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Topic of the Month : Unintended Pregnancy Prevention: Female Sterilization

More women in the United States have undergone tubal sterilization as a method of contraception, than any other single method available. Tubal sterilization is a highly effective and safe procedure; however, the possible existence of a “post-tubal ligation syndrome” of menstrual abnormalities has been debated for years. Therefore, researchers conducted a study using data from the U.S. Collaborative Review of Sterilization to determine if menstrual abnormalities were greater among women who had undergone tubal sterilization than among women who had not. This fact sheet is a brief summary of the study that was published in the December 7, 2000, issue of the New England Journal of Medicine


Questions and Answers About the U.S. Collaborative Review of Sterilization Study of Tubal Sterilization and Menstruation

Background: An article presenting results of the Collaborative Review of Sterilization (CREST) study was published in the December 7, 2000, issue of the New England Journal of Medicine (volume 343, pages 1681–1687). For nearly a half century, there has been some concern that tubal sterilization may result in menstrual abnormalities, such as an increase in menstrual pain and bleeding. Results of this study show that tubal sterilization is not associated with menstrual problems.

Why is the study important?

Tubal sterilization is the most common method of contraception used in the United States. More than 10 million women in the United States, and more than 100 million worldwide, have had the procedure. The concern that women who have had tubal sterilization may suffer from menstrual abnormalities following the procedure led many to classify such abnormalities as “post-tubal ligation syndrome.” Because such a large number of women could be affected, it was very important to determine whether adverse menstrual problems may result from tubal sterilization. This study provides evidence against any "syndrome" of menstrual abnormalities following tubal sterilization. In the study, women who had tubal sterilization were no more likely than women who had not had the procedure to experience menstrual abnormalities.

What types of questions about menstruation did the researchers ask women in this study?

Women in the study were asked several questions about their most recent menstrual periods, including the number of days of menstrual bleeding they had during their periods, the number of days from the beginning of one menstrual period to the beginning of the next, how regular their periods were, the amount of bleeding they experienced during their periods (such as whether their periods were heavy or light), the extent to which they had pain during menstruation, and whether they had bleeding or spotting between periods.

Did the study only include women who had undergone tubal sterilization? 

No. Changes in characteristics of menstruation occur throughout a woman's life, from menarche to menopause. In order to determine whether menstrual changes that occurred among women who had undergone tubal sterilization were associated with the sterilization itself rather than resulting from aging or some other factor, the researchers needed to also interview a “comparison group” of women who had not had tubal sterilization. Women whose partners had a vasectomy were enrolled to serve as the comparison group. This was a particularly good group for comparison purposes because these women would be unlikely to use other methods of contraception, such as birth control pills, which are known to affect menstrual cycles. In addition, both tubal sterilization and vasectomy are permanent methods of contraception; therefore, pregnancies would not be expected in either group and information about several years of menstrual cycles could be collected.

Were the women interviewed more than once about their menstrual cycles?

Yes. The women who had undergone tubal sterilization as well as the partners of men undergoing vasectomy were interviewed every year for at least five years. The researchers suspected that any true “syndrome” of menstrual abnormalities would be persistent. Certainly, menstrual changes that would be particularly bothersome to women would be those that were persistent and occurred over several cycles. Each woman was first interviewed just prior to her tubal sterilization or close to the time of her partner's vasectomy. Women were then interviewed each year for five years and asked the same questions about their most recent menstrual cycles. By collecting the information this way, the investigators were able to determine how the women's menstrual cycles changed following the procedure, whether any changes were persistent, and whether changes differed between the women who had undergone tubal sterilization and women whose partners had undergone vasectomy.

Would the specific type of procedure used for the tubal sterilization make a difference? Are some procedures more likely than others to result in menstrual abnormalities?

This was a concern of the researchers. To address this, they also analyzed the data by looking at the specific surgical methods used for tubal sterilization. None of the methods were associated with a syndrome of menstrual abnormalities.

What should a woman do if she has menstrual problems following a tubal sterilization?

Any woman who experiences menstrual problems that concern her should seek the advice of her doctor, whether or not she has had a tubal sterilization.

What about hysterectomies? 

Hysterectomies are sometimes recommended to treat menstrual abnormalities, and belief in a “post-tubal syndrome” has led some gynecologists to recommend hysterectomy as treatment for the “syndrome.” Previous analyses of CREST data found that women who had a tubal sterilization were more likely to later have a hysterectomy than women who had not had a tubal sterilization. However, a variety of treatment options are available for menstrual abnormalities, depending on the nature and severity of the problem as well as the patient's preference for treatment. In general, indications for hysterectomy should be the same regardless of whether a woman has had a tubal sterilization. The only obvious difference between sterilized and non-sterilized women with respect to hysterectomy is the fact that women who have chosen tubal sterilization have already selected a permanent and surgical method of contraception.

What else is important to know about tubal sterilization? 

Tubal sterilization is a safe and effective method of contraception. Tubal sterilization is a permanent form of contraception, and should therefore only be considered by those who no longer wish to bear children. Couples who are considering a permanent form of contraception may wish to also consider other permanent options, including vasectomy, or highly effective but not permanent options, such as an interuterine device (IUD).

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