Planned trial of transcervical resection of the endometrium versus hysterectomy

Dear Sir, Let us supposc that a new drug has been dcvclopcd to trcat dysfunctional uterine bleeding (DUB) and let us call that drug TCRE. Before its general use would be permitted let alone encouraged it would have to undergo carcful and controlled. and preferably randomized, trials to compare its efficacy and side effects with other drugs currently in use lor DUB, and be approved by the Committee of Safety of Medicines. Drug therapy is only one of a series of interventions available to us as clinicians. Surgery is another. Why is it, therefore, that attitudes towards thc assessment of thesc two types of intervention are so different? Kandomized controlled trials of ncw surgical procedures vs thc alternatives are virtually unknown in gynaecology. I would suggest that this is not only unscientific but also unethical. There is an intervention called TCRE (otherwise transcervical resection of endometrium) for DUB described by D e Cherney et al. (1987) and Magos et al. (1989) and discussed by Macdonald (1990) in his useful commentary on ‘modern treatment of menorrhagia’. Although endometrial ablation is an attractive potential alternative to hysterectomy the two have never been compared. The new techniques have been developed and promoted by enthusiastic skilled surgeons without the same constraints as are imposcd on our pharmaceutical colleagues. l h e ‘gold standard’ treatment for DUB is hysterectomy and endometrial ablation needs to be compared with that in a randomized controlled trial as advocated by Magos et ul. (1Y90). The fact that it may be difficult does not lessen thc nccd for, or obligation on us to do so. Once that comparison has been carried out, various ablative techniques can be compared with each other. Macdonald (1990) calls for long-term follow-up studics. Thesc are not sufficient. Surgery must be placed under the same constraints as other interventions and tested properly. We have embarked on a randomized controlled trial of TCRE vs hysterectomy in this unit funded by the local Research Committee of the South West Regional Health Authority. We would bc delighted to widen thc study to include other centres if they would like to join