Book Review

Menorrhagia

N Engl J Med 2000; 342:1224April 20, 2000

Article

Menorrhagia
Edited by Shirsh S. Sheth and Christopher J.G. Sutton. 375 pp., illustrated. Oxford, United Kingdom, ISIS Medical Media, 1999. $140. ISBN: 1-89906-693-4

Menorrhagia is a comprehensive survey of the management of a commonplace gynecologic malady. According to this book, 25 to 30 percent of women have excessive menstrual bleeding at some time in their lives. I think most gynecologists would agree that investigating reports of bleeding is the mainstay of practice.

The book has a British orientation, both in content and style. The intended audience seems to be practicing gynecologic surgeons and those in training. The initial chapters deal with pathophysiology and diagnosis; the middle chapters discuss special populations, such as adolescents, patients with infertility, and perimenopausal women; and the last part focuses on treatment. Although medical management is considered in several of these chapters, they mainly describe newer surgical interventions, including endometrial resection, myolysis (laparoscopic coagulation of fibroids), radiologic embolization of fibroids, and endometrial balloon ablation. Most of the surgical chapters contain excellent photographs or drawings that give the reader a clear understanding of the descriptive aspects of the techniques under consideration. Some chapters present views unlikely to be championed on this side of the Atlantic. For instance, chapter 9 advocates progestin-containing intrauterine devices as a near-panacea for menorrhagia (“every patient should be offered the option of an intrauterine system before hysterectomy is undertaken”).

One might ask how such a simple topic, menorrhagia, could lend itself to a book with 27 chapters. The length is occasioned by the format. To some extent, each chapter is an individual lecture, meant to stand on its own. This style has strengths and weaknesses.

One of the merits of the book is that it presents many points of view. There is no lack of controversy. If the authors of a chapter have based a particular opinion on their clinical experience, they say so. This is especially evident in the chapters on surgical treatment. There is no effort to reconcile differing or opposing recommendations. Some readers may find this approach disconcerting, but the fact is that most surgical techniques have not been subjected to formal prospective comparisons. Moreover, surgical approaches evolve so rapidly that comparisons involving more than a few years of follow-up are simply not feasible.

Two drawbacks of the format are redundancy and lack of consensus. The lack of clarity is most troublesome in reviews of diagnostic aspects. The authors rightly state that diagnosis is the cornerstone of appropriate therapy, yet it is not always clear how a diagnosis is to be made. In chapter 3, for example, Sheth presents a table of the final diagnosis in 1000 women with menorrhagia. The most common cause (in 44 percent) was adenomyosis. Yet nowhere in the book is there a good description or illustration of adenomyosis. Although several chapters mention it, there also is no agreement about how to diagnose adenomyosis. Should we rely on transvaginal ultrasonography, or must we proceed to magnetic resonance imaging in pursuit of the diagnosis of adenomyosis if other tests do not reveal a cause of menorrhagia?

The comprehensiveness of the textbook ameliorates these shortcomings. Several chapters should be mandatory reading for all practicing gynecologists. For instance, chapter 7, on the treatment of menorrhagia in women of childbearing age, is balanced and concise. Chapter 13, on endometrial resection and long-term follow-up, profiles the pros and cons in a lucid and succinct manner. Chapter 25, on the choice of treatment for menorrhagia, could serve as a summary of the latter half of the book. I especially enjoyed the comment that “menstrual problems recur after about one-quarter of endometrial ablations and the surgical workload has actually increased, with more hysterectomies being performed.” This chapter follows several chapters describing highly innovative techniques for ablating endometrium, but the editors wisely remind us that endometrial ablation is not a panacea and is unlikely to replace hysterectomy or nonsurgical approaches.

Sarah L. Berga, M.D.
University of Pittsburgh School of Medicine, Pittsburgh, PA 15213