Chronic menorrhagia: The surgical options

With excessive menstrual bleeding prompting about 2.7 million visits to United States physicians each year, it should come as no surprise that American women are looking for treatment options.¹ Among the nonsurgical options we discussed in Part 1 of this series (November 2005) were nonsteroidal anti-inflammatory agents, oral contraceptives and progestins, danazol, the antifibrinolytic agent tranexamic acid, the levonorgestrel-releasing intrauterine system, and gonadotropin-releasing hormone (GnRH) agonists.

But when medical therapy fails or is not acceptable to the patient, many surgical options exist. Dilation and curretage is commonly performed, but usually offers only temporary relief. It is best used as an acute treatment for severe bleeding or as a diagnostic procedure evaluating possible neoplasm. Let's review some of the other approaches.

Endometrial ablation

Endometrial ablation has several advantages. It is typically an outpatient procedure, has low morbidity, and is less invasive than hysterectomy. Disadvantages include the possible need for repeat ablation or hysterectomy. One study has found that up to 40% of patients undergoing electrocautery, laser, or radio-frequency ablation required a second ablation or hysterectomy within 4 years.² A meta-analysis has concluded that subsequent operative rates or need for a second procedure are not significantly different between standard and second-generation techniques including balloon, VESTA, microwave, and a hydrothermoablator.³

[Unfortunately, long-term outcome studies on some of the newest ablative procedures are not yet available. Major complications of these procedures are uncommon but can include uterine perforation, endometritis, hematometra, thermal injuries to surrounding structures, and bowel injury.⁴ ] When compared with the levonorgestrel IUS, endometrial ablation was found to be more effective in controlling menstrual blood loss at 1 year, but was equivalent at 2 and 3 years. Satisfaction rates and quality of life were equivalent at 1, 2, and 3 years with both treatments.⁵

The use of GnRH agonists to thin the endometrial lining prior to hysteroscopic resection or ablation has been associated with shorter operative time, easier surgery, and a higher rate of postoperative amenorrhea at 12 months, and reduced postop dysmenorrhea, when compared to no treatment. GnRH agonists appear to produce slightly more consistent results than danazol.⁶ Progestins have also been used preoperatively to decrease endometrial thickness, but are less well studied.

Standard ablative procedures

Advantages of standard ablative procedures like laser, rollerball desiccation, or endomyoresection include direct visualization, which permits immediate detection of structural anomalies, uterine perforation, and bleeding. These procedures can also be performed in about 10 minutes by an experienced operator.

Disadvantages of standard ablative procedures include the need to perform the procedure in an operating room under general anesthesia because of the discomfort of electroablation and cervical dilatation, which is needed to accommodate a large operative hysteroscope. In addition, these procedures require considerable operator skill and strict monitoring of the intake and output of distension fluid to avoid complications related to volume overload and hyponatremia.