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Concerns over the existence of post-tubal ligation syndrome, characterized by dysmenorrhea, heavy bleeding, or spotting, have been eased with the recent publication from a large prospective comparative study.1
Researchers used data from the U.S. Collabora-tive Review of Sterilization (CREST) to determine whether the likelihood of persistent menstrual abnormalities was greater among women who had undergone tubal sterilization than among women who had not. No other study of the potential for post-tubal ligation syndrome offers prospective data acquired in repeated interviews from such a large cohort over such a long period, notes a companion editorial published with the new study.2
The findings indicate that women who have undergone tubal sterilization are no more likely than other women to have menstrual abnormalities. Concerns that sterilization causes menstrual problems remain common among women and clinicians. Against this backdrop, the recent reassuring data from the study are particularly welcome, states Andrew Kaunitz, MD, professor and assistant chair in the obstetrics and gynecology department at the University of Florida Health Science Center/Jacksonville.
The chief reason for the new report was to attempt to resolve a longstanding debate regarding whether tubal sterilization causes menstrual abnormalities, says Herbert Peterson, MD, principal investigator of the U.S. Collaborative Review of Sterilization Working Group.
Since 1951, when Williams and colleagues first reported a higher than expected number of sterilized women with abnormal menstrual bleeding,3 the question, "Is there a post-tubal ligation syndrome of menstrual abnormalities?" has persisted, Peterson states. When sterilization became prevalent in the 1970s, concerns were heightened, with increased or abnormal menstrual bleeding with consequent hysterectomy reported in uncontrolled case series.4
In the United States, 11 million women rely on tubal sterilization to prevent pregnancy.5 With such great numbers of women involved, it was important to resolve the issue, says Peterson.
Investigators followed the experiences of 9,514 women who underwent tubal sterilization and 573 women whose partners underwent vasectomy for up to five years by means of annual telephone interviews. All women were asked the same questions about six characteristics of their menstrual cycles in the presterilization and follow-up interviews. Multiple logistic-regression analysis was used to assess the risk of persistent menstrual changes.
Researchers found that the women who had undergone sterilization were no more likely than those who had not been sterilized to report persistent changes in intermenstrual bleeding or the length of the menstrual cycle.
There were no differences in intermenstrual bleeding or length of menstrual cycles, but the women who underwent tubal sterilization were more likely to have shorter menstrual periods, less bleeding, and more irregular cycles than the women whose partners underwent vasectomy, according to the findings.
Add data to counseling
Providers can counsel patients prior to sterilization that the procedure does not appear to cause menstrual abnormalities, states Peterson.
"Menstrual abnormalities are common in sterilized and nonsterilized women," he observes. "When menstrual abnormalities occur after sterilization, women should determine with their providers whether treatment is necessary and, if so, whether medical or surgical therapy is most appropriate."
In general, the indications for hysterectomy for sterilized women should be the same as those for nonsterilized women, states Peterson.
If women have been using combination oral contraceptives (OCs) or depot medroxyprogesterone acetate (DMPA) contraceptive injections prior to sterilization, Kaunitz says he prepares them for potential changes following the procedure.
"I advise such women that if they notice heavy flow, cramps, or unpredictable bleeding, it will not be caused by the tubal sterilization procedure, but rather will represent that they have discontinued their hormonal contraception which was causing light regular cycles [with OCs] or amenorrhea [with DMPA]," states Kaunitz.
Kaunitz says he tells women scheduling sterilization that it is not unusual or inappropriate for those going off hormonal contraception after their sterilization to restart hormonal treatment later, to address unpleasant menstrual periods.
"Giving women and their partners relevant information about risks, benefits, and alternatives is central to family planning," states Carolyn Westhoff, MD, professor of obstetrics, gynecology, and public health at Columbia University in New York City, in the editorial accompanying the new CREST data. "Such informed consent is most important for sterilization — both tubal ligation and vasectomy — because these methods are permanent."
The CREST investigation has yielded several important findings supporting the safety and efficacy of sterilization. What will be the next installment from this large body of research?
"Upcoming reports from CREST include an evaluation of regret after vasectomy as compared with regret after tubal sterilization," says Peterson.
1. Peterson HB, Jeng G, Folger SG, et al. The risk of menstrual abnormalities after tubal sterilization. N Engl J Med 2000; 343:1,681-1,687.
2. Westhoff C. Tubal sterilization — safe and effective. N Engl J Med 2000; 343:1,724-1,726.
3. Williams EL, Jones HE, Merrill RE. Subsequent course of patients sterilized by tubal ligation. Am J Obstet Gynecol 1951; 61:423-426.
4. Gentile GP, Kaufman SC, Helbig DW. Is there any evidence for a post-tubal sterilization syndrome? Fertil Steril 1998; 69:179-186.
5. Peterson HB, Xia Z, Hughes JM, et al. The risk of pregnancy after tubal sterilization: Findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol 1996; 174:1,161-1,170. n