Earlier, hysterectomy seemed to be the solution to dysfunctional uterine bleeding in pre-menopausal women, who had completed their families. Now, things are a changing with a new method called thermal ablation with a uterine balloon.
Menorrohagia, or excessive menstrual bleeding, is defined as more than 8o cc of blood loss during a menstrual cycle. Because actual blood loss is not usually measured, physicians typically identify a patient with menorrhagia as one who bleeds for more than seven days, or a women who routinely uses more than 10 pads a day during her period. Menorrhagia affects approximately 22% of healthy women. In the United States, approximately 7.6 million pre-menopausal women aged between 30 and 55 perceive their menstrual bleeding to be excessive. Excessive menstrual bleeding does not discriminate by age. It may begin as early as a women's first menstrual Cycle. It can be chronic condition. While drug therapy is the first line of treatment, most women resort to surgery if drugs fail to control the bleeding.
There are two general types of excessive menstrual bleeding: structural and dysfunctional. The structural causes of excessive menstrual bleeding are physical abnormalities, which can be seen, in diagnostic tests.
These abnormalities include fibroids, polyps, or other anatomical or systemic disorders (e.g. Hepatic or renal disease, thyroid dysfunction).
Dysfunctional bleeding, the focus of this article, is primarily caused by a hormone imbalance. The uterus has no observable abnormalities. Dysfunctional bleeding is the diagnosis in approximately 75%of patients with abnormal menstrual bleeding. Dysfunctional bleeding is most commonly seen in patients at the extremes of their reproductive life. Women over 45 years old account to 50% of patients with dysfunctional uterine bleeding.
In treating menorrhagia, success is usually defined as a reduction in menstrual flow to normal bleeding levels or less. Treatment options include drug therapy, dilatation and curettage (D&C), hysterectomy, or the destruction of the endometrial lining using a laser or electrosurgical probe.
Recently, Gynecare received US approval to market a new device to treat this condition. This new system uses a uterine balloon to thermally ablate the endometrium. It can be performed under local or general anaesthesia in the physician's office or in the OR.
Drug Therapy
The typical treatment regimen for women with menorrahagia begins with drug therapy, which may reduce, but not eliminate, menstrual bleeding. This treatment does not compromise a woman's ability to become pregnant once therapy is discontinued. Drug therapy is the first line of treatment prescribed by approximately three-quarters of physicians.
Selection of the appropriate therapy for each individual, and appropriate timing for the therapy remains a challenge. Current medical therapy consists of hormones (progestins or any of the currently available combination oral contraceptives) or prostaglandin synthestase inhibitors (nonsteroidal anti-inflammatory drugs such as mefenamic acid, ibuprofen and naproxen).
Oral contraceptives and non-steroidal anti-inflammatory medications are often used in women who want to retain fertility. The effectiveness of this therapy depends on the continued use of the drug. These medications may need to be taken until menopause symptoms may return if treatment is topped. In addition, women may experience side effects typically associated with oral contraceptive drugs, (eg. headaches) or nonsteroidal anti-inflammatory drugs (eg. gastrointestinal reactions).
· Oral contraceptives work by suppressing pituitary gonadotropin release, which inhibits ovulation and results in a more stable endometrial lining. As a result, menstrual blood loss decreases.
· Nonsteroidal anti-inflammatory drugs have been shown to be effective in reducing blood loss, particularly when used concomitantly with oral contraceptive therapy.
· Antifibrinolytic agents (e.g. Aminocaproic acid) have also been shown to reduce blood loss in patients with menorrhagia. However their use is associated with frequent side of nausea, dizziness, diarrhoea, headache, abdominal pain and allergic manifestations. While these drugs are widely used in Scandinavia, their use in the United States is limited due to these side effects.
Dilatation and Currettage
If drug therapy is unsuccessful, dilatation and currettage is usually recommended. In this procedure, the cervical canal of the uterus is expanded (dilatation) to allow the surgeon to scrape the surface lining of the uterine wall (curettage). D&C is used both for diagnostic and therapeutic purposes. While this therapy has been used for many years , its efficacy in reducing menstrual flow is generally limited to the first few menstrual cycles after the procedure. Frequently a women under treatment for excessive menstrual bleeding will have multiple Ds&Cs.
Hysterectomy
Approximately 1.8 million hysterectomies are performed each year throught the world. It is the second most frequently performed female surgical procedure in the United states, surpassed only by ceasarean section. In the United states, approximately 600,000 hysterectomies are performed each year, more than 30% of which are for excessive menstrual bleeding. Annual hospital costs for this procedure are estimated to exceed $5 billion.
Hysterectomy is considered to be an appropriate treatment for women who experience menorrhagia, who have not been successfully treated with drug therapy and who have completed their families. However, hysterectomy is associated with a range of no-potential surgical and psychological risks and typically requires a four-day hospital stay and a three to six week recovery period.
Endometrial ablation with laser or electrosurgical probe
In the past decade, endometrial ablation has emerged as an effective treatment for excessive menstrual bleeding. With this procedure, the lining of the uterus is examined with a hysteroscope and then destroyed with laser or electrosurgical techniques.
The cost associated with endometrial ablation is lower than those of hysterectomy. Patients are not hospitalised, and recovery time is short - approximately three to five days. A relatively small numbers endometrial (20,000) are performed in the United States because of the surgical skill required.
This procedure is performed in the OR with a physician trained in endometrial ablation and a scrub person. The patient is given a light, general anaesthesia. Patients who cannot tolerate general anaesthesia are sedated and a local anaesthetic is administered.
A neodymium: YAG laser or high-powered electrical "rollerball" is used to burn off the endometrial glands a 2mm to 3mm of myometrium. Patients usually receive antiestrogenic or antigonadotophic drugs to shrink the uterus. While either laser rollerball electro coagulation may be used, most procedures are performed using the rollerball because it is more available, and considered safer and easier to use.
The most serious risk of endometrial ablation is fluid overload from the fluid that is used to distend the uterus. Other risks include hyponatremia, perforation of the uterus or adjacent organs, uterine rupture, infection or haemorrhage. Overall, endometrial ablation has a morbidity rate of 3%.
Because this procedure destroys the endometrial lining that must be intact to bring normal pregnancy to term, it generally renders the patients sterile. Endometrial ablation laser or electrosurgical probe takes between 15 and 30 minutes. Patients are discharged two or three hours after the procedure. Following endometrial ablation, patients should be counselled to avoid exercise, heavy lifting and sexual intercourse for one week. As the uterus heals in the first six weeks after the procedure, the patient notices a blood-tinged or yellow discharge. The patient should be reassured that this discharge is normal.
Endometrial ablation using a thermal balloon
Gynecare has received US approval to market a new device for the treatment of excessive menstrual bleeding. Thermal ablation uses heat to remove the lining of the uterus.
The system consists of two components - a balloon catheter containing heating and sensing elements, and a controller connected to the catheter that monitors and controls pressure, time and temperature during treatment. After local anaesthesia is administered, a balloon catheter is inserted vaginally, through the cervix and into the uterus. A heating element inside the balloon raises the temperature to approximately 87 degrees Celsius, which is maintained for eight minutes.
The controller continuously monitors and displays catheter pressure, and regulates temperature and time throughout the procedure. After the treatment cycle has been completed, the balloon is deflated and balloon catheter is withdrawn and discarded. Thermal ablation of the uterine lining results from the contact of the endometrium with the heated balloon.
The procedure is performed under either local or general anaesthesia depending on the patient's preference. The system was designed as an outpatient procedure using local anaesthesia and intravenous sedation. The procedure is easy to perform: some surgeons equate it to inserting an intrauterine device (IUD).
Some women, when treated under local anaesthesia, may experience a pressure or cramping sensation similar to that experienced during their menstrual cycles. This mild or moderate cramping can be managed effectively with a nonsteroidal anti-inflammatory drug (NSAID) suppository administered 45 minutes prior to the procedure. Most patients do not feel a strong sensation of heat during the procedure.
Patients rest under supervision in an outpatient recovery area for two to four hours following the procedure. Rest at home is recommended for the remainder of the day. They may experience mild to moderate cramping during the first day, which can be alleviated with anti-inflammatory pain relievers. After resting at home, most patients can resume normal activities the next day.
Patients should be counselled that they might experience vaginal discharge or spotting, which normally changes to a watery discharge, that can last between 10 and 30 days. This discharge is normal.
As with laser or rollerball electro coagulation ablation, this procedure is intended for use by women who have already completed their families. As there is a chance that pregnancy may still occur after endometrial ablation, contraception must be provided for as long as the patient is childbearing age.
This procedure is available at some of the government & private hospitals in the
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