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Menstrual disorders - Surgery

Description

An in-depth report on the causes, treatment, and prevention of menstrual cramps.

Alternative Names

Dysmenorrhea; Menorrhagia; Amenorrhea; Cramps; Heavy menstrual bleeding

Surgery:

Women with heavy menstrual bleeding, dysmenorrhea, or both have medical and surgical options available to them. Most procedures eliminate or significantly affect the possibility for childbearing, however. Hysterectomy removes the entire uterus while endometrial ablation destroys the uterine lining.

For some women, an intrauterine device (IUD) that releases hormones is proving to be a good medical alternative to surgery. The levonorgestrel-releasing intrauterine system, or LNG-IUS (Mirena), is increasingly being used instead of surgery to treat heavy menstrual bleeding. Studies have found the LNG-IUS to work just as well as ablation. Women should be sure to ask their doctors about all medical options before undergoing surgical procedures.

Endometrial Ablation

In endometrial ablation, the entire lining of the uterus (the endometrium) is removed or destroyed. For most women, this procedure stops the monthly menstrual flow. In some women, menstrual flow is not stopped but is significantly reduced.

Candidates. Endometrial ablation is not appropriate for women who:

  • Have gone through menopause
  • Have recently been pregnant
  • Would like to have children in the future
  • Have certain gynecologic conditions such as cancer of the uterus, endometrial hyperplasia, uterine infection, or an endometrium that is too thin

Considerations. Endometrial ablation significantly decreases the likelihood a woman will become pregnant. However, pregnancy can still occur and this procedure increases the risks of complications, including miscarriage. Women who have this procedure must be committed to not becoming pregnant and to using birth control. Sterilization after ablation is another option.

A main concern of endometrial ablation is that it may delay or make it more difficult to diagnose uterine cancer in the future. (Postmenopausal bleeding or irregular vaginal bleeding can be warning signs of uterine cancer.) Women who have endometrial ablation still have a uterus and cervix, and should continue to have regular Pap smears and pelvic exams.

Types of Endometrial Ablation. Endometrial ablation used to be performed in an operating room using electrosurgery with a resectoscope (a hysteroscope with a heated wire loop or roller ball.) Laser ablation was another older procedure. These types of endometrial ablation have largely been replaced by newer types of procedure that do not use a resectoscope.

The newer procedures can be performed either in an operating room or a doctor ' s office. They include:

  • Radiofrequency. The NovaSure system uses a mesh electrode probe that emits electromagnetic energy to destroy the lining.
  • Heated fluid. In the HydroThermAblator system, a saline solution is inserted into the uterus with a hysteroscope and heated until the lining is destroyed. In the thermal balloon method, a balloon inserted into the uterus with hysteroscope is filled with heated fluid and expanded until it touches and destroys the endometrium.
  • Freezing. Cryoablation uses liquid nitrogen to freeze the uterine lining.
  • Microwave. Microwave endometrial ablation applies very low-power microwaves to the uterus.

Before the Procedure. In preparing for the ablation procedure, the doctor will perform an endometrial biopsy to make sure that cancer is not present. If the woman has an intrauterine device (IUD), it must be removed before the procedure. In some cases, hormonal drugs, such as GnRH analogs, may be given a few weeks before ablation to help thin the endometrial lining.

During the Procedure. Endometrial ablation is an outpatient procedure. The doctor usually applies a local anesthetic around the cervix. (The patient also receives medication for pain and to help her relax.) The doctor will dilate the cervix before starting the procedure. Patients may feel some mild cramping or discomfort, but many of the newer types of endometrial procedures can be performed in under 10 minutes.

After the Procedure. Patients may experience menstrual-like cramping for several days and frequent urination during the first 24 hours. The main side effect is watery or bloody discharge that can last for several weeks. This discharge is especially heavy in the first few days following ablation. (Patients need to wear pads, not tampons during this time, and to wait to have sex until the discharge has stopped.) Patients are generally able to return to work or normal activities within a few days after the procedure.

Complications. Complications of endometrial ablation may include perforation of the uterus, injury to the intestine, hemorrhage, or infection. If heated fluid is used in the procedure, it may leak and cause burns. However, in general, the risk of complications is very low.

Nearly all women have reduced menstrual flow after endometrial ablation, and nearly half of women have their periods stop. Some women, however, may continue to have bleeding problems and ultimately decide to have a hysterectomy.

Hysterectomy

Hysterectomy is the surgical removal of the uterus.


Hysterectomy - series
Click the icon to see an illustrated series detailing a hysterectomy.

Heavy bleeding, often from fibroids, and pelvic pain are the reasons for many hysterectomies. However, with newer medical and surgical treatments available, hysterectomies are performed less often than in the past. In its support, hysterectomy, unlike drug treatments and less invasive procedures, cures menorrhagia completely, and most women are satisfied with the procedure. Less invasive hysterectomy procedures are also improving recovery rates and increasing satisfaction afterward.

Still, any woman who is uncertain about a recommendation for a hysterectomy to treat fibroids or heavy bleeding should certainly seek a second opinion.

[For more information, see In-Depth Report #73: Uterine fibroids or In-Depth Report #74: Endometriosis.]

Nerve Destruction Techniques for Treating Dysmenorrhea

Some evidence suggests that surgically cutting the pain-conducting nerve fibers leading from the uterus diminishes the pain from dysmenorrhea. Two procedures, uterine nerve ablation and laparoscopic presacral neurectomy, can block such nerves. Small studies have shown benefits from these procedures, but stronger evidence is needed before they can be recommended for women with severe primary dysmenorrhea.

Resources

References

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Witt CM, Reinhold T, Brinkhaus B, Roll S, Jena S, Willich SN. Acupuncture in patients with dysmenorrhea: a randomized study on clinical effectiveness and cost-effectiveness in usual care. Am J Obstet Gynecol. 2008 Feb;198(2):166.e1-8.

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  • Reviewed last on: 8/5/2009
  • Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
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