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Dysfunctional
Uterine Bleeding
Almost 50% of patients, who traditionally
would be treated by hysterectomy have no actual disease
in the uterus itself but are the victims of either heavy,
erratic or prolonged menstrual bleeding which interferes
with their lifestyle, which is often collectively called
dysfunctional uterine bleeding (DUB). For this reason
removal of the uterus seems a fairly drastic step to cure
the problem, while the frequent or regular use of oral
medication is tiresome and may result in unwanted side-effects.
Your investigation should include with a clinical examination,
a blood count, a trans-vaginal ultrasound and a biopsy
of the lining of the womb (endometium) before deciding
on the most appropriate treatment for you.
Mirena(r) IUD
This highly effective long-term
contraceptive intra-uterine device is increasingly used
to help control heavy periods for women with DUB. It contains
a core of progestogen hormone (levonorgestrel) which is
slowly released into the endometrium causing this to thin,
and hence subsequently reduce menstrual loss. Because
the device delivers high doses of the hormone within the
uterus it is more effective than similar medications taken
by orally as tablets. It is so effective at thinning the
endometrium that we have even used it in the treatment
of endometrial cancer when patients have been too unwell
to undergo standard treatment by either surgery or radiotherapy.
Mirena has the added advantage of offering reliable long-term
contraception, but some women may suffer some systemic
side-effects from the progestogens including bloating
and breast tenderness. The Mirena device may be fitted
like any other IUD under local anaesthetic in the clinic,
but it takes around eight weeks for the endometrium to
settle down during which time spotting may occur.
Back to top Ablation of the endometrium
(TCRE)
This day case surgical
technique was pioneered by an American gynaecologist,
Professor Milton Goldrath in Detroit in the early 1980s,
and was subsequently widely taken up world-wide. Like
many good ideas it is essentially simple. A laser (Neodymium
YAG) is used to ablate the lining of the womb (the endometrium)
so that it is completely removed and the muscle layers
of the womb then fuse over so that very little of the
uterine cavity is left. This means that there is a reduced
bleeding surface at the time of the period and results
either in absence of the periods, very light periods (which
often amounts to spotting) or in some patients the periods
return to normal and are no longer troublesome. A number
of variations and developments have been made using this
basic idea, and a number of similar treatment options
are available. Each uses slightly different techniques
or equipment. Individual gynaecologists tend to have one
or two preferred techniques with which they are most familiar.
The results of all of these alternatives appear to be
very similar with approximately 70% of women finding the
results of treatment satisfactory after long term follow-up.
The satisfaction rate does tend to slowly diminish with
time for all techniques used. In so-called 'first generation
techniques' the whole operation is performed through a
hysteroscope. This is a small telescopic instrument, which
is passed through the neck of the womb into the uterine
cavity so that the operation can be performed under the
surgeon's direct vision. Either a laser is used to destroy
the endometrium, or an electrical cutting loop attachment
is used to resect it. A solution of dextrose saline (for
the laser) or glycine (for electro-surgical resection)
is used to irrigate the inside of the uterus and to get
rid of the debris and charred remains of the endometrium.
Back to top Transcervical resection
of the endometrium and fibroids
Electro-surgical resection
is the most flexible technique, and hence the one that
I prefer in most cases, as it allows the surgeon to tailor
the surgery to the particular patient. In particular it
allows resection of individual polyps or fibroids from
within the cavity of the uterus, either with or without
resection of the remaining endometrium. This is important
if one wishes to preserve the woman's fertility. Occasionally
fibroids may still need to be resected in this manner
following embolization.
Back to top Second generation techniques
to destroy the endometrium
These do not use hysteroscopy,
but instead specially designed disposable instruments,
which are inserted blindly into the uterine cavity and
then use a computerized programme to deliver energy to
destroy the endometrium. These include microwave endometrial
ablation (MEA), and hot fluid-filled balloons, which are
expanded within the uterine cavity. Several similar products
are on the market, and use of some of the first of these
have been approved by NICE (National Institute for Clinical
Excellence) for the treatment of menorrhagia. They are
most suitable for women with DUB who have troublesome
periods, but who have no obvious disease within the uterus.
Many of these techniques may be performed under local
anaesthetic or sedation as a day-case. However, I would
still advise the patient to have a friend or partner to
take them home after such a procedure, and that they should
not drive themselves home. These techniques have the advantage
that they are simple to perform, and do not require extensive
training in the technique, and they may be performed under
local. However, the gynaecologist has no view of the uterine
cavity which hysteroscopy offers, often revealing unexpected
polyps or fibroids within the cavity and are not suitable
for women who have yet to complete their family. Furthermore,
the gynaecologist is much less likely to be aware if there
is any complication, such as a uterine perforation or
burn to the bowel or other organ.
Back to top How long will I be
in hospital and when can I go back to work following TCRE?
TCRE is performed under
a short day-case general anaesthetic and most patients
will find that they can leave hospital a few hours after
the operation as long as someone is available to take
them home. For obvious reasons you are not allowed to
drive yourself within twenty-four hours of a general anaesthetic.
Most patients find that they have minimal discomfort and
are fit to return to work in a few days. Some patients
experience some uterine cramps rather like period pains
and simple analgesics such as paracetamol or ibuprofen
can be taken to relieve these. All patients have a watery,
blood-stained discharge. This usually lasts for around
3-4 weeks but in some cases lasts as long as 6-8. A. similar
discharge often occurs following a traditional hysterectomy.
It is quite permissible to use internal protection and
even to have intercourse during this time.
Are there any complications
from the operation?
The operation is relatively
free of complications mainly because the thickness of
the muscle layer of the womb (the myometrium) provides
a considerable safety factor and prevents the heat, laser
or the electric energy used for the treatment from going
beyond the womb itself. A small number of patients (<5%)
may suffer a perforation of the uterus which is a recognised
complication of any procedure where instruments are inserted
into the uterus, even with simple procedures such as a
D & C. Uterine perforation may prevent the procedure from
being completed, but in itself is usually not dangerous.
In most cases a diagnostic laparoscopy would be indicated
to ensure that there has been no inadvertent injury to
neighbouring organs such as the bowel or the bladder,
and that the small puncture hole in the uterus is not
bleeding. Very rarely this involves one of the large arteries
supplying the womb and if the bleeding is uncontrollable
it may be necessary to perform an emergency hysterectomy.
In my own experience this has never been necessary. A
balloon catheter may be inserted into the uterine cavity
to control heavy bleeding following the procedure, but
this is also very rarely required. The complication rate
is certainly very much less than that associated with
traditional surgical hysterectomy.
Back to top What about the results?
I have been performing
endometrial resection or ablation since 1993, with encouraging
results and without any serious complications. My senior
colleague Professor Chris Sutton, who first taught me
the technique, has followed up over 1000 cases. Overall
long-term satisfaction is around 70%. Similar results
have been confirmed in a national UK study conducted by
the RCOG. Approximately 20% of women may experience no
further bleeding at all, while the majority find their
periods much more normal and tolerable. Approximately
30% of women are not satisfied with the result long-term
and wish to have further treatment. Only about 10% of
patients fail to derive any benefit from the procedure
and although it is always possible to repeat the ablation,
most of these patients will opt for a hysterectomy.
The results are, to some extent, age related and the patients
over 45 have a better result than younger ones. Those
patients with a large uterine cavity, with uterine fibroids
or adenomyosis (endometrial tissue inside the muscular
wall of the womb) tend to have a poorer result. It must
be remembered that the lining of the womb is shed every
month with the period and each month it re-grows very
quickly. We are dealing with a tissue that is capable
of rapid regeneration and it is only necessary to leave
a small island of tissue behind for the endometrium to
re-grow and monthly bleeding recurs.
Back to top Is it still possible
to get pregnant?
Yes. Endometrial resection/ablation
is not contraceptive, though if your periods disappear
completely you are unlikely to get pregnant. Additional
contraceptive precautions should be taken as any subsequent
pregnancies may be complicated by adherence of the placenta
to the scarred lining of the uterus, which may result
in heavy bleeding after delivery. If you have completed
your family or do not wish children you should consider
sterilisation, which could be done at the same time as
the endometrial ablation, or alternatively vasectomy for
your partner.
Back to top How do I set about
having an endometrial resection?
After explaining the procedure
to you we will arrange a convenient date for you to come
into hospital. I recommend taking Danazol 200 mg twice
daily starting with your next period, which you should
take until you come in for the operation. This may be
obtained from ourselves or from your GP. It effectively
thins the lining of the womb so that we can see clearly
what we are doing during the operation through the hysteroscope.
This drug is very effective and if taken for only 6 weeks
causes very little in the way of unpleasant side effects,
but occasionally causes a little fluid retention and increase
in weight short-term. This is usually lost immediately
after the course of treatment is over. To minimise this
we would advise you to watch your diet and cut out any
high fat and salt-containing foods and at the same time
to increase your intake of normal drinking water. Other
possible side effects such as headaches, or occasional
spots will disappear as soon as the treatment is completed.
Interestingly, the side effects can be abolished almost
entirely if you perform vigorous exercises for at least
half an hour every day. It is essential that you take
these tablets right up until you are admitted to hospital
for the endometrial ablation otherwise the procedure may
be technically difficult and the long-term results compromised.
The TCRE may be performed as a day case but some patients
may wish to remain in hospital overnight, particularly
if they have travelled some distance to us, or if the
operation is performed later in the day. You should be
able to return to work within 48 hours and many patients
return to full activity the following day. If you have
any menstrual cramps take some paracetamol or ibuprofen
as you would for a painful period. You will not be able
to assess the final result until four to six months after
the operation so do not get worried if the pink discharge
seems to take a long time to settle down. In spite of
this most women find the whole procedure will be very
much less traumatic and uncomfortable than a standard
hysterectomy. The time to get over it and resume full
activity is certainly very much shorter and we have found
the long-term results very satisfactory and even after
6 years we have been able to avoid hysterectomy in 4 out
of 5 patients with DUB.
Back to top What happens when I
go home following a TCRE?
* Bleeding can last for
approximately 6 to 8 weeks following the TCRE. It may
initially be fairly heavy and red, but will change to
a watery brown discharge. If it becomes a problem, or
you are at all worried, do not hesitate to contact the
ward or G.P. for advice.
* You may notice what appears to be tissue or brownish/black
debris in your vaginal loss. Again this is normal.
* The first or second period following TCRE may still
be heavy. The next period will then hopefully be a little
shorter in duration and lighter in menstrual flow.
* You may use sanitary towels or tampons as you prefer
but remember to change them frequently to avoid infection.
* You may have a bath or shower as preferred but avoid
the use of talcum powder or vaginal deodorants.
* You may experience some abdominal discomfort. This will
usually be relieved by paracetamol or simple analgesics
such as ibuprofen. If the pain persists or increases,
or if you get an increase of bleeding or an offensive
discharge please contact your GP who will prescribe some
antibiotics. You are given antibiotics during the operation
to prevent secondary infection but in spite of this it
occasionally occurs.
* You may resume sexual intercourse at your own preference.
* You should take things quietly for 1 or 2 days following
TCRE, but should be able to resume normal activities in
2 to 4 days. Returning to work is up to the individual
concerned. You may return as soon as you feel fit and
usually this is in 7-10 days.
* If you are taking Hormone Replacement Therapy prior
to, or following a TCRE, then you must ensure that it
contains a 'progestagen'. (If in doubt check with the
doctor who prescribed the HRT)
* It takes approximately 6 months to fully evaluate the
success of TCRE and you will receive an out-patient appointment
through the post at this time for a follow-up consultation.Back to top
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