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 sterilization 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:
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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