BTL (Control group). These groups were comparable to each other in terms of age, parity and Hemoglobin levels. Also Patients and Methods statistical analysis showed that there was no This case-control study was conducted at Department association between BTL and hysterectomy due to of Obstetrics and Gynaecology, Avicenna Medical DUB (OR=0.623; 95% CI: 0.41- 0.93) College and Teaching Hospital, Lahore, over a period Conclusion: Bilateral tubal ligation is not a risk of two years from January, 2013 to December, 2014. All factor for future hysterectomy in patients with female patients undergoing hysterectomy due to history of bleeding of endometrial origin. abnormal uterine bleeding were included in the study. Key Words: Hysterectomy, Tubal Ligation, Other inclusion criteria were patients aged 38-50 Sterilization years,multiparous and menstrual cycle shorter than 21 days. Exclusion criteria included: patients with history Introduction of abnormal uterine bleeding due to fibroid , Dysfunctional uterine bleeding (DUB) is defined as ,, patients with abnormal uterine bleeding in the absence of organic bleeding disorder; patients with medical disorders and disease.1 Among many causes of DUB in adult those receiving hormonal therapy. All the patients

168 Journal of Rawalpindi Medical College (JRMC); 2015;19(2):168-170 were worked up for the underlying cause of abnormal Table 2:Cause of hysterectomy (DUB or Non uterine bleeding and those undergoing hysterectomy DUB) in women with and without BTL only due to bleeding of endometrial origin or DUB* Bilateral Tubal Ligation (BTL)** dysfunctional uterine bleeding were included. These + - patients were divided into two groups. Group A Number %age Number %age (study group) were those who had undergone BTL in + 28 31.4 61 68.5 past and Group B (control group) were those not - 38 30.6 86 69.4 having history of tubal ligation. Hysterectomy was *DUB=Disfunctional Uterine Bleeding; ** BTL=Bilateral done in all these patients and demographic data Tubal Ligation including age, hemoglobin (Hb) level and parity were Discussion recorded. The incidence of hysterectomy in patients Among women, many ways of contraception and with DUB was compared in both groups..Frequencies sterilization are in practice and among surgical and percentages were calculated for qualitative options, one is bilateral tubal ligation. It is a permanent variables like number of patients undergoing type of contraception which blocks the passage of hysterectomy in both groups using chi-square test. The sperm cells through fallopian tubes. It can be done as Odd’s Risk (OR) and its 95% Confidence Interval (CI) part of cesarean section, as a separate procedure both was calculated and p-value ≤ 0.05 was considered as open and laparoscopically and fallopian tubes can be significant. closed with clips, rings, by electrocoagulation and

excision.6 Results It is a highly effective way of contraception but at the A total of 213 patients underwent hysterectomy during same time, post-operative complications associated this duration at our department. Out of them, 89 with this procedure are highly prevalent and termed patients had hysterectomy purely for the bleeding of as Post-tubal ligation syndrome. This term was endometrial origin. Among 89 patients 28 patients proposed in 1951 and it is called a syndrome because it (31.46%) had previous history of BTL (Case group) is a constellation of various symptoms including while 61 (68.53%) women who had hysterectomy due menorrhagia, pelvic discomfort and ovarian cystic to bleeding of endometrial origin had no history of changes. The pathophysiology behind these symptoms BTL (Control group). Both groups were comparable to after BTL is disruption of blood supply to the each other in terms of mean age, parity and Hb and uterus with disturbance of ovulatory functions.7 levels(Table 1). Because of the reason of DUB being associated with Table 1: Demographic details of the patients this syndrome, some patients opt for hysterectomy and in two groups this was the objective of this study to find risk of Group A Group B p- hysterectomy in patients undergoing BTL. (Control (Study Value In this study we found that DUB was cause of group) group) hysterectomy in 89 of 213 patients (41.7%). DUB has been found as main cause of hysterectomy in many Age 43.08 ± 5.26 45.5 ± 3.48 0.02 studies. Tiwana KK and colleagues found DUB as a (Mean) cause of hysterectomy in more than 50% of the In years patients. Also many other studies have found DUB as Parity 4.21 ± 1.59 4.25 ± 1.85 0.3 a principal cause in most of the patients undergoing Hb 8.38 ± 1.15 8.2 ± 1.4 0.20 hysterectomy(8). However in our study it was in 41.7% (mg/dl) patients. The reason of this relatively less number may be because in our study, we included all the patients The mean duration of hysterectomyafter BTL was undergoing hysterectomy including pathological and 15.30 ± 5.3 years. The mean onset of DUB was at 42.05 oncological causes unlike other referenced studies. ± 2.3 years of age. Also statistical analysis showed that Many authors have investigated and found there was no association between BTL and contradictory reports regarding DUB being associated hysterectomy due to DUB (OR=0.623; 95% CI: 0.41- with BTL. As Peterson and colleagues conducted their 0.93) (Table 2). trial and included 95 patients who underwent BTL and

169 Journal of Rawalpindi Medical College (JRMC); 2015;19(2):168-170 they found that there were no persistent changes in References inter-menstrual bleeding or the length of the menstrual 1. Baxi SN, Panchal NS. Histopathology-like categories based cycle but these patients had more decrease in the on endometrial imprint cytology in dysfunctional uterine number of days with bleeding.9 Bernard et al. found bleeding.J Cytol. 2015;32:96-101 that length of menstruation, menstrual irregularity, 2. Mehra N, Farshid S, Lamba M, Singh SS.Post-ablation tubal sterilization syndrome.J ObstetGynaecol Can. length of cycle, flow volume, dysmenorrhea and 2011;33:1085-88. hormone levels are similar in women with and 3. Kayastha S. Study of endometrial tissue in dysfunctional without tubal ligation, but parous women with a uterine bleeding.Nepal Med Coll J. 2013;15:27-30. history of CS and BTL more than 5 years of age 4. Magon N, Divakar H, Kirpalni A. The use, misuse, and abuse experienced a marginal increase in volume of of hysterectomy. Journal of Mid-Life Health.2013;4:1-4. 5. Kjer JJ, Knudsen L. Hysterectomy subsequent to laparoscopic menstrual flow compared with women who did not sterilization. Eur J Obstet Gynecol Reprod Biol 1990;35:63- undergo BTL.10 68. Also OR in this study was found to be 0.623 which 6. McMartin k. Hysteroscopic Tubal Sterilization: An Evidence- shows a non-significant association between BTL and Based Analysis. Ont Health Technol Assess Ser. 2013;13:1– 35. hysterectomy due to DUB. Mackenzie and colleagues 7. Hellier S and Berkhoudt K. A case of postablation tubal have found that about 6% of patients undergo sterilization syndrome.AdvEmergNurs J. 2012;34:204-08. hysterectomy after BTL or . And 8. Tiwana KK, Nibhoria S, Monga T, Phutela R. this may be due to DUB, but still in their study BTL Histopathological audit of 373 nononcological hysterectomies in a teaching hospital.Patholog Res Int. was not found having any association with 2014;2014:468-71. 11 hysterectomy. Similarly Moradan S and Gorbani R 9. Peterson HB, Jeng G, Folger SG, Hillis SA, Marchbanks PA . conducted a similar trial and they found relative risk U.S Collaborative Review of Sterilization Working Group. of 0.85 in their study between BTL and hysterectomy.12 The risk of menstrual abnormalities after tubal sterilization. N Engl J Med 2000;343:1681-87. These findings are consistent with our study results. In 10. Harlow BL, Missmer SA, Cramer DW, Barbieri RL. Does another study Ozerkan et al. found that some kind of tubal sterilization influence the subsequent risk of changes in menstrual pattern do happen in 7.6% of menorrhagia or dysmenorrhea? FertilSteril 2002;77:754-60. patients after BTL,however these are mild changes .13 11. MacKenzie IZ, Thompson W, Roseman F, Turner E. A prospective cohort study of menstrual symptoms and morbidity over 15 years following laparoscopic. Filshie clip Conclusion sterilisation. Maturitas 2010;65:372-77. 12. Ozerkan K, Aydin G, Koc I, Uncu Y, Uncu G. Menstrual There was no significant association between patients pattern following tubal sterilization. Med Sci Monit undergoing hysterectomy due to dysfunctional 2010;16:910-93 Uterine Bleeding (DUB) and previous surgery for 13. Moradan S and Gorbani R. Is Previous Tubal Ligation a Risk Bilateral Tubal Ligation(BTL). Factor for Hysterectomy because of Abnormal Uterine Bleeding?Oman Med J. 2012;27:326-28.

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