Boulcott Hospital is located on
High Street, Lower Hutt - next to Hutt Hospital.
You can find a map here.
Heavy menstrual bleeding affects 1:5 women and leads to 21% of gynaecological referral. It is an important cause of morbidity. It is estimated that 1:5 women will have a hysterectomy by the age of 55, mostly for menstrual related illness.
Historically, medical treatments such as combined oral contraceptives, norethisterone, tranxenemic acid and mefenamic acid have been offered to women with varying degrees of success. It is limited by side effects and the need for regular and possibly long term treatment. It may not meet the woman’s expectations and can lead to poor compliance and treatment failure.
Other modalities of treatment for heavy menstrual bleeding which are becoming more popular include:
- Levonorgestrel-releasing intrauterine system
- Endometrial ablation /resection
- Hysterectomy (vaginal, abdominal, laparoscopic or laparoscopic-assisted)
- Myomectomy or uterine artery embolisation (where large fibroids are present)
I will discuss minimal access techniques, which I offer my patients.
The levonorgestrel-releasing intrauterine device (LNG-IUS) (Mirena) releases 20mcg of levonorgestrel in 24 hrs and is effective for 5 years. It results in 80-90% reduction in menstrual flow rate with amenorrhoea rate of 20-30%.
LNG-IUS also offers the benefit of ease of application, lack of anaesthesia, a contraceptive and is fertility-preserving.
It also treats painful periods and provides endometrial protection for patients with high risk of endometrial cancer.
The principle behind this technique is to cause traumatic destruction of the endometrium to induce amenorrhoea or lighter periods.
The first generation techniques which involved destruction with resectoscope, diathermy or laser are associated with higher complication rates which can potentially be fatal and have got steep learning curves, and have largely been taken over by second generation techniques which are much safer with minimal complications and good patient satisfaction.
I offer my patients Thermachoice endometrial ablation – a second generation techniquue which uses a small, soft flexible balloon attached to a catheter. The balloon is placed in the uterine cavity and filled up with dextrose saline. The balloon is made of silicone and can fit in cavities with different shapes and contours, therefore enabling uniform pereation of thermal energy to the whole uterine cavity. The dextrose saline is then heated to 87 degree Celsius and circulated for eight minutes. This destroys the endometrium to the depth of 4-5mm which is then sloughed off like a period.
The procedure offers best results if the uterus is normal size and for women with greater age, but can be used for uteruses up to 12cm. Pregnancy is contraindicated after this procedure, therefore the patient should have completed her family.
Thermachoice is associated with postoperative nausea and uterine cramps probably related to uterine distension and prostaglandin release. Therefore patients require analgesia, antiemetic and possibly overnight stay.
Success rate ranges from 85-91% with 30% amenorrhoea. It also treats dysmenorrhoea in a significant number of cases, and may also relieve symptoms of pre-menstrual syndrome.
Hysterectomy is a gold standard treatment for menstrual problems. It leads to amenorrhoea in almost 100% of cases, and results in the highest quality-of-life indices of all the treatments available.
The impetus for taking laparoscopic approach is to reduce the morbidity of abdominal hysterectomy. I use bipolar energy source (Gyrus ACMI) to coagulate and dissect all pedicles laparoscopically. The uterus is then dissected off the vault and delivered into the vagina to maintain pneumoperitoneum and the vault is sutured laparoscopically.
The patient is in hospital overnight or for two nights and requires much less analgesia. There are four very small skin incisions – two x 1cm and two x 0.5cm; subumbilical and in iliac fossas and therefore is more aesthetic.
Other advantages of this approach is lesser risk of wound and other infections, lesser blood loss, quicker return to work as compared to abdominal hysterectomy, but comparable to vaginal approach.
The complication rates are similar to abdominal approach if unintended conversion to laparotomy is not included; which is rather a surgical judgement.
Embolisation of uterine artery is still under evaluation. It involves injecting polyvinyl particles under fuoroscopic guidance to block blood supply to the fibroids. Studies have shown 85% improvement in fibroid related symptoms ie. mnorrhagia. The mean fibroid volume was found to decrease by 30-60% in trials. UAE is associated with higher postoperative complications such as vaginal discharge, post-puncture haematoma, post-embolisation syndrome (pain, fever, nausea and vomiting) and readmission rates when compared with hysterectomy. There are also reports suggesting possible premature ovarian failure following the procedure.
UAE is not currently recommended for women who wish to conserve fertility because of inadequate safety data.