|Less Is More|
One of medicine's most frustrating paradoxes is that, although women use more health-care services than men, less is known about human female physiology and disease. Women's medicine, however, got a major boost at Brown this fall when epidemiologist and Associate Professor of Community Health Kay Dickersin arrived from the University of Maryland Medical School. Dickersin, a nationally known advocate for breast-cancer survivors, arrived on campus as the lead investigator for the four-year, twenty-center Surgical Treatments Outcomes Project for Dysfunctional Uterine Bleeding (STOP-DUB), the first clinical trial in this country to compare surgical options for DUB.
Dysfunctional uterine bleeding often brings with it chronic discomfort, pain, and depression, and for thousands of women each year, the cure for these symptoms is a hysterectomy, or removal of the uterus. Many causes of uterine bleeding, such as fibroid growths, polyps, and sometimes cancer, can often be treated without resorting to this drastic surgical procedure, but unexplained abnormal uterine bleeding every year prompts between 30,000 and 240,000 American women to undergo a hysterectomy. The total medical bill for the procedure may be as high as $2 billion a year. Dickersin and her fellow researchers want to know: is there a less-invasive, less-expensive alternative?
Most women recognize that, after treatment with aspirin, ibuprofen, or hormonal therapies, hysterectomy is the treatment of last resort. Many readily opt for it. However, just as many are unaware of such less-invasive options as endometrial ablation, in which selected portions of the uterine lining are electrically destroyed. "Hysterectomy is the second-most-commonly performed surgery in women," says Dickersin, who is her-self a cancer survivor, "and there are definite issues of cost and necessity. There are huge variations across communities in how often it's performed, and we still don't know what kind of outcomes the surgery provides."
While hysterectomy has a mortality rate of about one in 1,000 procedures, it has never been compared with other therapies. Endometrial ablation and such other approaches as thermal-balloon therapy result in virtually no mortality, and patients can go home the same day. In contrast, hysterec-tomy patients typically require three days of post-surgical hospitalization. "These less-invasive, outpatient approaches are used much less frequently," Dickersin says, "and we're still not sure why."
The study, which will involve 900 women, will try to answer a number of such questions, including how much bleeding results from the two approaches, what their comparative complication rates are, and how effective are their respective abilities to quell discomfort and pain. The study will also assess how these treatments affect mood as well as mental and physical functioning. Then there is the question of cost-effectiveness: hospitalization and surgery for a hysterectomy together average about $4,000, whereas the total cost of an endometrial ablation is less than $2,000.
"Hysterectomy is clearly an example of a surgical procedure that should be investigated more thoroughly," says Dickersin. "DUB itself is still largely a mystery. We don't know how often women get better on their own, or how long it takes. If we knew that in three-quarters of women the problem ends on its own within a relatively short period of time, it would certainly affect the decision to have surgery. We'll know more about that, too, after four years."