Editorial Comment on Uterine Suspension. A New Approach. Treating Pain From a Retroverted Uterus.

To the Editors:

ABRIDGED

Introduction

Sexual intercourse shouldn't be painful. Unfortunately, painful sex is common among women. It's estimated that nearly 10 million women suffer from chronic pelvic pain. nearly 20 percent of those women have a retroverted, tipped uterus that may cause collision dyspareunia and dysmenorrhea.

Old and New

Traditionally, open-uterine-suspension procedures were the primary therapy for a retroverted uterus. They involved extended hospital stays and lengthy postoperative recovery time. Although the surgery was once common because physicians associated retroverted uterus with myriad medical and emotional problems, overuse and poor patient selection caused it gradually to fall out of use.

Since 1995, a procedure that is simpler and uses laparoscopy (UPLIFT) has brought back the use of surgery for retroverted uterus. An improvement over the older surgery, the laparoscopic procedure takes 12 minutes on average and is minimally invasive.

Current research and advanced instrumentation has sparked renewed interest in uterine positioning as a therapy for pain. Now women with a symptomatic uterus no longer have to choose between two unfavorable options: live with the severe pain during sexual intercourse and menstruation or have a hysterectomy.

Won Over

Initially, because of my training, I was skeptical of using a surgical procedure for the condition. When I started to identify patients with deep dyspareunia and a tender retroverted uterus, however, I could see that laparoscopic uterine suspension might be effective.

Patient Selection

Women who experience dyspareunia as a result of deep thrust collision with a retroverted uterus are potentially good candidates for laparoscopic uterine suspension. Appropriate surgical candidates can be identified during pelvic examination by diagnostic palpation of the retroverted uterus and replication of the pain. This part of the pelvic examination can identify dyspareunia even in patients who are reluctant to bring up the topic of painful intercourse. Although not a routine part of the pelvic exam, the diagnostic maneuver can be added without difficulty.

Outcomes

The laparoscopic techniques for uterine suspension not only are more cost effective than the open surgery and less traumatic to patients, but they also offer good outcomes. The procedure involves repositioning the uterus to a more neutral or anteverted position. Results are consistent with those previously reported for other uterine-suspension procedures for relief of collision dyspareunia.

Advantages

In describing the laparoscopic procedure in a May 1999 article in the Journal of Reproductive Medicine, James E. Carter, M.D., cited "ease of performance." In addition to positioning the uterus appropriately, UPLIFT strengthens, thickens and shortens the round ligaments with an invested, permanent suture. It relies upon the strength and integrity of the antereolateral abdominal wall fascial bridge, together with fixation of the permanent suture within the round ligament to provide the support necessary to maintain the uterus in the correct position.

The procedure can be used for other applications or in conjunction with other procedures. For example, in the process of treating one patient for endometriosis, I was able to offer her a laparoscopic procedure at the same time, solving a dyspareunia problems she had not recognized as treatable. Still another example of the procedure's usefulness is the ability to suspend the uterus to prevent recurrence of severe adhesions in the cul-de-sac area.

Most health insurers recognize the new procedure as a reimbursable treatment for symptomatic uterine retroversion, but because of the relative newness, many physicians are not aware that minimally invasive treatment for dyspareunia is available. They should note that pain relief also may improve a woman's ability to conceive, because sexual relations that are less painful can increase the odds of a pregnancy for many patients.