Estudo comparativo do sistema intrauterino de levonorgestrel com a histerectomia laparoscópica no tratamento do sangramento menstrual excessivo em úteros aumentados de volume
Data
2023-07-11
Autores
Depes, Daniella de Batista 
Orientadores
Di Bella, Zsuzsanna Ilona Katalin de Jármy
Tipo
Tese de doutorado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Introdução: Sangramento menstrual excessivo é o que interfere no bem-estar físico, emocional e social da mulher, reduzindo sua qualidade de vida. O tratamento cirúrgico é altamente eficaz, porém tem riscos e, em úteros de volume normal, vem sendo substituído com sucesso pelo tratamento clínico com o sistema intrauterino de levonorgestrel (SIU-LNG). Objetivos: Avaliar a eficácia do SIU-LNG no tratamento das pacientes com sangramento menstrual excessivo e útero aumentado de volume e comparar a satisfação, complicações e custos com a histerectomia videolaparoscópica (HVLP). Métodos: Estudo coorte retrospectivo comparativo realizado no ambulatório de Ginecologia de hospital público de ensino em São Paulo, Brasil, de 62 mulheres com sangramento menstrual excessivo e útero aumentado de volume, tratadas e acompanhadas por quatro anos. O grupo 1 foi submetido à inserção do SIU-LNG e o grupo 2 à HVLP. Resultados: No grupo 1 (n=31), 21 pacientes (67,7%) apresentaram melhora no padrão de sangramento sendo que 11 pacientes (35,5%) ficaram em amenorreia. Cinco pacientes (16,1%) mantiveram o sangramento intenso e foram consideradas falha de tratamento. No grupo 2 a eficácia foi 100%. Houve sete expulsões do SIU-LNG (22,6%), em cinco pacientes o sangramento manteve-se intenso, e em duas pacientes o sangramento tornou-se semelhante à menstruação normal. Não houve relação entre a falha do tratamento e histerometrias maiores (p=0,40) ou volumes uterinos maiores (p=0,50), enquanto a expulsão foi maior nos úteros com menores histerometrias (p=0,04*). Ocorreram 13 (21%) complicações, sendo sete (53,8%) no grupo 1, todas expulsões do dispositivo; e seis (46,2%) no grupo cirúrgico, estas mais graves (p=0,76). Quanto à satisfação, 12 pacientes (38,7%) estavam insatisfeitas no grupo 1 e uma (3,23%) no grupo 2 (p=0,00*). O custo do tratamento clínico, incluindo suas complicações foi quase cinco vezes inferior ao custo do tratamento cirúrgico com suas complicações. Conclusões: O tratamento com o SIU-LNG em pacientes com sangramento menstrual excessivo e útero aumentado de volume foi eficaz e, quando comparado à histerectomia VLP, teve menor taxa de satisfação, mesma taxa de complicações, porém de menor gravidade, além de menor custo.
Introduction: Excessive menstrual bleeding interferes with women's physical, emotional, and social well-being, reducing their quality of life. Surgical treatment is highly effective but carries risks and, in normal-volume uteruses, has been successfully replaced by clinical treatment with the levonorgestrel (LNG) intrauterine device (IUD). Objectives: To evaluate the LNG-IUD effectiveness in treating patients with excessive menstrual bleeding and an enlarged uterus and compare satisfaction, complications, and costs with video laparoscopic hysterectomy (VLH). Methods: Comparative cross-sectional observational study carried out at the Gynecology clinic of a public teaching hospital in São Paulo, Brazil, of 62 women with excessive menstrual bleeding and an enlarged uterus, treated and followed up for four years. Group 1 was submitted to the LNG-IUD insertion and Group 2 to VLH. Results: In group 1 (n=31), 21 patients (67.7%) showed improvement in the bleeding pattern and 11 patients (35.5%) remained in amenorrhea. Five patients (16.1%) maintained heavy bleeding and were considered a treatment failure. In group 2 the efficacy was 100%. There were seven LNG-IUD expulsions (22.6%), in five patients the bleeding remained heavy, and in two patients the bleeding became similar to normal menstruation. There was no relation between treatment failure and higher hysterometries (p=0.40) or larger uterine volumes (p=0.50), while expulsion was greater in the uterus with lower hysterometries (p=0.04*). There were 13 (21%) complications, seven (53.8%) in group 1, all device expulsions; and six (46.2%) in the surgical group being more severe (p=0.76). As for satisfaction, 12 patients (38.7%) were dissatisfied in group 1 and one (3.23%) in group 2 (p=0.00*). The cost of clinical treatment, including its complications, was almost five times lower than the cost of surgical treatment with its complications. Conclusions: Treatment with the LNG-IUD in patients with excessive menstrual bleeding and an enlarged uterus was effective and, when compared to laparoscopic hysterectomy, had a lower satisfaction rate, the same rate of complications, but less severe, in addition to a lower cost.
Introduction: Excessive menstrual bleeding interferes with women's physical, emotional, and social well-being, reducing their quality of life. Surgical treatment is highly effective but carries risks and, in normal-volume uteruses, has been successfully replaced by clinical treatment with the levonorgestrel (LNG) intrauterine device (IUD). Objectives: To evaluate the LNG-IUD effectiveness in treating patients with excessive menstrual bleeding and an enlarged uterus and compare satisfaction, complications, and costs with video laparoscopic hysterectomy (VLH). Methods: Comparative cross-sectional observational study carried out at the Gynecology clinic of a public teaching hospital in São Paulo, Brazil, of 62 women with excessive menstrual bleeding and an enlarged uterus, treated and followed up for four years. Group 1 was submitted to the LNG-IUD insertion and Group 2 to VLH. Results: In group 1 (n=31), 21 patients (67.7%) showed improvement in the bleeding pattern and 11 patients (35.5%) remained in amenorrhea. Five patients (16.1%) maintained heavy bleeding and were considered a treatment failure. In group 2 the efficacy was 100%. There were seven LNG-IUD expulsions (22.6%), in five patients the bleeding remained heavy, and in two patients the bleeding became similar to normal menstruation. There was no relation between treatment failure and higher hysterometries (p=0.40) or larger uterine volumes (p=0.50), while expulsion was greater in the uterus with lower hysterometries (p=0.04*). There were 13 (21%) complications, seven (53.8%) in group 1, all device expulsions; and six (46.2%) in the surgical group being more severe (p=0.76). As for satisfaction, 12 patients (38.7%) were dissatisfied in group 1 and one (3.23%) in group 2 (p=0.00*). The cost of clinical treatment, including its complications, was almost five times lower than the cost of surgical treatment with its complications. Conclusions: Treatment with the LNG-IUD in patients with excessive menstrual bleeding and an enlarged uterus was effective and, when compared to laparoscopic hysterectomy, had a lower satisfaction rate, the same rate of complications, but less severe, in addition to a lower cost.
Descrição
Citação
DEPES, Daniella de Batista. Estudo comparativo do sistema intrauterino de levonorgestrel com a histerectomia laparoscópica no tratamento do sangramento menstrual excessivo em úteros aumentados de volume. 2023. 62 f. Tese (Doutorado em Ginecologia) - Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP). São Paulo, 2023