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International Women's Health Update

Surgical Options

Cervical Dilation and Uterine Curettage/Endometrial Sampling

Many of these operations are in women under the age of 40 years and many of them have no evidence of proven benefit. In women under the age of 40 years complaining of menorrhagia who have normal gynaecological examination, we recommend vaginal ultrasound assessment of their endometrium. At our institution for women over 40 years of age, we advise out-patient hysteroscopy and endometrial sampling. We believe that this will reduce the load of unnecessary operations for an apparent diagnosis of dysfunctional uterine bleeding in our patients. If there is vaginal ultrasound evidence of endometrial abnormalities, particularly endometrial polyps, then hysteroscopy is indicated.

Endometrial Ablation

Endometrial resection, ablation or extirpation has been variously used for surgical management of heavy periods (Fig 4). In our teaching hospital, we have found that the use of chemical agents pre-operatively has been most helpful in reducing the thickness of endometrium to be removed at this operation. A gonadotrophin hormone releasing hormone agonist such as goserelin (Zoladex) or danazol tablets for 2 months would be most commonly recommended at our institution. The expense of goserelin in this use is its major disadvantage, although it is the most effective treatment at reducing the thickness of endometrium.

Figure 4.

Figure 4

Three methods of removing endometrium in patients with heavy periods.
  1. Endometrial resection, using a rectoscope loop, is favoured for heavy periods due to submucosal fibroids.
  2. Endometrial ablation is recommended for heavy periods due to dysfunctional uterine bleeding.
  3. Laser endometrial extirpation is now uncommonly used.

Roller ball endometrial ablation is our preferred operation for dysfunctional uterine bleeding. Of course, removal of submucous fibroids can also be undertaken with this technique at the same time in cases of heavy periods. In our experience, selection of patients who truly have heavy periods, without significant pelvic pain, is most important for ensuring a high likelihood of a satisfied patient 5 years after the procedure. Our prospective follow up of such women indicates that 9 of 10 subjects are highly satisfied 5 years after endometrial ablation and we do emphasise the importance of taking care with the correct diagnosis before recommending this procedure. In our experience endometrial ablation is not an effective operation for severe secondary dysmenorrhoea nor for vague chronic pelvic pain. Endometrial ablation is one of a number of increasingly commonly performed gynaecological day surgery cases or ambulatory surgery cases. It must be understood by all patients that such procedures do have side effects and risks.
In our institution, the incidence of major complications with endometrial ablation is approximately 1.2 per thousand procedures. A major complication was defined in our studies as one which required laparotomy.4

Hysterectomy

Hysterectomy is a very effective operation for patients with heavy periods in which all simpler treatments have been unsuccessful. Traditionally, hysterectomy has been performed by either the abdominal or the vaginal method. Vaginal hysterectomy is typically quicker, has fewer post-operative complications and less post-operative discomfort than abdominal hysterectomy. Nevertheless, over 75% of patients in 2 recent reports relating to trends in the United States and the United Kingdom have had abdominal hysterectomies. Probably the same situation occurs in Australia.
Laparoscopic hysterectomy appears to offer advantages over abdominal hysterectomy in reduced post-operative discomfort, hospital stay and recovery time. Laparoscopy hysterectomy is especially suitable as an alternative to abdominal hysterectomy where vaginal hysterectomy is considered difficult or inappropriate, such as in cases of heavy periods in nulligravid women where there is no uterine descent.
We recently undertook a cost comparison of laparoscopic versus abdominal hysterectomy.5 We found that patients undergoing laparoscopic hysterectomy for heavy periods had a reduced length of hospital stay, although a longer operating time than did women undergoing abdominal hysterectomy. The total cost of laparoscopic hysterectomy, which included all direct and indirect costs, is equivalent between the two types of hysterectomies. The cost of the increased operating time and the use of disposable equipment in the laparoscopic hysterectomy was offset by its much shorter hospital stay. Such innovations, strongly favoured by patients because of the smaller incisions and diminished post-operative pain of laparoscopic hysterectomy as well as by hospital managers, have the potential for higher output and use of theatre based resources.

Future Directions

The modern approach to heavy periods begins with care and diligence in making the correct diagnosis. Particular care should be taken for a diagnosis of dysfunctional uterine bleeding. Some form of endometrial sampling should be undertaken before making this diagnosis in women over the age of 40 years.
Once a clear diagnosis has been made, modern management of heavy periods means tailoring the appropriate management options to the individual patient. In many patients, the use of medical therapies will be acceptable. This may include progestogens, administered for 20 days in each cycle and in appropriate dosage. For many patients with heavy periods, prescription of an anti-fibrinolytic such as tranexamic acid will reduce excessive menstrual bleeding to acceptable volumes for gynaecological comfort. The methods are inexpensive and should be more widely used, before resorting to expensive surgical treatments, which may be quite unnecessary. This particularly applies to incorrect use of dilatation and curettage or the premature use of endometrial ablation or resection procedures in a patient with an inappropriate diagnosis.
Hysterectomy remains an excellent treatment for refractory heavy periods in individual women. It is imperative that more widespread training and development of laparoscopic hysterectomy skills in each region for the benefit of patients with refractory heavy periods. Effective ambulatory surgery and preceptorships is one way to bring this about.6

References

  1. Rybo G. Tranexamic acid therapy-effective treatment in heavy menstrual bleeding. Clinical update on safety. Therapeutic Advances 1991;4:1-8
  2. Gleeson NC, Buggy F, Sheppard BL & Bonnar J. The effect of tranexamic acid on measured menstrual blood loss and endometrial fibrinolytic enzymes in dysfunctional uterine bleeding. Acta Ostet Gynaecol Scand 1994;73:274-277
  3. Bonnar J & Sheppard BL. Treatment of menorrhagia during menstruation: randomised controlled trial of ethamsylate, mefenamic acid, and tranexamic acid. British Medical Journal 1996;313:579-582
  4. Tsaltas J, Healy D, and Lloyd D. Review of major complications of laparoscopy in free standing gynaecological day case hospital. Gynaecological Endoscopy 1996;5:265-270
  5. Tsaltas J, Magnus A, Mamers P, Lawrence A, Lolatgis N and Healy D. Laparoscopy and abdominal hysterectomy: a cost comparison. Medical Journal of Australia 1997;166:205-207
  6. Healy DL, & Petrucco. Effective Gynaecological Day Surgery, Chapman Hall 1998; In press.

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