Post Tubal Ligation Syndrome Review
Frederick R. Jelovsek MD
What To Expect After Tubal Ligation
After having a tubal ligation, some women will complain of increased menstrual flow or cramps, increased premenstrual syndrome, and gynecological problems in general with even some claims that the sterilization procedure precipitates menopause. The aggregate symptoms are often referred to as post tubal ligation syndrome. Because all outcomes after tubal ligation involve emerging symptoms as a woman gets older, it has been difficult to sort out whether the tubal ligation is the cause of these problems or whether it is just coincidental with the aging process and other decisions or willingness to undergo surgery.
In order to examine this effect, there have been comparisons in the literature between women undergoing tubal ligation and women whose husbands chose vasectomy. If women whose husbands had vasectomy had the same occurrence of new gynecological problems over the follow up period (e.g., 1, 5, 10 years) then you might assume that the new gynecologic problems were due to the natural history of aging rather than the tubal ligation. If there are more problems, it is possible that the tubal ligation itself may affect ovarian or vascular function presumably interfering, compromising or totally interrupting blood supply to the uterus or ovary during the procedure. No one has ever conducted a randomized sterilizatio
n study so there is always the argument that there may be differences in women who choose tubal versus partners who choose vasectomy. The literature supports there are differences in couples who choose one method over the other but it is impossible to tell if those differences are likley to bias a study with a resultant difference in menstrual problems.
Many studies in the literature have looked at this problem and they can be lined up on both sides of the question. Doctors have seemed to focus on the studies that show no difference after tubal ligation and some women's groups, e.g., Vasectomy-Tubal Coalition and have felt this is a biased literature evaluation and that adverse effects are being ignored or hidden from women to make informed choices. With that in mind, and a recent message board question about menopause occurring after a surgery for diagnosis, I thought it would be helpful to review as many abstracts as I could find on Medline addressing this subject. This review has helped answer the following questions:
Common Tubal Ligation Questions
Is there such an entity as post tubal ligation syndrome?
After looking at all of the articles both for and against the existence of post tubal ligation syndrome, I have changed my mind. There IS a higher incidence of menstrual dysfunction and noncyclic pain following tubal ligations than the same time progression in women without tubal ligations. Premenstrual syndrome does not appear to be part of this syndrome but luteal phase defects that alter cycle length may well be part of it. Premature menopause DOES NOT appear to be part of the post tubal ligation syndrome but it may be an occasional complication of a sterilization procedure. The menstrual abnormalities are delayed and may be as much as 5% more in women undergoing tubals.
Does the type of tubal ligation performed make a difference?
There is evidence and suggestion, although not absolutely confirmatory, that methods of tubal ligation such as cautery which may impair the uteroovarian blood supply, are more likely to cause such abnormalities. Unipolar cautery techniques which were often used previously are more likely to cause problems, bipolar cautery less likely. Noncautery, occlusion methods such as postpartum and Pomeroy tubal ligation, falope ring, and Hulka clip cause less changes. Clips may be the least likely to cause problems but they also have the highest pregnancy rates. Surgeons need to take as much care as possible not to disrupt the blood supply that runs immediately under the tube.
Does the age at which a tubal is done make a difference?
The incidence of menstrual problems after tubal ligation may be higher in women who undergo the procedure in their 20's and be less of a problem in women over 30. If the tubal ligation technique does sometimes impair blood flow to the ovary, it is conceivable that it basically depletes follicles and this leads to menstrual irregularities or a perimenopausal state earlier than normal. There is the possiblility that age is not related, but rather women who chose to have a tubal ligation in their earlier years are more frequent and willing utilizers of the health care system.
Are women who have tubal more likely to end up needing a hysterectomy?
Yes. Two studies have shown a higher rate of hysterectomy in the years following tubal ligation. One study found it was confined to younger women (under age 30) and another study found it in all ages both at risk ratios of 3-4 times. On the other hand it is hazardous to conclude that this is due to cause and effect. This is because women who chose tubal ligation as a sterilization procedure may be inheritantly different than women who do not have any sterilization procedure and women whose husbands have vasectomy. From a physician's experience point of view, women who are afraid of surgery are much less likely to undergo any surgery and are more likely to "put up" with menstrual difficulties or seek non surgical therapies for them. Fear of surgery affects a significant number of women. There is also a significant population of women who are without partners and thus do not need a sterilization procedure. Since pelvic pain is a common reson for hysterectomy it is probable that women having sexual relations are much more likley to have their pain aggravated and thereby seek hysterectomy as treatment. These are just a few of the examples that can explain hysterectomy differences.
If I want to have a tubal ligation for sterilization, what outcomes I can expect?
- serious complications are well under 1%.
- pregnancy rates are about 1-3%
- increased risk of heavy menses following tubal ligation is about 5-25% in the long term
- increased risk of noncyclic pain is about 5%
- increased future gynecologic rate of surgery, including hysterectomy, of about 5%
- increased rate of irregular menstrual length of about 5%
- a rare but possible incidence of premature ovarian failure
- there is a general long term decrease in sexual desire and sexual frequency with age, however, initially there is an increase in intercourse frequency after tubal ligation
- there is a 50% decrease in the long term incidence of ovarian cancer after tubal ligation
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