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      To the Editors:

      We appreciate the interest in our study shown by O'Connor and Magos. We are grateful for the comments expressed by such a prominent investigator in this field. Certainly, the issue of small sample size is valid and care must be taken in drawing conclusions from our experience alone. However, our results differ from those of O'Connor and Magos in only two areas. First, we chose not to perform repeat ablations after an initial failure, unlike O'Connor and Magos
      • O'Connor H
      • Magos A
      Endometrial resection for the treatment of menorrhagia.
      and O'Connor et al.
      • O'Connor H
      • Broadbent JA
      • Magos AL
      • McPherson K
      Medical research council randomised trial of endometrial resection versus hysterectomy in management of menorrhagia.
      Second, our reoperation rate continued at the same rate beyond 3 years, whereas that of O'Connor and Magos
      • O'Connor H
      • Magos A
      Endometrial resection for the treatment of menorrhagia.
      did not. We would like to address these issues further.
      Our 34% hysterectomy rate represents the total reoperation rate over 5 years. Because of our concerns with the ablation procedure itself and the possibility of unrecognized gynecologic disease, we did not perform repeat ablations. Repeat ablations have a significantly lower success rate and a higher complication rate than the initial procedure does.
      • O'Connor H
      • Magos A
      Endometrial resection for the treatment of menorrhagia.
      • O'Connor H
      • Broadbent JA
      • Magos AL
      • McPherson K
      Medical research council randomised trial of endometrial resection versus hysterectomy in management of menorrhagia.
      Our reoperation rate is not higher than that reported in other studies. Sculpher et al.
      • Sculpher MJ
      • Dwyer N
      • Byford S
      • Stirrat GM
      Randomised trial comparing hysterectomy and transcervical endometrial resection: effect on health related quality of life and costs two years after surgery.
      reported a 23% reoperation rate (hysterectomy, repeat ablation, or both) during the first 2 years of follow-up after transcervical endometrial resection in the Bristol trial. O'Connor and Magos
      • O'Connor H
      • Magos A
      Endometrial resection for the treatment of menorrhagia.
      reported a 20% reoperation rate at 3 years in their long-term study. Most recently, O'Connor et al.
      • O'Connor H
      • Broadbent JA
      • Magos AL
      • McPherson K
      Medical research council randomised trial of endometrial resection versus hysterectomy in management of menorrhagia.
      have reported a 22% reoperation rate within 3 years after endometrial resection in their own randomized trial of endometrial resection versus hysterectomy. Our reoperation rate at 3 years was 19.5%. Thus it seems unlikely that either operator experience or operative technique is a major factor accounting for the difference in long-term outcome between our patients and those of O'Connor and Magos.
      • O'Connor H
      • Magos A
      Endometrial resection for the treatment of menorrhagia.
      Of course, differences in our respective patient populations could account for the reoperation rate continuing to increase beyond 3 years in our series, whereas it did not in the long-term series of O'Connor and Magos.
      • O'Connor H
      • Magos A
      Endometrial resection for the treatment of menorrhagia.
      Unfortunately, neither our patients nor theirs had preoperative measurement of menstrual blood loss, so it is difficult to assess whether these are really identical populations under study. Indeed, there is evidence that they are not. Although 11 of the 14 women undergoing hysterectomy in our series were found to have gynecologic pathologic features, only 21 of 42 in the series of O'Connor and Magos
      • O'Connor H
      • Magos A
      Endometrial resection for the treatment of menorrhagia.
      demonstrated similar pelvic disease. As reported in both our article and their own randomized series, the presence of underlying pelvic pathologic features may negatively impact the outcome of endometrial ablation. Finally, criteria for success are subjective and postoperative satisfaction may be more related to preoperative expectations (patient or physician) than to objective results.
      Again, we appreciate the comments of O'Connor and Magos. Our small series is meant to stimulate further study in the area of menorrhagia and the role of endometrial ablation in its treatment. Objective methods to ensure proper patient selection and to evaluate long-term outcome are clearly needed.

      References

        • O'Connor H
        • Magos A
        Endometrial resection for the treatment of menorrhagia.
        N Engl J Med. 1996; 335: 151-156
        • O'Connor H
        • Broadbent JA
        • Magos AL
        • McPherson K
        Medical research council randomised trial of endometrial resection versus hysterectomy in management of menorrhagia.
        Lancet. 1997; 349: 897-901
        • Sculpher MJ
        • Dwyer N
        • Byford S
        • Stirrat GM
        Randomised trial comparing hysterectomy and transcervical endometrial resection: effect on health related quality of life and costs two years after surgery.
        Br J Obstet Gynaecol. 1996; 103: 142-149