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An Evaluation of the Methods for Treating Non-malignant Uterine Bleeding in the Menopause
Department of Practical Problems in Obstetrics and Gynecology CONDUCTED BY WILLIAM
J, DIECKMANN, M.D.
AN EVALUATION OF THE METHODS FOR TREATING NONMALIGNANT UTERINE BLEEDING IN THE MENOPAUSE J.
ROBERT WILLSON,
M.S., M.D.,
CHICAGO, ILL.
(From the Department of Obstetrics and Gynecology of the Unitversity of Chicago and the Chioago Lying-in Hospital)
T
HE choice between hysterectomy and irradiation castration for the control of benign menopausal bleeding from the normal-sized uterus, the fibrous uterus, or that associated with myomas must be governed by several factors. Questions which must he answered before a decision as to type of treatment is made are: ( 1) are the two methods comparable in effectiveness~ ( 2) is the associated morbidity and mortality appreciably higher for either of the procedures? (3) is the incidence of uterine cardnoma following irradiation high enough to be a distinct hazard~ and ( 4) is either method of treatment contraindicated for any individual patent~ In the following discussion an attempt will be made to evaluate the methods of treating this selected group of patients.
Indications and Contraindications In general the contraindications for either of the two methods of treatment may be used as an indication for the other. The patients in whom the removal of the uterus is contraindicated are those who are poor risks for any major surgical procedure. Included in this group are the obese individuals in whom operation would be hazardous and difficult, those with degenerative diseases such as diabetes and cardiovascular renal disease, those with blood dyscrasias, and the aged individual whose life expectancy is short. The upper limits of uterine size usually considered acceptable for radium treatment is that comparable to a ten to twelve weeks' gestation. Deep x-ray therapy may be used effectively in this size tumor as well as in those which are much larger; in the latter, however, operative removal is usual1y a preferable procedure. The primary effect of both x-ray and radium is the inhibition of ovarian function. The latter, however, also produces sclerosis of the endometrium which aids in stopping the bleeding. Thus the insertion of radium in the larger myomas may fail to control bleeding completely because the large cavity and the thick uterine wall increase the distance from the source of radiation to a point at which the ovaries are not effectively irradiated. Enlarged uteri producing symptoms other than bleeding should be removed if possible since treatment by castration, while it may stop bleeding, does nothing to relieve the associated symptomatology. Most enlarged uteri become smaller after cessation of ovarian function, but the amount of regression and the extent to which the symptoms will be relieved cannot be predicted. Degenerated fibroids obviously are best 307
308
AMERICAN .JOURNAL OJ<' OBS'l'ETRIC:'l AND OY:\'ECOLOGY
treated by surgical removal. Sinee tlw bleeding from pedunculated :mL:mucous myomas often is from a<'tual destruction of tht• t nmor rather than from the endometr·ium the insertion of radium may, in some cases, increase the necrosis in tlH• neoplasms and exagxerate rather than relien• the symptoms. If the enuometrium over a :,;nhnnH•ouH myoma is vet·y thin, the destruC'tion from the radium may ht> followed by local infection and OC'casionally sepsis. Pedunculated subserous filn·oids may degenerate following irradiation as a result of a decrease in tmlilable blood supply and arc best treated surgically. Patients who have had either previous pelvic surgery or pelvic inflammatory disease often an• not good C'andidates for irradiation. Loops of bowel which may have become adherent in the pelYis at'e likely to receive destructive doses of radiation resulting in stricture, and quiescent inflammatory processes may be activated. The palpa1 ion of adnexal masses contraindiPates radiation therapy hecause of the impossibility of diagnosing accurately tlw type and (•xtent of the pathology present by bimanual examination alone. The common association of x-ra,- or radium with the treatment of malignant tumors may, as a purel.v psychologie measure, be an indication for hystereetomy. Irradiation, if forced upon the patient, may be followed hy undesirable mental reactions even though the result of therapy be perfect. Age of the patient must be one of the primary eonsideratiom; before a plan of therapy is outlined. Sinee both radium and x-ray therapy desti·oy ov1irian function, neither is the treatmt'nt of choice for the yotmger individual in whom the uterus can be removed and the ovaries, if normal, retained. Taussig sets the lower age limit for irradiation at 42, but in et•rtain patients in whom menopausal symptoms are already pre~ent irradiation may be justifiable earlier.
Technique of Irradiation The desired effect, castration with control of the bleeding, may be accomplished satisfactorily by adequate dosages of either radium or deep x-ray therapy. Brown and others have demonstrated that the lower the total dosage of radium the less likely is permanent castration to follow and therefore recommend the administration of about 2,000 mg. hours of intrauterine radium ot· radon irradiation to effect control of the bleeding. Although ovarian function can be inhibited in some instances by much Rmaller dosages, it is well to use an adequate amount of irradiation for each patient sinee the toler:mee of individual ovaries cannot be measured. Because the desired effect from the use of radium is primarily inhibition of ovarian funetion rather than a local action on the endometrium the pt'netrating gamma rays must be utilized fully. The local destruction produced hy tlw soft beta 1·ays may be prevented by the use of a capsule with a filtration eapaeity equivalent to that of 2 mm. of brass. A thin layer of rubber or some other organic material around the capsule will filter out the seeondary ~oft radiation from the capsule; the resultant radiation should he almost entirely from the gamma rays and the lo<•al tissut:• destruction will be redueed to a minimum. Because of the necessity for delivering the radiation to the endome~ trium and the ovaries the radium should be applied to the cavity of the uterus and not in the cm·vi<:al canaL This method r~sults in a maximum radiation of the desired structures without danger of destruction of the cervix. Obviously the duration of the application depends upon the
WILLSON:
TREATING BLEEDING IN :MENOP"\USE
309
amount of radium used. but in most instances no more than 100 mg. of radium or radon should be inserted for castration. Brown and his co-authors also describe the technique for the administration of external irradiation and present dosage tables calculated to deliver 625 roentgen, a castration dose, to the ovaries in various sized individuals. Either procedure must be proceded by evaluation of the patient, thorough pelvic examination and curettage to rule out malignancy. If at the time of pelvic examination under anesthesia a condition whi{~h eontraindicates radiation is discovered the plan of treatment should he altered.
E:tfectiveness Obviously removal of the uterus will stop the bleeding in all instances. This may also he accomplished by the adminil;ltration of sufficient amounts of radiation properly to selected patients; failures can for the most part be explained. The cessation of bleeding following reradiation in patients to whom inadequate initial dosages were given must be classified as successful. The failure of the bleeding to respond in improperly chosen cases or with too' little treatment cannot be classified as a failure of the method. Many patients may have one or two periods of bleeding following irradiation; consequently evaluation of results cannot be made immediately. With the exception of a small number of unexplained failures a continuation of bleeding after irradiation usually is an indication of the improper selection of cases or of an amount of therapy too small to affect ovarian :function. Morbidity and Mortality The mortality and morbidity following the irradiation of a wellselected group of cases should be much lower than that following surgery in a comparable group. The average morbidity in collected cases is only 0.3 per cent for the irradiated group. In most instances the morbidity following irradiation is represented by an unexplained temperature elevation which may be due to a mild exacerbation of a chronic pelvic inflammatory process or to local tissue destruction. Occasionally, following the insertion of radium, a quiescent inflammatory lesion may develop into a serious acute infection with abscess formation and peritonitis. The inevitable mortality from hysterectomy should be reduced to a minimum in operations for benign menopausal bleeding. The mortality rate of 2.5 per cent for 16,165 collected subtotal h~'sterectomies reported by Cashman and Frank, however, does not approach that of 0.05 per cent following irradiation in 8,175 cases. Many authors are of the opinion that the mortality rate is even higher when complete hysterectomy is performed. This obviously is a point in favor of irradiation. Danforth, on the other hand, has reported a series of hysterectomies with a totall mortality rate of only 0.5 per cent. In this group the mortality rate for total hysterectomy was 0.66 per cent, for subtotal 0.8 per cent, and for vaginal hysterectomy 0 per cent. Carcinoma Following Treatment The incidence of uterine carcinoma developing following irradiation is 0.5 per cent in 6,883 cases collected from the liternture. Since it is sometimes impossible to detect early corpus carcinoma even by careful curettage and since a few of these cases developed within a relatively short period of time after therapy, it is not unreasonable to assume that s.ome of the malignancies were present when the treatment was instituted
310
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OJ;'
OBSTETRICS AND GY~ECOLOGY
and thus cannot be considered as a result either of irradiation or of leaving the uterus. Removal of the uterus and the eervix in every patient would, of course, completely eliminate the development of uterine carcinoma, but subtotal hysterectomy does not since the incidence of carcinoma developing in the cervical stump is about 0.6 per cent o1· the same as that following irradiation. This incidenre of stump rarcinoma, however, may also be high since many of the cases reported were diagnosed within a few months of the time of hysterertomy and may have been overlooked during the original operation. Martzloff suggests that any cervical malignancy developing within thr<'e years of the hysterectomy may have been present and undiagnosed. Even though the mortality rate for total hysterectomy was the same as for subtotal it is doubtful that it would be less than the combined mortality from irradiation and carcinoma developing in the irradiated uterus. ·
The Present Status of the Treatment of Benign Menopausal Bleeding In an effort to obtain information concerning the present status of the treatment of benign menopausal bleeding, a -questionnaire was sent to a representative group of gynecologists throughout the United States. A tabulation of the data (Table I) reveals that 79 per cent of those contacted favor irradiation castration for the treatment of menopausal bleeding from the normal size uterus; of this group 73 per cent perf erred to use radium, 18 per cent x-ray, and 9 per cent either radium or external irradiation. Of the 21 per cent who performed hysterectomy as a method of controlling the bleeding, 33 per cent favored total hysterectomy, none subtotal hysterectomy, and 67 per cent either total or subtotal hysterectom,v, depending upon parity or the eondition of the cervix. TABLE
1. METHODS Q;' TREATMENT OF BLEEDING JN 'I'HE MENOPAUSAL PERIOD AssoCIATED Wn'H SMALL MYOMAs AND FROM THE NoR~!Ar, SIZE F1'ERrs BY A GROUP OF AMEJlJ('AN GYNECOLOGISTS SURGERY
IRRADIATION
Small myomas
Normal uterus
Radium X-ray Either Radium X-ray Either
57%
62.5% 25.0% 12.5%
79%
9%
43%
Total hysterectomy Subtotal hysterectomy Either 21% Total hysterectomy Subtotal hysterectomy Either
33% 17% 50% 33% 0% 67%
For the treatment of small myomas in menopausal patients in whom the only symptom is bleeding, 57 per cent of the group utilize irradiation ( 62.5 per cent radium, 25 per cent x-ray, and 12.5 per cent either). Surgical removal of the uterus was considered to be the treatment of choice by 43 per cent (17 per cent subtotal hysterectomy, 33 per cent total hysterectomy, and 50 per cent either total or subtotal). Only 27 per cent of those responding were impressed by either the complications or the mortality associated with irradiation castration. Cervical stenosis followed b,v retention of secretions within the uterus was mentioned by several as a eomplication more apt to follow radium insertion than x-ray therapy. The majority (93 per cent) were of the opinion that the small incidence of carcinoma developing in the irradiated uterus was not suffieient indication for routine hysterectomy.
WILLSON:
TREATING BLEEDING IK MENOPAUSE
311
Summary While the opm10ns concerning the best method for treating benign uterine bleeding in a selected group of menopausal patients are divided, the data presented here indicate that irradiation, either by x-ray or radium has certain advantages over surgery. Even in a group of patients who are good surgical risks for the relatively simple operation of removing a normal sized uterus there will be operative deaths as well as postoperative complications. If irradiation can accomplish the same effect with a much lower morbidity and mortality rate, it might well be utilized more frequently. To achieve the best results from irradiation each case should be eonsidered in the light of indications and contraindieations before treatment is instituted and a plan of therapy, designed to produce permanent castration, should be drawn up in advance for each individual. Adequate treatment combined with a careful selection of cases should produce results favorably comparable to those with hysterectomy. The morbidity associated with the use of either radium or x-ray may be kept at a minimum. A careful evaluatinn of the history, a thorough pelvic examination and dilatation and curettage to rule out malignancy should precede either x-ray therapy or the insertion of radium. The haphazard use of radium by inexperienced operators may be followed by continuation of the bleeding, complications such as local or generalized sepsis, chronic discharge from radium destruction, cervical stricture, or death of the patient. The incidence of carcinoma developing in the uterus after irradiation is about 0.6 per cent' or the same as that of carcinoma developing in the eervix after subtotal hysterectomy. The number in both groups is even lower when correction is made for those malignancies present when treatment was instituted. Since the deaths from carcinoma developing in the uterus added to the primary mortality associated with .x-ray or radium castration must be fewer than the death.'! following hysterectomy, it is doubtful that the potential development of carcinoma can be considered as a contraindication to irradiation.
Conclusions 1. Irradiation is a safe effective method of treating benign menopausal bleeding with a mortality rate much lower than for operation. 2. The failures are for the most part due either to poor selection of patients or to inadequate treatment. 3. The only method of eliminating uterine carcinoma is by total extirpation of the pelvic organs. The mortality from this procedure undoubtedly would exceed the combined mortality from irradiation and carcinoma following irradiation. The author wishes to express his appreciation for the response to the questionnaires from which part of the information used in this paper was compiled.
References 1. Brown, W. E., Kretzschmar, N. R., Peck, W. E., and Me Greer, J.: AM. J. OBST. & GYNEC. 41: 295, 1941. 2. Castalow, W. E.: J. A. M. A. 116: 464, 1941. 3. Corscaden, J. A.: Am. J. Roentgenol. 45: 661, 1941. 4. Danforth, W. C.: AM. J. 0BST. & GYNEC. 42: 587, 1941. 5. Macfarlane, 0.: AM. J. OBST. & GYNEC. 23: 108, 1932. 6. Norris, C. C., and Behney, C. A.: Am. Gynec. Soc. Trans. 61: 197, 1936. 7. Norsworthy, 0. L.: Am. J. Roentgenol. 24: 516, 1933. 8. Pemberton, F.: Am. Gynec. Soc. Trans. 61: 207, 1936. 9. Weintraub, F,: AM. J. 0BST. & GYNEC 36: 476, 1938.
J, DIECKMANN, M.D.
AN EVALUATION OF THE METHODS FOR TREATING NONMALIGNANT UTERINE BLEEDING IN THE MENOPAUSE J.
ROBERT WILLSON,
M.S., M.D.,
CHICAGO, ILL.
(From the Department of Obstetrics and Gynecology of the Unitversity of Chicago and the Chioago Lying-in Hospital)
T
HE choice between hysterectomy and irradiation castration for the control of benign menopausal bleeding from the normal-sized uterus, the fibrous uterus, or that associated with myomas must be governed by several factors. Questions which must he answered before a decision as to type of treatment is made are: ( 1) are the two methods comparable in effectiveness~ ( 2) is the associated morbidity and mortality appreciably higher for either of the procedures? (3) is the incidence of uterine cardnoma following irradiation high enough to be a distinct hazard~ and ( 4) is either method of treatment contraindicated for any individual patent~ In the following discussion an attempt will be made to evaluate the methods of treating this selected group of patients.
Indications and Contraindications In general the contraindications for either of the two methods of treatment may be used as an indication for the other. The patients in whom the removal of the uterus is contraindicated are those who are poor risks for any major surgical procedure. Included in this group are the obese individuals in whom operation would be hazardous and difficult, those with degenerative diseases such as diabetes and cardiovascular renal disease, those with blood dyscrasias, and the aged individual whose life expectancy is short. The upper limits of uterine size usually considered acceptable for radium treatment is that comparable to a ten to twelve weeks' gestation. Deep x-ray therapy may be used effectively in this size tumor as well as in those which are much larger; in the latter, however, operative removal is usual1y a preferable procedure. The primary effect of both x-ray and radium is the inhibition of ovarian function. The latter, however, also produces sclerosis of the endometrium which aids in stopping the bleeding. Thus the insertion of radium in the larger myomas may fail to control bleeding completely because the large cavity and the thick uterine wall increase the distance from the source of radiation to a point at which the ovaries are not effectively irradiated. Enlarged uteri producing symptoms other than bleeding should be removed if possible since treatment by castration, while it may stop bleeding, does nothing to relieve the associated symptomatology. Most enlarged uteri become smaller after cessation of ovarian function, but the amount of regression and the extent to which the symptoms will be relieved cannot be predicted. Degenerated fibroids obviously are best 307
308
AMERICAN .JOURNAL OJ<' OBS'l'ETRIC:'l AND OY:\'ECOLOGY
treated by surgical removal. Sinee tlw bleeding from pedunculated :mL:mucous myomas often is from a<'tual destruction of tht• t nmor rather than from the endometr·ium the insertion of radium may, in some cases, increase the necrosis in tlH• neoplasms and exagxerate rather than relien• the symptoms. If the enuometrium over a :,;nhnnH•ouH myoma is vet·y thin, the destruC'tion from the radium may ht> followed by local infection and OC'casionally sepsis. Pedunculated subserous filn·oids may degenerate following irradiation as a result of a decrease in tmlilable blood supply and arc best treated surgically. Patients who have had either previous pelvic surgery or pelvic inflammatory disease often an• not good C'andidates for irradiation. Loops of bowel which may have become adherent in the pelYis at'e likely to receive destructive doses of radiation resulting in stricture, and quiescent inflammatory processes may be activated. The palpa1 ion of adnexal masses contraindiPates radiation therapy hecause of the impossibility of diagnosing accurately tlw type and (•xtent of the pathology present by bimanual examination alone. The common association of x-ra,- or radium with the treatment of malignant tumors may, as a purel.v psychologie measure, be an indication for hystereetomy. Irradiation, if forced upon the patient, may be followed hy undesirable mental reactions even though the result of therapy be perfect. Age of the patient must be one of the primary eonsideratiom; before a plan of therapy is outlined. Sinee both radium and x-ray therapy desti·oy ov1irian function, neither is the treatmt'nt of choice for the yotmger individual in whom the uterus can be removed and the ovaries, if normal, retained. Taussig sets the lower age limit for irradiation at 42, but in et•rtain patients in whom menopausal symptoms are already pre~ent irradiation may be justifiable earlier.
Technique of Irradiation The desired effect, castration with control of the bleeding, may be accomplished satisfactorily by adequate dosages of either radium or deep x-ray therapy. Brown and others have demonstrated that the lower the total dosage of radium the less likely is permanent castration to follow and therefore recommend the administration of about 2,000 mg. hours of intrauterine radium ot· radon irradiation to effect control of the bleeding. Although ovarian function can be inhibited in some instances by much Rmaller dosages, it is well to use an adequate amount of irradiation for each patient sinee the toler:mee of individual ovaries cannot be measured. Because the desired effect from the use of radium is primarily inhibition of ovarian funetion rather than a local action on the endometrium the pt'netrating gamma rays must be utilized fully. The local destruction produced hy tlw soft beta 1·ays may be prevented by the use of a capsule with a filtration eapaeity equivalent to that of 2 mm. of brass. A thin layer of rubber or some other organic material around the capsule will filter out the seeondary ~oft radiation from the capsule; the resultant radiation should he almost entirely from the gamma rays and the lo<•al tissut:• destruction will be redueed to a minimum. Because of the necessity for delivering the radiation to the endome~ trium and the ovaries the radium should be applied to the cavity of the uterus and not in the cm·vi<:al canaL This method r~sults in a maximum radiation of the desired structures without danger of destruction of the cervix. Obviously the duration of the application depends upon the
WILLSON:
TREATING BLEEDING IN :MENOP"\USE
309
amount of radium used. but in most instances no more than 100 mg. of radium or radon should be inserted for castration. Brown and his co-authors also describe the technique for the administration of external irradiation and present dosage tables calculated to deliver 625 roentgen, a castration dose, to the ovaries in various sized individuals. Either procedure must be proceded by evaluation of the patient, thorough pelvic examination and curettage to rule out malignancy. If at the time of pelvic examination under anesthesia a condition whi{~h eontraindicates radiation is discovered the plan of treatment should he altered.
E:tfectiveness Obviously removal of the uterus will stop the bleeding in all instances. This may also he accomplished by the adminil;ltration of sufficient amounts of radiation properly to selected patients; failures can for the most part be explained. The cessation of bleeding following reradiation in patients to whom inadequate initial dosages were given must be classified as successful. The failure of the bleeding to respond in improperly chosen cases or with too' little treatment cannot be classified as a failure of the method. Many patients may have one or two periods of bleeding following irradiation; consequently evaluation of results cannot be made immediately. With the exception of a small number of unexplained failures a continuation of bleeding after irradiation usually is an indication of the improper selection of cases or of an amount of therapy too small to affect ovarian :function. Morbidity and Mortality The mortality and morbidity following the irradiation of a wellselected group of cases should be much lower than that following surgery in a comparable group. The average morbidity in collected cases is only 0.3 per cent for the irradiated group. In most instances the morbidity following irradiation is represented by an unexplained temperature elevation which may be due to a mild exacerbation of a chronic pelvic inflammatory process or to local tissue destruction. Occasionally, following the insertion of radium, a quiescent inflammatory lesion may develop into a serious acute infection with abscess formation and peritonitis. The inevitable mortality from hysterectomy should be reduced to a minimum in operations for benign menopausal bleeding. The mortality rate of 2.5 per cent for 16,165 collected subtotal h~'sterectomies reported by Cashman and Frank, however, does not approach that of 0.05 per cent following irradiation in 8,175 cases. Many authors are of the opinion that the mortality rate is even higher when complete hysterectomy is performed. This obviously is a point in favor of irradiation. Danforth, on the other hand, has reported a series of hysterectomies with a totall mortality rate of only 0.5 per cent. In this group the mortality rate for total hysterectomy was 0.66 per cent, for subtotal 0.8 per cent, and for vaginal hysterectomy 0 per cent. Carcinoma Following Treatment The incidence of uterine carcinoma developing following irradiation is 0.5 per cent in 6,883 cases collected from the liternture. Since it is sometimes impossible to detect early corpus carcinoma even by careful curettage and since a few of these cases developed within a relatively short period of time after therapy, it is not unreasonable to assume that s.ome of the malignancies were present when the treatment was instituted
310
AMERICAN ,JOUR~AL
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OBSTETRICS AND GY~ECOLOGY
and thus cannot be considered as a result either of irradiation or of leaving the uterus. Removal of the uterus and the eervix in every patient would, of course, completely eliminate the development of uterine carcinoma, but subtotal hysterectomy does not since the incidence of carcinoma developing in the cervical stump is about 0.6 per cent o1· the same as that following irradiation. This incidenre of stump rarcinoma, however, may also be high since many of the cases reported were diagnosed within a few months of the time of hysterertomy and may have been overlooked during the original operation. Martzloff suggests that any cervical malignancy developing within thr<'e years of the hysterectomy may have been present and undiagnosed. Even though the mortality rate for total hysterectomy was the same as for subtotal it is doubtful that it would be less than the combined mortality from irradiation and carcinoma developing in the irradiated uterus. ·
The Present Status of the Treatment of Benign Menopausal Bleeding In an effort to obtain information concerning the present status of the treatment of benign menopausal bleeding, a -questionnaire was sent to a representative group of gynecologists throughout the United States. A tabulation of the data (Table I) reveals that 79 per cent of those contacted favor irradiation castration for the treatment of menopausal bleeding from the normal size uterus; of this group 73 per cent perf erred to use radium, 18 per cent x-ray, and 9 per cent either radium or external irradiation. Of the 21 per cent who performed hysterectomy as a method of controlling the bleeding, 33 per cent favored total hysterectomy, none subtotal hysterectomy, and 67 per cent either total or subtotal hysterectom,v, depending upon parity or the eondition of the cervix. TABLE
1. METHODS Q;' TREATMENT OF BLEEDING JN 'I'HE MENOPAUSAL PERIOD AssoCIATED Wn'H SMALL MYOMAs AND FROM THE NoR~!Ar, SIZE F1'ERrs BY A GROUP OF AMEJlJ('AN GYNECOLOGISTS SURGERY
IRRADIATION
Small myomas
Normal uterus
Radium X-ray Either Radium X-ray Either
57%
62.5% 25.0% 12.5%
79%
9%
43%
Total hysterectomy Subtotal hysterectomy Either 21% Total hysterectomy Subtotal hysterectomy Either
33% 17% 50% 33% 0% 67%
For the treatment of small myomas in menopausal patients in whom the only symptom is bleeding, 57 per cent of the group utilize irradiation ( 62.5 per cent radium, 25 per cent x-ray, and 12.5 per cent either). Surgical removal of the uterus was considered to be the treatment of choice by 43 per cent (17 per cent subtotal hysterectomy, 33 per cent total hysterectomy, and 50 per cent either total or subtotal). Only 27 per cent of those responding were impressed by either the complications or the mortality associated with irradiation castration. Cervical stenosis followed b,v retention of secretions within the uterus was mentioned by several as a eomplication more apt to follow radium insertion than x-ray therapy. The majority (93 per cent) were of the opinion that the small incidence of carcinoma developing in the irradiated uterus was not suffieient indication for routine hysterectomy.
WILLSON:
TREATING BLEEDING IK MENOPAUSE
311
Summary While the opm10ns concerning the best method for treating benign uterine bleeding in a selected group of menopausal patients are divided, the data presented here indicate that irradiation, either by x-ray or radium has certain advantages over surgery. Even in a group of patients who are good surgical risks for the relatively simple operation of removing a normal sized uterus there will be operative deaths as well as postoperative complications. If irradiation can accomplish the same effect with a much lower morbidity and mortality rate, it might well be utilized more frequently. To achieve the best results from irradiation each case should be eonsidered in the light of indications and contraindieations before treatment is instituted and a plan of therapy, designed to produce permanent castration, should be drawn up in advance for each individual. Adequate treatment combined with a careful selection of cases should produce results favorably comparable to those with hysterectomy. The morbidity associated with the use of either radium or x-ray may be kept at a minimum. A careful evaluatinn of the history, a thorough pelvic examination and dilatation and curettage to rule out malignancy should precede either x-ray therapy or the insertion of radium. The haphazard use of radium by inexperienced operators may be followed by continuation of the bleeding, complications such as local or generalized sepsis, chronic discharge from radium destruction, cervical stricture, or death of the patient. The incidence of carcinoma developing in the uterus after irradiation is about 0.6 per cent' or the same as that of carcinoma developing in the eervix after subtotal hysterectomy. The number in both groups is even lower when correction is made for those malignancies present when treatment was instituted. Since the deaths from carcinoma developing in the uterus added to the primary mortality associated with .x-ray or radium castration must be fewer than the death.'! following hysterectomy, it is doubtful that the potential development of carcinoma can be considered as a contraindication to irradiation.
Conclusions 1. Irradiation is a safe effective method of treating benign menopausal bleeding with a mortality rate much lower than for operation. 2. The failures are for the most part due either to poor selection of patients or to inadequate treatment. 3. The only method of eliminating uterine carcinoma is by total extirpation of the pelvic organs. The mortality from this procedure undoubtedly would exceed the combined mortality from irradiation and carcinoma following irradiation. The author wishes to express his appreciation for the response to the questionnaires from which part of the information used in this paper was compiled.
References 1. Brown, W. E., Kretzschmar, N. R., Peck, W. E., and Me Greer, J.: AM. J. OBST. & GYNEC. 41: 295, 1941. 2. Castalow, W. E.: J. A. M. A. 116: 464, 1941. 3. Corscaden, J. A.: Am. J. Roentgenol. 45: 661, 1941. 4. Danforth, W. C.: AM. J. 0BST. & GYNEC. 42: 587, 1941. 5. Macfarlane, 0.: AM. J. OBST. & GYNEC. 23: 108, 1932. 6. Norris, C. C., and Behney, C. A.: Am. Gynec. Soc. Trans. 61: 197, 1936. 7. Norsworthy, 0. L.: Am. J. Roentgenol. 24: 516, 1933. 8. Pemberton, F.: Am. Gynec. Soc. Trans. 61: 207, 1936. 9. Weintraub, F,: AM. J. 0BST. & GYNEC 36: 476, 1938.