- Email: [email protected]
Menstrual disturbance
ARTICLE IN PRESS Current Obstetrics & Gynaecology (2004) 14, 216–219
www.elsevier.com/cuog
Menstrual disturbance S. Tao, I. Symonds* Academic Department of Obstetrics and Gynaecology, School of Human Development, The Medical School, Derby City General Hospital, Clinical Sciences Building, Uttoxeter Road, Derby DE22 3NE, UK
KEYWORDS Menorrhagia; Fibroids; Endometrial ablation; Dysfunctional uterine bleeding; Mirena
Summary In the past, the mainstay of surgical treatment of menorrhagia was hysterectomy. This is an effective form of treatment in terms of outcome but it does carry a degree of morbidity and prolonged convalescence. Endometrial ablation techniques were initially developed using the urological resectoscope, and recently, simpler methods have been developed to strive to obtain high patient satisfaction rates with less associated morbidity. This article looks at the considerations in the development of these new treatments, as well as medical treatment options such as the use of intra-uterine progestogens. & 2004 Elsevier Ltd. All rights reserved.
Introduction Disturbances of menstruation are a major social as well as medical problem for women, having an impact on the lives of their families as well as the women themselves. Heavy bleeding is the most common complaint, with one in 20 women between the ages of 30 and 49 years consulting their general practitioner (GP) every year. Menorrhagia can be measured objectively and is defined as the loss of more than 80 ml of menstrual blood every month. This has no real place in the clinical situation as the majority of women’s assessment of their symptoms bears little resemblance to the objective blood loss. It is important to take a history to exclude any systemic or pelvic pathology as a cause for menorrhagia, although in approximately 50% of cases, there is no pathological cause found. These cases are referred to as dysfunctional uterine bleeding. The length of the periods and menstrual cycle, along with any abnormal, intermenstrual or postcoital bleeding, should be ascertained, along with
*Corresponding author. Tel.: þ 44-1332-724665; fax: þ 441332-724697. E-mail address: [email protected] (I. Symonds).
the presence of any pain during periods or during intercourse, and a history of cervical cytology. Abdominal, bimanual and speculum examinations need to be performed to exclude any pathology, and full blood count should be measured. Thyroid function tests and coagulation tests should only be considered if there is any indicative history. There are usually no indications for any other hormonal investigations. Transvaginal ultrasound should be carried out and endometrial biopsy considered if anything in the history suggests the need to exclude endometrial cancerFwomen with abnormal heavy bleeding over 45 years of age, abnormal smear, family history of endometrial or colonic cancer, obesity, diabetes or tamoxifen use.
Case one A 41-year-old woman with a body mass index of 33 kg/m2 was referred to the gynaecology outpatient department with a history of heavy regular periods that had improved slightly with tranexamic acid but she was not happy to take this on a longterm basis. She was otherwise medically fit and well. She had three children, all delivered normally, and had a laparoscopic sterilization 7 years
0268-0890/$ - see front matter & 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.curobgyn.2004.02.009
ARTICLE IN PRESS Menstrual disturbance
217
previously. A transvaginal ultrasound revealed a uterus of normal size and shape with no fibroids and a thickened regular endometrium.
Treatment options Most medical treatments for menorrhagia (Table 1) are only moderately effective or are not acceptable to women as a long-term treatment option, with many women seeing these as temporary measures prior to other treatments. Traditionally, if first-line medical treatment failed or was unacceptable, the next step was often abdominal hysterectomy. This meant that many women underwent major abdominal surgery and had a normal uterus removed. Although mortality rates after hysterectomy for benign disease are low, the associated morbidity is high. Peri-operative morbidity rates have been reported to be 24–43% with complications of post-operative fever and infections, haemorrhage requiring transfusion, urinary tract and gastro-intestinal damage, and anaesthetic accidents. Other more long-term complications of hysterectomy include bowel obstruction secondary to adhesions and premature ovarian failure. In this case, after discussion of the options, the patient opted for thermal balloon ablation of the
Table 1
Medical treatments for menorrhagia.
Hormonal
Non-hormonal
Combined oral contraceptive pill
Non-steroidal antiinflammatories * * *
Hormone replacement therapy
e.g. mefenamic acid Naproxen Ibuprofen
Antifibrinolytics
*
e.g. tranexamic acid
Intra-uterine progestagens *
e.g. Mirena IUS
Other * *
e.g. Danazol GnRH analogues
Note: GnRH, gonadotrophin-releasing hormone; IUS, intra-uterine system.
endometrium. This was carried out under general anaesthetic and she was discharged home the following morning. Less invasive surgical endometrial ablation procedures have been used for the treatment of dysfunctional uterine bleeding for the last 10–15 years, with the first procedure being carried out in the UK in 1988. Studies have shown that in comparison with hysterectomy as a treatment for menorrhagia, there is a significantly lower incidence of post-operative complications with endometrial ablation. Also, satisfaction rates are high amongst women who have chosen endometrial ablation over hysterectomy for treatment of their heavy periods. In this group of women, the endpoint of complete amenorrhoea is not important, and they probably view ablation as an alternative to prolonged drug therapy, with the additional benefit of delaying and possibly even avoiding hysterectomy. The avoidance of major surgery and, more importantly for many women, a prolonged hospital stay and recovery period is seen as a major advantage to those women who choose an ablation procedure. Some women will have a different opinion of which end results are important, with complete amenorrhoea preferable to some. In a randomized controlled trial comparing transcervical endometrial resection and total abdominal hysterectomy, there was a slightly higher satisfaction rate 4 months after surgery amongst the women who had hysterectomy (94% compared with 85%); dissatisfaction with endometrial resection was associated with intra-operative uterine perforation, continued menorrhagia or worsened dysmenorrhoea. Trials looking at menstrual outcome following first-generation ablation techniques (TCRE, rollerball, laser ablation) have shown similar results of approximately 95% good outcome after 13–24 months, 85% after 25–36 months and 75% after more than 36 months. Amenorrhoea rates are approximately 27% after 36 months. Women aged 45 years or more are more likely to become amenorrhoeic and be more satisfied with the procedure, with satisfaction rates also being higher in those women with genuine objectively measured excessive menstrual loss. The traditional techniques of endometrial ablation are hysteroscopic, and success and safety are dependent on a high level of skill. In studies that looked at the comparison between the different methods of endometrial ablation, the incidence of uterine perforation or length of procedure reduced with operator experience, with the highest number of complications occurring in the first 100 cases carried out by each individual surgeon. Perhaps
ARTICLE IN PRESS 218
S. Tao, I. Symonds
Table 2 Second-generation endometrial ablation techniques. Balloon * *
Heating element within balloonFThermochoice Separate heating elementFCavaTerm, Menotreat
Radio frequency *
Thermal energy causing desiccationFVestablate, Novacept
Cryo-ablationFHer-Option device, CARMEN LaserFELITT Heated fluid instillationFEnAbl Fluid under direct visionFHydro ThermAblator Electromagnetic energyFmicrowave frequency endometrial resection Photodynamic therapyFcurrently being evaluated but not available yet
because of this, the number of ‘first-generation’ procedures carried out has decreased in most countries. ‘Second-generation’ ablation techniques (Table 2) require less operator skill, are easier to learn, need less hysteroscopic skills to carry out the procedure, and have a shorter operation time. The lack of a ‘learning phase’ for these newer techniques is reflected in a lower morbidity, particularly when being developed. Another feature that helps keep morbidity low is the potential to learn the procedures in a simulator setting. There is a vast choice of endometrial ablation methods and all procedures are relatively new. In terms of safety, these methods need to be compared with each other as well as with the more traditional methods, as the potential exists for undetected complications as most of these techniques are blind. The second-generation endometrial ablation techniques have been marketed as possible outpatient procedures, but the majority of cases are carried out under general anaesthetic or with intravenous sedation.
taken the combined oral contraceptive pill but had to stop due to problems with high blood pressure. There was no abnormality to be found on general and pelvic examination, and vaginal swabs showed no evidence of infection.
Treatment options In this case, the preservation of fertility is likely to be an issue as well as the avoidance of major surgery. The use of intra-uterine progestogens is another option in the treatment of dysfunctional uterine bleeding. Cyclical oral progestogens have been used for a number of years to regulate heavy bleeding associated with anovulatory cycles, but these are not effective in the treatment of regular heavy periods. There is also a high rate of discontinuation of oral progestogens due to the poor side-effect profile. The Mirenas intra-uterine system (IUS) releases levonorgestrel locally from a reservoir on the T-shaped frame through a ratelimiting membrane at 20 mg/24 h over 5 years. It has a Pearl index of o0.5 making it more effective as a contraceptive than female sterilization. Its mode of action is by the induction of endometrial atrophy. It has been shown that there is a significant reduction of menstrual blood loss with Mirena use after 3 months and this is continued by 12 months. Studies have found that patient satisfaction is high, although in some women, the IUS is either expelled (approximately 5%) or removed on patient request (approximately 15%) after the first few months of insertion because of unacceptable symptoms of erratic vaginal bleeding. Two studies have looked at women given the Mirena IUS while on waiting lists for hysterectomy for dysfunctional uterine bleeding; they found removal rates from the waiting list of 82% and 64% after 6 months of treatment. The benefits of the Mirena IUS over endometrial ablation are the preservation of fertility, particularly in younger women, and the ease of insertion, which can be carried out in the outpatient or primary care setting.
Case three Case two A 30-year-old woman was referred to the gynaecology outpatient department by her GP with a history of heavy regular periods since the birth of her last child 18 months previously. She had two normal vaginal deliveries in the past and used condoms for contraception. She had previously
A 38-year-old nulliparous woman was referred to the gynaecology clinic with a history of increasingly heavy painful periods, with problems of flooding and passing clots. She had already tried mefenamic acid which had initially helped but now her symptoms were worsening. She had recently been found to have haemoglobin of 10.5 g/dl and ferritin 10 ng/ml and was taking ferrous sulphate. A
ARTICLE IN PRESS Menstrual disturbance
transvaginal ultrasound scan showed her to have a fibroid uterus with one fundal 4 cm fibroid and a distorted endometrial cavity suggestive of a submucous fibroid.
Treatment options Menorrhagia can lead to iron-deficiency anaemia, although the symptom is usually very subjective. Often, the main problem is not a serious threat to the woman’s health but a serious impact on her quality of life. If there is anaemia, this needs to be treated. Further investigations need to be carried out to ascertain the exact nature of the fibroids. The uterine cavity can be inspected using hysteroscopy or can be examined using saline infusion sonohysterography. The latter procedure involves transcervical infusion of saline into the uterine cavity to distend the uterus and thus increase the contrast between the endometrium and the cavity itself. This has been shown to be more accurate at diagnosing submucous fibroids and endometrial polyps than ultrasound alone, but is not generally available. If there is any need to confirm the presence of fibroids in a patient with heavy periods, the procedure of choice is hysteroscopy, either under general anaesthetic or in the outpatient setting. In this case, the submucous fibroid was confirmed by hysteroscopy and then resected hysteroscopically. The removal of submucous fibroids in a woman with menorrhagia has been shown to improve the symptoms with minimal recurrence if the myomas are completely removed. This may require more than one procedure, particularly if the fibroids are mainly intramural. Fertility is preserved in these cases, although the conception rates do not seem to be greatly improved if fertility is already a problem. Fibroids are resected hysteroscopically, usually after endometrial preparation with Danazol or gonadotrophin-releasing hormone analogues, but some of the second-generation ablatim techniques are being investigated as possible treatments, e.g. microwave endometrial ablation. Embolization of symptomatic fibroids is an alternative to surgical removal. This has been carried out for the last 10 years or so, and seems to be successful at reducing uterine fibroid size and symptoms. However, longer-term follow-up is required to assess the safety of future pregnancies. There have been some serious complications described after embolization including infection, bowel obstruction and loss of ovarian function.
219
Conclusion There is now a wide range of options for the treatment of menorrhagia, with less invasive surgical techniques as an alternative to hysterectomy. It is important to treat each case as an individual, and the decision-making process has to take the wishes of the patient into account. Some patients will choose to have hysterectomy for the treatment of dysfunctional uterine bleeding because their most important outcome is complete amenorrhoea, whereas it will be important to other women to avoid a prolonged stay in hospital and recovery time. There is a lot of work being carried out to develop new, simple, preferably ‘office’ procedures but it is necessary to realize that there will never be a ‘one size fits all’ method. When counselling a patient, it is necessary to fully explain the pros and cons of each procedure and allow her to make the right decision for her. Due to the importance of choice and the resultant quality-of-life issues, it can often be difficult to compare different treatments in a well-designed, preferably randomized study, but more studies of this type are needed to continue to evaluate new techniques.
Further reading Clarke A, Black N, Rowe P, Mott S, Howle K. Indications for and outcome of total abdominal hysterectomy for benign disease: a prospective cohort study. Br J Obstet Gynaecol 1995;102: 611–20. Cooper K, Jack S, Parkin D, Grant A. Five-year follow up of women randomised to medical management or transcervical resection of the endometrium for heavy menstrual loss: clinical and quality of life outcomes. Br J Obstet Gynaecol 2001;108:1222–8. Dwyer N, Hutton J, Stirrat M. Randomised controlled trial comparing endometrial resection with abdominal hysterectomy for the surgical treatment of menorrhagia. Br J Obstet Gynaecol 1993;100:237–43. Nagele F, Rubinger T, Magos A. Why do women choose endometrial ablation rather than hysterectomy? Fertil Steril 1998;69:1063–6. Oehler MK, Rees MCP. Menorraghia: an update. Acta Obstet Gynecol Scand 2003;82:405–22. Pellicano M, Guida M, Acunzo G, Cirillo D, Bifulco G, Nappi C. Hysteroscopic transcervical endometrial resection versus thermal destruction for menorrhagia: a prospective randomised trial on satisfaction rate. Am J Obstet Gynaecol 2002;187:545–50. Stewart A, Cummins C, Gold L, Jordan R, Phillips W. The effectiveness of the levenorgestrel-releasing intra-uterine system in menorrhagia: a systematic review. Br J Obstet Gynaecol 2001;108:74–86.
www.elsevier.com/cuog
Menstrual disturbance S. Tao, I. Symonds* Academic Department of Obstetrics and Gynaecology, School of Human Development, The Medical School, Derby City General Hospital, Clinical Sciences Building, Uttoxeter Road, Derby DE22 3NE, UK
KEYWORDS Menorrhagia; Fibroids; Endometrial ablation; Dysfunctional uterine bleeding; Mirena
Summary In the past, the mainstay of surgical treatment of menorrhagia was hysterectomy. This is an effective form of treatment in terms of outcome but it does carry a degree of morbidity and prolonged convalescence. Endometrial ablation techniques were initially developed using the urological resectoscope, and recently, simpler methods have been developed to strive to obtain high patient satisfaction rates with less associated morbidity. This article looks at the considerations in the development of these new treatments, as well as medical treatment options such as the use of intra-uterine progestogens. & 2004 Elsevier Ltd. All rights reserved.
Introduction Disturbances of menstruation are a major social as well as medical problem for women, having an impact on the lives of their families as well as the women themselves. Heavy bleeding is the most common complaint, with one in 20 women between the ages of 30 and 49 years consulting their general practitioner (GP) every year. Menorrhagia can be measured objectively and is defined as the loss of more than 80 ml of menstrual blood every month. This has no real place in the clinical situation as the majority of women’s assessment of their symptoms bears little resemblance to the objective blood loss. It is important to take a history to exclude any systemic or pelvic pathology as a cause for menorrhagia, although in approximately 50% of cases, there is no pathological cause found. These cases are referred to as dysfunctional uterine bleeding. The length of the periods and menstrual cycle, along with any abnormal, intermenstrual or postcoital bleeding, should be ascertained, along with
*Corresponding author. Tel.: þ 44-1332-724665; fax: þ 441332-724697. E-mail address: [email protected] (I. Symonds).
the presence of any pain during periods or during intercourse, and a history of cervical cytology. Abdominal, bimanual and speculum examinations need to be performed to exclude any pathology, and full blood count should be measured. Thyroid function tests and coagulation tests should only be considered if there is any indicative history. There are usually no indications for any other hormonal investigations. Transvaginal ultrasound should be carried out and endometrial biopsy considered if anything in the history suggests the need to exclude endometrial cancerFwomen with abnormal heavy bleeding over 45 years of age, abnormal smear, family history of endometrial or colonic cancer, obesity, diabetes or tamoxifen use.
Case one A 41-year-old woman with a body mass index of 33 kg/m2 was referred to the gynaecology outpatient department with a history of heavy regular periods that had improved slightly with tranexamic acid but she was not happy to take this on a longterm basis. She was otherwise medically fit and well. She had three children, all delivered normally, and had a laparoscopic sterilization 7 years
0268-0890/$ - see front matter & 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.curobgyn.2004.02.009
ARTICLE IN PRESS Menstrual disturbance
217
previously. A transvaginal ultrasound revealed a uterus of normal size and shape with no fibroids and a thickened regular endometrium.
Treatment options Most medical treatments for menorrhagia (Table 1) are only moderately effective or are not acceptable to women as a long-term treatment option, with many women seeing these as temporary measures prior to other treatments. Traditionally, if first-line medical treatment failed or was unacceptable, the next step was often abdominal hysterectomy. This meant that many women underwent major abdominal surgery and had a normal uterus removed. Although mortality rates after hysterectomy for benign disease are low, the associated morbidity is high. Peri-operative morbidity rates have been reported to be 24–43% with complications of post-operative fever and infections, haemorrhage requiring transfusion, urinary tract and gastro-intestinal damage, and anaesthetic accidents. Other more long-term complications of hysterectomy include bowel obstruction secondary to adhesions and premature ovarian failure. In this case, after discussion of the options, the patient opted for thermal balloon ablation of the
Table 1
Medical treatments for menorrhagia.
Hormonal
Non-hormonal
Combined oral contraceptive pill
Non-steroidal antiinflammatories * * *
Hormone replacement therapy
e.g. mefenamic acid Naproxen Ibuprofen
Antifibrinolytics
*
e.g. tranexamic acid
Intra-uterine progestagens *
e.g. Mirena IUS
Other * *
e.g. Danazol GnRH analogues
Note: GnRH, gonadotrophin-releasing hormone; IUS, intra-uterine system.
endometrium. This was carried out under general anaesthetic and she was discharged home the following morning. Less invasive surgical endometrial ablation procedures have been used for the treatment of dysfunctional uterine bleeding for the last 10–15 years, with the first procedure being carried out in the UK in 1988. Studies have shown that in comparison with hysterectomy as a treatment for menorrhagia, there is a significantly lower incidence of post-operative complications with endometrial ablation. Also, satisfaction rates are high amongst women who have chosen endometrial ablation over hysterectomy for treatment of their heavy periods. In this group of women, the endpoint of complete amenorrhoea is not important, and they probably view ablation as an alternative to prolonged drug therapy, with the additional benefit of delaying and possibly even avoiding hysterectomy. The avoidance of major surgery and, more importantly for many women, a prolonged hospital stay and recovery period is seen as a major advantage to those women who choose an ablation procedure. Some women will have a different opinion of which end results are important, with complete amenorrhoea preferable to some. In a randomized controlled trial comparing transcervical endometrial resection and total abdominal hysterectomy, there was a slightly higher satisfaction rate 4 months after surgery amongst the women who had hysterectomy (94% compared with 85%); dissatisfaction with endometrial resection was associated with intra-operative uterine perforation, continued menorrhagia or worsened dysmenorrhoea. Trials looking at menstrual outcome following first-generation ablation techniques (TCRE, rollerball, laser ablation) have shown similar results of approximately 95% good outcome after 13–24 months, 85% after 25–36 months and 75% after more than 36 months. Amenorrhoea rates are approximately 27% after 36 months. Women aged 45 years or more are more likely to become amenorrhoeic and be more satisfied with the procedure, with satisfaction rates also being higher in those women with genuine objectively measured excessive menstrual loss. The traditional techniques of endometrial ablation are hysteroscopic, and success and safety are dependent on a high level of skill. In studies that looked at the comparison between the different methods of endometrial ablation, the incidence of uterine perforation or length of procedure reduced with operator experience, with the highest number of complications occurring in the first 100 cases carried out by each individual surgeon. Perhaps
ARTICLE IN PRESS 218
S. Tao, I. Symonds
Table 2 Second-generation endometrial ablation techniques. Balloon * *
Heating element within balloonFThermochoice Separate heating elementFCavaTerm, Menotreat
Radio frequency *
Thermal energy causing desiccationFVestablate, Novacept
Cryo-ablationFHer-Option device, CARMEN LaserFELITT Heated fluid instillationFEnAbl Fluid under direct visionFHydro ThermAblator Electromagnetic energyFmicrowave frequency endometrial resection Photodynamic therapyFcurrently being evaluated but not available yet
because of this, the number of ‘first-generation’ procedures carried out has decreased in most countries. ‘Second-generation’ ablation techniques (Table 2) require less operator skill, are easier to learn, need less hysteroscopic skills to carry out the procedure, and have a shorter operation time. The lack of a ‘learning phase’ for these newer techniques is reflected in a lower morbidity, particularly when being developed. Another feature that helps keep morbidity low is the potential to learn the procedures in a simulator setting. There is a vast choice of endometrial ablation methods and all procedures are relatively new. In terms of safety, these methods need to be compared with each other as well as with the more traditional methods, as the potential exists for undetected complications as most of these techniques are blind. The second-generation endometrial ablation techniques have been marketed as possible outpatient procedures, but the majority of cases are carried out under general anaesthetic or with intravenous sedation.
taken the combined oral contraceptive pill but had to stop due to problems with high blood pressure. There was no abnormality to be found on general and pelvic examination, and vaginal swabs showed no evidence of infection.
Treatment options In this case, the preservation of fertility is likely to be an issue as well as the avoidance of major surgery. The use of intra-uterine progestogens is another option in the treatment of dysfunctional uterine bleeding. Cyclical oral progestogens have been used for a number of years to regulate heavy bleeding associated with anovulatory cycles, but these are not effective in the treatment of regular heavy periods. There is also a high rate of discontinuation of oral progestogens due to the poor side-effect profile. The Mirenas intra-uterine system (IUS) releases levonorgestrel locally from a reservoir on the T-shaped frame through a ratelimiting membrane at 20 mg/24 h over 5 years. It has a Pearl index of o0.5 making it more effective as a contraceptive than female sterilization. Its mode of action is by the induction of endometrial atrophy. It has been shown that there is a significant reduction of menstrual blood loss with Mirena use after 3 months and this is continued by 12 months. Studies have found that patient satisfaction is high, although in some women, the IUS is either expelled (approximately 5%) or removed on patient request (approximately 15%) after the first few months of insertion because of unacceptable symptoms of erratic vaginal bleeding. Two studies have looked at women given the Mirena IUS while on waiting lists for hysterectomy for dysfunctional uterine bleeding; they found removal rates from the waiting list of 82% and 64% after 6 months of treatment. The benefits of the Mirena IUS over endometrial ablation are the preservation of fertility, particularly in younger women, and the ease of insertion, which can be carried out in the outpatient or primary care setting.
Case three Case two A 30-year-old woman was referred to the gynaecology outpatient department by her GP with a history of heavy regular periods since the birth of her last child 18 months previously. She had two normal vaginal deliveries in the past and used condoms for contraception. She had previously
A 38-year-old nulliparous woman was referred to the gynaecology clinic with a history of increasingly heavy painful periods, with problems of flooding and passing clots. She had already tried mefenamic acid which had initially helped but now her symptoms were worsening. She had recently been found to have haemoglobin of 10.5 g/dl and ferritin 10 ng/ml and was taking ferrous sulphate. A
ARTICLE IN PRESS Menstrual disturbance
transvaginal ultrasound scan showed her to have a fibroid uterus with one fundal 4 cm fibroid and a distorted endometrial cavity suggestive of a submucous fibroid.
Treatment options Menorrhagia can lead to iron-deficiency anaemia, although the symptom is usually very subjective. Often, the main problem is not a serious threat to the woman’s health but a serious impact on her quality of life. If there is anaemia, this needs to be treated. Further investigations need to be carried out to ascertain the exact nature of the fibroids. The uterine cavity can be inspected using hysteroscopy or can be examined using saline infusion sonohysterography. The latter procedure involves transcervical infusion of saline into the uterine cavity to distend the uterus and thus increase the contrast between the endometrium and the cavity itself. This has been shown to be more accurate at diagnosing submucous fibroids and endometrial polyps than ultrasound alone, but is not generally available. If there is any need to confirm the presence of fibroids in a patient with heavy periods, the procedure of choice is hysteroscopy, either under general anaesthetic or in the outpatient setting. In this case, the submucous fibroid was confirmed by hysteroscopy and then resected hysteroscopically. The removal of submucous fibroids in a woman with menorrhagia has been shown to improve the symptoms with minimal recurrence if the myomas are completely removed. This may require more than one procedure, particularly if the fibroids are mainly intramural. Fertility is preserved in these cases, although the conception rates do not seem to be greatly improved if fertility is already a problem. Fibroids are resected hysteroscopically, usually after endometrial preparation with Danazol or gonadotrophin-releasing hormone analogues, but some of the second-generation ablatim techniques are being investigated as possible treatments, e.g. microwave endometrial ablation. Embolization of symptomatic fibroids is an alternative to surgical removal. This has been carried out for the last 10 years or so, and seems to be successful at reducing uterine fibroid size and symptoms. However, longer-term follow-up is required to assess the safety of future pregnancies. There have been some serious complications described after embolization including infection, bowel obstruction and loss of ovarian function.
219
Conclusion There is now a wide range of options for the treatment of menorrhagia, with less invasive surgical techniques as an alternative to hysterectomy. It is important to treat each case as an individual, and the decision-making process has to take the wishes of the patient into account. Some patients will choose to have hysterectomy for the treatment of dysfunctional uterine bleeding because their most important outcome is complete amenorrhoea, whereas it will be important to other women to avoid a prolonged stay in hospital and recovery time. There is a lot of work being carried out to develop new, simple, preferably ‘office’ procedures but it is necessary to realize that there will never be a ‘one size fits all’ method. When counselling a patient, it is necessary to fully explain the pros and cons of each procedure and allow her to make the right decision for her. Due to the importance of choice and the resultant quality-of-life issues, it can often be difficult to compare different treatments in a well-designed, preferably randomized study, but more studies of this type are needed to continue to evaluate new techniques.
Further reading Clarke A, Black N, Rowe P, Mott S, Howle K. Indications for and outcome of total abdominal hysterectomy for benign disease: a prospective cohort study. Br J Obstet Gynaecol 1995;102: 611–20. Cooper K, Jack S, Parkin D, Grant A. Five-year follow up of women randomised to medical management or transcervical resection of the endometrium for heavy menstrual loss: clinical and quality of life outcomes. Br J Obstet Gynaecol 2001;108:1222–8. Dwyer N, Hutton J, Stirrat M. Randomised controlled trial comparing endometrial resection with abdominal hysterectomy for the surgical treatment of menorrhagia. Br J Obstet Gynaecol 1993;100:237–43. Nagele F, Rubinger T, Magos A. Why do women choose endometrial ablation rather than hysterectomy? Fertil Steril 1998;69:1063–6. Oehler MK, Rees MCP. Menorraghia: an update. Acta Obstet Gynecol Scand 2003;82:405–22. Pellicano M, Guida M, Acunzo G, Cirillo D, Bifulco G, Nappi C. Hysteroscopic transcervical endometrial resection versus thermal destruction for menorrhagia: a prospective randomised trial on satisfaction rate. Am J Obstet Gynaecol 2002;187:545–50. Stewart A, Cummins C, Gold L, Jordan R, Phillips W. The effectiveness of the levenorgestrel-releasing intra-uterine system in menorrhagia: a systematic review. Br J Obstet Gynaecol 2001;108:74–86.