Photo by Brenda Washington www.bjw-photo.com

    Introduction
    Vocabulary of Menstrual Disorders
    Causes of Menstrual Disorders
        Hormonal
        Clotting Disorders
        Anatomic
        Medication and Supplements
        The "APPARENTLY" Normal Uterus
        Miscellaneous causes
    Your First Visit and "Testing"
    Treatments
        Observation
        Medication and IUDs
        Minimally Invasive Surgery
            Endometrial Ablation
            Endomyometrial Resection (EMR)
            Myomectomy and Polypectomy
            Uterine Artery Embolization
        Hysterectomy
    What you need to know about Fibroids
    What happens when treatment fails?
    Choosing a physician and a treatment

INTRODUCTION

Some women sail through their monthly periods with few symptoms--their periods are like clockwork, beginning and ending at nearly the same time of the month. Other women, experience a host of physical and emotional symptoms that include heavy bleeding, incapacitating cramps, sleep disturbance, exhaustion and worry that they'll bleed at an inopportune time.

Most menstrual cycle disorders are benign, but many of them can be overwhelming and should be evaluated. There are many treatment options today that were unavailable in your mother's generation. The first and most important step is to discuss your symptoms with your health care professional so he or she can accurately diagnose your condition and help you choose the best way to help.

We will want to know specific information about your cycle length (normally 25 – 31 days), the number of days you experience bleeding and how many of them you consider "heavy." If you experience more than 3 days of heavy bleeding per month you should consider some help. We will also want to know whether you experience spotting between periods or after intercourse, whether or not you have excessive clotting or cramping. One very important question I always ask is whether or not you need to change pads or tampons in the middle of the night (nocturrhagia). When menstrual disorders lead to sleep disturbance they are often associated with fatigue and irritability.

While it's appropriate to be concerned about any change in your periods it is worthwhile remembering that while menstrual disorders are very common cancer is not. In the vast majority of cases menstrual disorders are inconvenient but they aren't life-threatening.

Menstrual disorders frequently occur at both ends of the reproductive spectrum—women under the age of 15 and over the age of 40. Women in these two groups often experience irregular cycles, spotting between periods, lighter-than-normal or heavier-than-normal periods. Many women, however, simply suffer from periods that are heavy and require frequent pad or tampon changes. Oftentimes, heavy periods are associated with cramps that vary from mild to severe.

THE VOCABULARY OF MENSTRUAL DISORDERS

Listed below are the common types of menstrual disorders you may find in books, articles and on web-sites.

Menorrhagia (heavy menstruation)--With this disorder, the cycle interval (generally 27-32 days) is consistent from cycle to cycle. Women experiencing menorrhagia often complain of frequent pad changes (more than every two hours), nocturrhagia (see below), passage of large clots, or severe cramps. Menorrhagia is the single most common menstrual disorder that we evaluate and treat. It is often associated with hypermenorrhea.

Hypermenorrhea—menstruation that lasts longer than 7 days

Nocturrhagia—menstruation that interferes with a woman's sleep pattern by forcing her to change pads or tampons in the middle of the night.

Polymenorrhea—a disorder in which cycles are shorter than 25 days. This pattern is often associated with infertility or recurrent miscarriages.

Oligomenorrhea—a change in menstrual flow characterized by light periods or spotting. This often occurs in older women as a precursor to menopause and younger women who may experience infertility.

Metorrhagia—spotting between periods. Women with this disorder generally have regular cycles with a predictable number of days of bleeding. However, they may experience spotting during any portion of the cycle. This tends to be a more common problem of women in their late thirties and forties.

Dysfunctional uterine bleeding, irregular menses—loss of cycle regularity (no 'rhyme or reason'). Women with irregular menses notice that their cycles are no longer regular. They cannot predict when their menses start or stop. The actual number of days of bleeding may vary from cycle to cycle. Some cycles may be heavy or 'hemorrhagic,' while there are occasional 'skipped' periods.

Amenorrhea—cessation of menses, altogether.

Dysmenorrhea—excessive menstrual cramps. With dysmenorrhea, periods may be extremely painful, causing the woman to miss days of work or be confined to bed. Most women experience some cramps just prior to and during menstruation. Generally, these cramps are relieved with a heating pad or over-the-counter anti-inflammatory agents. Women with dysmenorrhea often experience many restrictions to their lifestyle around their menstrual flow.

Premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD). These syndromes are characterized by fatigue, bloating, back pain, cramping, breast tenderness, headaches, mood changes, or a worsening of underlying depression. Some women experience uncontrollable anger, rage, or inability to deal with normal life stressors.

CAUSES OF MENSTRUAL DISORDERS

Menstrual flow is the result of the complex interplay of many factors that arise from the central nervous system, the pituitary gland, the ovary, the uterine muscle, and its lining. Regulation of menstrual flow is also dependent on a normally functioning clotting system. The specific evaluation of a problem for a particular woman will often depend on the duration of the problem, the age of the woman, her specific medical history, her physical exam, and her ultrasound examination. Occasionally, the cause of a particular menstrual abnormality is complex and arises from abnormalities of pituitary, adrenal and ovarian function.

The causes of various menstrual disorders can be summarized as follows

A. HORMONAL CAUSES

Pituitary gland problems
Thyroid gland abnormalities
Adrenal gland abnormalities
Ovarian dysfunction

B. CLOTTING ABNORMALITIES

Clotting abnormalities may be responsible for 5% of cases of abnormally heavy menstrual bleeding. Women with clotting abnormalities generally have a history of easy bruisability or excess bleeding from relatively minor cuts and scrapes.

Platelet dysfunction abnormalities such as Thrombocytopenia
Clotting factor abnormalities such as Von Willebrand Disease

Von Willebrand Disease Thrombocytopenia

C. ANATOMIC PROBLEMS

About 25% of women with heavy menstrual periods have one of the anatomic reasons listed below. In our practice the most common anatomic reason for heavy menstrual bleeding is uterine fibroids, which account for the majority of "anatomic problems" that cause abnormally heavy menstrual bleeding. A summary of "anatomic problems" include.

Fibroids (these benign tumors originate from the uterine muscle)
Polyps (these originate from the uterine lining)
Adenomyosis (lining tissue of the uterus is found within the muscle of the uterus)
Decreased uterine contractile strength
Endometrial cancer
A uterus with a large surface area

            Example of uterus with fibroids                           Endometrial polyps


              Endometrial(uterine) cancer                                     Adenomyosis

There are several important things to remember about "anatomic problems" that cause abnormally heavy periods. First, cancer accounts for less than 1% of these. Although cancer is among the causes of abnormal uterine bleeding it is rare in women under the age of 50 and, if caught early, is a very curable disease. Second, once your health care provider has determined that you don't have cancer the treatment is generally one of choice rather than necessity.

Though this may be obvious to your physician or nurse practitioner it bears repeating that the majority of women in their 30s and 40s who have periods that are heavy because of anatomic reason do not have cancer. For most women it is at least comforting to know that however inconvenient or disabling their symptoms may be, it is the rare woman with heavy periods that has uterine cancer.

1) Fibroids: the most common benign tumor in women

The uterus contains two types of tissue. The inner lining, called the endometrium, is the tissue that sheds each month during menstruation. Most of the uterus, however, is composed of muscle tissue or myometrium. Both tissues are capable of producing benign "tumors." Overgrowth of the endometrium causes uterine polyps while overgrowth of the myometrium causes myomas—commonly called fibroids. The name is somewhat misleading as the tissue is not fibrous—it's simply muscle tissue that grows in the shape of a sphere.

Fibroids occur in almost 25% of all women in the United States and are responsible for over 200,000 hysterectomies annually. They can occur anywhere in the uterus and can vary in size from the size of a pea to a watermelon!

Most women with fibroids don't even know they have them. We find them frequently at the time of you annual visit during your ultrasound exam. Most fibroids occur in the body of the uterus. The one's that lie in the uterine cavity –submucosal fibroids--are often the most troublesome as they tend to produce heavy vaginal bleeding. In the drawing above you can see a submucosal ("Sub-mew-koh-sal") fibroid lies partly in the uterine cavity and partly in the muscle. The intramural ("in-trah-mew-ril") fibroid shown above does not distort the uterine cavity and probably doesn't produce any symptoms. The subserous (sub-sir-us") fibroid typically distorts the outside of the uterine cavity. In general subserous fibroids produce few symptoms unless they get quite large or are located near the bladder. Fibroids located near the bladder can make you feel like you're constantly running to the bathroom—urinary frequency.

What causes fibroids to grow?

The simple truth is that we're just beginning to understand some of the reasons that fibroids grow. For most women the answer you'll hear from your practitioner is "I don't know!" We do know that fibroids are sensitive to estrogen. For instance, fibroids grow during pregnancy—sometimes dramatically. We also know that fibroids tend to get much smaller after menopause. In general, fibroids grow slowly but occasionally one encounters a woman whose fibroids grow rapidly.

The factors associated with the growth of fibroids include obesity, never having given birth to a child, early onset of menstruation and being of African American heritage.

What symptoms can fibroids produce?

Many fibroids produce no symptoms at all. For instance, the two subserosal fibroids shown in the drawing above would probably produce no symptoms and would require no treatment.

However, some fibroids do cause symptoms that include:

Heavy menstrual bleeding—typically, fibroids that produce heavy menstrual bleeding are located near the surface of the uterine lining or within the uterine cavity.

Urinary frequency—fibroids can dramatically increase the size of the uterus. Remember that the front wall of the uterus sits right behind the bladder. Therefore any enlargement at this point can reduce the bladder capacity and make you feel as if you have to go the bathroom frequently.

Fullness in the lower abdomen—in truth many women complain of a feeling of bloatedness and "fullness" in the lower abdomen yet most of them do not have fibroids. But a significantly enlarged uterus can cause a sense of fullness or bloodedness in the lower abdomen.

Painful intercourse—again, depending on the location of the fibroid(s) intercourse may become painful, especially during deep penetration.

Infertility—fibroids, especially those located, inside the uterine cavity are associated with infertility.

Reproductive problems—fibroids are sensitive to estrogen and progesterone; hormones made in abundance during pregnancy. Pregnancy is a time when fibroids can grow rapidly. Some of the complications of fibroids in pregnancy involve miscarriage and premature labor.

Can fibroids turn into cancer?

The likelihood that a fibroid may become cancerous is between 1/1000 and 1/10,000. Rarely are fibroids ever removed because of a concern that they are cancerous.

How do I know if I have fibroids?

Large fibroids can be detected on physical examination. Smaller ones are generally seen on ultrasound exam, CT scans and MRIs. Ultrasound, however, is quite accurate and cost effective and so this test is the one most often used.

Fibroids can also be detected on laparoscopy and hysteroscopy.

What if I have fibroids? What does it mean for me?

In most cases it means nothing for you. The vast majority of fibroids that we detect don't produce any symptoms. They may be small and located in a portion of the uterus where they are not likely to produce any symptoms.

D. MEDICATIONS AND SUPPLEMENTS THAT CAUSE MENSTRUAL DISORDERS

There are a variety of medications that can cause menstrual disorders. These include:

Aspirin
Estrogens
Coumadin or Heparin
Vitamin E, Ginkgo biloba
Estrogens
Nonsteroidal anti-inflammatory drugs such as ibuprofen or naproxen

E. THE "APPARENTLY" NORMAL UTERUS

The vast majority of women we see with abnormal uterine bleeding have what appears to be a "normal looking" uterus—which is to say that there's no evidence of fibroids, polyps, hyperplasia or cancer. Additionally, these women turn out to have normal thyroid functions, normal clotting abilities and no evident "hormonal" problem. So why do these women bleed heavily?

This is a complex and compelling issue. Medical logic tells us that if there's a problem we need to find the cause in order to treat it. In theory that would be intellectually and scientifically rewarding but life and medicine are imperfect. It turns out that often the diagnostic procedure may be more uncomfortable than the problem or the treatment.
Let me provide two examples:

There are a substantial number of women who have a uterine abnormality called adenomyosis. Adenomyosis is a disease in which there are pockets of uterine-lining tissue (endometrium) buried within the muscular wall (myometrium) of the uterus.

These are normal glands in an abnormal place. Adenomyosis is a specific type of endometriosis. Unfortunately, it is difficult to diagnose without surgery. In fact, the diagnosis of adenomyosis is often made after hysterectomy. Today we have other methods to diagnose adenomyosis but they still involve at least some surgical biopsies. The point is that there are other ways to treat women with suspected adenomyosis and avoid biopsies altogether. Some of these methods are as simple as a low-dose oral contraceptive or a hormone containing intrauterine device (IUD). Therefore, in situations where the diagnosis is more invasive than the treatment it's wise to treat rather than biopsy—it's less invasive, risky and costly.

A second example is one that is rarely written about—the uterus that doesn't function normally. We know that after childbirth that some women bleed heavily and even hemorrhage because of the failure of their uterus to properly contract. Immediately following childbirth the uterus is often massaged in order to stimulate its contraction. In many cases medications are administered that have similar effects. Apparently, strong uterine contractions are necessary to limit blood loss after childbirth. One can also postulate that some women experience heavy periods as a result of their uterus' inability to adequate contract. In this example, the uterine may look normal (even microscopically) but doesn't function normally. There's no way to test for this problem yet it too can be treated with minimally invasive approaches. Some recently published work even suggests that the "aging" uterus may contain small arteries that lose their ability to contract and therefore control bleeding.

F. MISCELLANEOUS CAUSES OF ABNORMAL BLEEDING

There are other uncommon and even rare causes of abnormal uterine bleeding. Some of these include cervical cancer, uterine infections, severe liver or kidney disease, rare ovarian tumors, unsuspected pregnancy, miscarriage, acute emotional stress and obesity.

YOUR FIRST VISIT AND "TESTING"
FOR MENSTRUAL DISORDERS

A. YOUR HISTORY. As you prepare for your first visit it might help to understand what you might expect. One of the most important parts of your first visit is your menstrual history. Your history itself is one of the most important (and inexpensive) "tests" that can be performed by your health care provider. There are a number of things we'll want to know.

What is your cycle length? That's the interval between the first day of your period and the first day of your next period. It's usually 28 to 30 days. Don't get this confused with how many days your period lasts—normal is 3-7 days.

Are your periods regular in cycle length? Sometimes women have cycles that vary dramatically in length. One woman may experience a cycle length of 21 days and then might skip 2 or 3 months before the onset of the next one. If you skipped 2 periods your cycle length for that particular cycle would be 90 days—remember, you need to count from the first day of one period to the first day of the next.

Regular cycles are an indication of regular ovulation. Conversely if your cycle length varies quite a bit or is very prolonged that's a pretty good indication that you're not ovulating on a regular basis.

How long does your bleeding last?

Do you bleed between periods?

How many days, if any, do you consider "heavy" during each cycle?

During your "heavy days" do you wear tampons, pads or both?

How long can you go between pad and/or tampon changes?

Do you need to get up in the middle of the night to change pads or tampons?

Do you pass clots? How large are they? (dimes, nickels, quarters?)

Are your periods painful? How would you rate them on a 10 point scale? (10 being the worst pain you've ever experienced).

Do you bleed after intercourse?

Do you have to plan your life around your periods? Do you miss work because of them?

B. THE TRANSVAGINAL ULTRASOUND (TVUS)

The transvaginal ultrasound is quickly becoming the standard of all gynecologic exams. The standard pelvic examination performed 10 or 20 years ago as part of your annual exam is not very helpful in assessing a woman with abnormal uterine bleeding. A 'growth' no larger than a grape can cause very heavy menstrual bleeding yet is almost impossible to detect by a digital examination. The ultrasound exam offers several advantages, among which are that it is less uncomfortable and provides far greater information along with an image of your uterus and ovaries which can be printed and kept on file for future reference.

Normal uterus Uterus with fibroid in the center

Consider the ultrasound on the left of an anatomically normal uterus versus the one on the right that shows a small fibroid in the center of the uterine cavity. On bimanual ("pelvic") examination both of these uteri will feel virtually identical to the examiner. Yet the quarter-sized fibroid seen on the right is enough to wreak havoc on your periods! For about 3/4 of the women we see with menstrual abnormalities the medical history, menstrual history and the ultrasound examination provides us with enough information to develop a treatment plan.

If your ultrasound is completely normal—which is true 75% of the time—you may still require various blood tests or an endometrial biopsy (a biopsy of the uterine lining). If your ultrasound is abnormal you may require a test called a sonohysterogram or a diagnostic hysteroscopy. In general we try to keep testing to a minimum and we avoid testing that will not affect your treatment.

C. ENDOMETRIAL BIOPSY

Only a small percentage of the women we see require an endometrial biopsy. The reason is simple—much of the information we require can be obtained from your ultrasound. Endometrial biopsy is important in those cases in which there is a suspicion that the abnormal uterine bleeding you are experiencing is the result of a uterine cancer or one of its precursors called endometrial hyperplasia. In such instances a small biopsy instrument is passed through the

Biopsy instrument in the uterus What the pathologist sees under 100x magnification

vagina and cervix into the uterine cavity and a biopsy is taken. Does it hurt? The honest answer is yes—for most women it does (although for only a few seconds). Every woman is different, however, and we adjust our routines to fit your needs. For some women the procedure can be done under local anesthesia while for others we may ask you to take a sedative prior to the test. Many women request conscious sedation for this test—something we're trained, equipped and accredited for!

D. THE SONOHYSTEROGRAM (SHG)

A sonohysterogram is a simple ultrasound exam with one twist—a catheter is placed into the uterine cavity to fill it with water or saline. The procedure is quite painless, though some women require a mild sedative. The advantage of a sonohysterogram over a standard ultrasound is that the water infused into the uterus appears "black" on ultrasound and therefore outlines any polyps, fibroids or possible cancers. Only a small fraction of our patients require sonohysterograms for evaluating abnormal bleeding. It can however be a useful tool when trying to sort through an ultrasound that appears to show one or more abnormal growths.

Note that the picture on the left, which shows the uterus distended with water, translates into the picture on the right when viewed with an ultrasound machine.

The uterus on the left reveals a solitary polyp. The one on the right shows several "growths" – probably polyps. To distinguish polyps from fibroids removal and analysis may be required.

When one or more abnormalities are found within the uterus they are easily "highlighted" by the water. The sonohysterogram is excellent for determining if a polyp or fibroid is present though it may have difficulty distinguishing one from the other. For instance, the trained eye would know that the growth on the left is a uterine polyp. However, the 3 growths on the right may be a mixture of fibroids and polyps. The only way to know for sure would be to view them directly with a hysteroscope, remove then and let the lab decide.

E. DIAGNOSTIC HYSTEROSCOPY

Most women with menstrual disorders will not require a diagnostic hysteroscopy. However there are situations that you and your physician will discuss in which a diagnostic hysteroscopy can help you decide what treatment is best for you. Diagnostic hysteroscopies are carried out in our office under intravenous conscious sedation (unless you request otherwise). During a diagnostic hysteroscopy a lit telescope is passed into the uterus in order to look inside the uterine cavity. It's usually done when the ultrasound exam is abnormal and the physician needs further information that will help him or her decide how best to manage your particular issue.



         Example of Normal Uterus                                    Uterus with Large polyp


            Uterus divided by a septum                       Uterus with Fibroid
F. BLOOD TESTS

Frequently, some blood tests are necessary to help in the diagnosis of a particular menstrual disorder. These tests may range from certain hormonal measurements (thyroid hormone, adrenal hormones or pituitary hormones) to tests that measure your ability to clot (platelet count and bleeding time). The kinds of blood tests that you might require will depend on your menstrual history and your initial ultrasound exam.

TREATMENT OF MENSTRUAL DISORDERS

A. OBSERVATION

In many instances women chose not to treat a menstrual disorder. For instance, the woman who has gone without a period for 6 months and suddenly has a bout of heavy bleeding lasting 3 days needs to be evaluated. However, once it's been established that the cause is benign it is reasonable to simply observe her to see if this recurs. In another situation a woman might be satisfied to know that the cause of her heavy vaginal bleeding is because of several small uterine fibroids. Now that the cause is known—and is benign—she may simply choose to see if it gets worse noting that she can tolerate it at this point in time.
Observation is always an option when it comes to treating a menstrual disorder except in the rare instance of a cancer or life-threatening hemorrhage.

B. MEDICATIONS AND IUDS

There's a very long list of medications that can be used to manage abnormal uterine bleeding. The kinds of medication depend on what might be causing the disorder in the first place. For instance, if the cause is hypothyroidism the goal is to treat the thyroid problem with replacement hormone. Menstrual irregularity, the kind that accompanies an ovulation disorder, can be treated with oral contraceptives. Heavy periods are often managed with oral contraceptives (combinations of estrogen and progestins) or simple progestins. Since 2001 we've treated many women with heavy periods with the Mirena IUD. The Mirena IUD "secretes" a small amount of a progestin called levonorgestrel every day. It is very effective in reducing menstrual flow and has the advantage of being easy to insert in an office setting.


                                                Example of the Mirena IUD

C. MINIMALLY INVASIVE SURGERY

When I first started practice in 1980 there were few treatments for most menstrual disorders. Today we have a whole spectrum of treatments, the newest variety of which can often be performed in a doctor's office.

Back in 1980 medications were limited in their usefulness. Low dose oral contraceptives, while available, were rarely used to control abnormal menses—in part because they weren't what we consider "low dose" today. From the standpoint of "medication management" we relied mostly on a hormone called Provera, a progestin, which few women found acceptable because of its side-effects--weight gain and bloatedness.

Surgically, there were few options, as well. The D and C—widely used for many years--was a poor diagnostic tool for abnormal uterine bleeding and certainly didn't offer relief from heavy periods beyond a month or two. The only other surgical option was hysterectomy--a very successful "cure" but one that requires major surgery, a length recovery and carries significant risks.

So let's summarize. Back in the early 1980s a woman's options were few and consisted of oral progestins, the D and C, and hysterectomy. You can see why many women chose a fourth option—just to live with it until the onset of their natural menopause

1) ENDOMETRIAL ABLATION

Stop and think about it for a minute. In most women who have abnormal uterine bleeding the only thing that's "malfunctioning" or "abnormal" is their uterine lining (the endometrium). The lining is about 5% of the uterus by weight. So until the late 1980s if the lining didn't function properly the cure was to remove the entire uterus—a little like cutting off a finger to cure a hangnail. Although the technology prior to this time left no good alternative, the development of minimally invasive surgery in gynecology allowed for removal of only the uterine lining. The lining can be removed by two types of techniques: ablation and resection. In this first section we'll talk primarily about ablation. In endometrial ablation the lining destroyed by either heating it up or freezing it so that the uterine lining doesn't grow back and cause continued problems. If all goes well, the lining is replaced by scar tissue. Endometrial ablation is appealing because:

The surgery can be performed through the cervix—no incisions are necessary.
The surgery, unlike hysterectomy, doesn't come close to vital structures such as the bowel, bladder or major blood vessels and therefore reduces the possibilities of injuring other organs.
Because the surgery requires no incision it can be performed in an outpatient department or even in an office.
Recovery is a matter of 1-2 days as opposed to 4-8 weeks.
There are far fewer complications with endometrial ablation than with hysterectomy.

History of Endometrial Ablation

In 1987 the FDA approved a certain kind of laser called the Nd:YAG (or simply the "YAG Laser"). This color-sensitive laser has the ability to thermally destroy (or cauterize) the inside of the uterus called the endometrium—the lining portion. This was the first type of endometrial ablation. The laser was introduced through a hysteroscope, which is a special "lit-telescope" to visualize the inside of the uterus.

Although the laser was a remarkable surgical innovation it never gained wide acceptance because of its prohibitive cost. Two years after the FDA approved the YAG laser a new instrument called the "rollerball" resectoscope was approved by the FDA and allowed the physician yet an easier and inexpensive method to "cauterize" the uterine lining. This extraordinary breakthrough could prevent hysterectomies in 80-90% of women who underwent the procedure. About 45% of women who underwent this form of endometrial ablation stopped having periods altogether, while most of the remainder had light and acceptable periods. Since the rollerball required a telescope (hysteroscope) to accomplish its work this technique became known as hysteroscopic endometrial ablation. Over the next 20 years various other methods of endometrial ablation were developed that were simpler to perform. Most of these techniques no longer required a hysteroscope, or telescope, to guide the surgery. Instead the techniques became automated so that almost any physician with minimal training could perform them. So, at this time we have 2 types of endometrial ablation: one that's performed while the physician looks through the uterus and adjusts the procedure to the contour of the uterus (hysteroscopic endometrial ablation) and a second group of procedures called "global" endometrial ablation in which a direct view of the uterus isn't necessary. The global procedures are "one size fits all procedures" and for that reason, in my opinion, they don't work as well. I will present some information to support this opinion in the paragraphs below.

Hysteroscopic* Endometrial ablation is a minimally invasive procedure in which the uterine lining is destroyed—usually by heating it up. Amy Daggett and I performed the very first successful hysteroscopic endometrial ablations at Highland Hospital in 1988 using the "YAG" laser. A year later, in 1989 the FDA approved an instrument depicted below called the Gyn "rollerball resectoscope". This instrument was an improvement over the laser though more than half the women treated with the resectoscope continued having periods—though most had significant improvement.

"Rollerball Resectoscope" introduced 1989

*Hysteroscopic means that the procedure is carried out with a lit telescope attached to a video-camera. The lit telescope is a hysteroscope and allows the surgeon to look at the progress of the procedure.

In 1993 Amy Daggett and I published the largest series of "rollerball" endometrial ablation in the United States.

Global endometrial ablation: what are the different kinds of global endometrial ablation and how do they compare?

Simply stated, endometrial ablation is a technique used for women with menstrual abnormalities in which the uterine lining is thermally damaged. The surgeon either heats it (with a laser, or electricity, or hot liquid) or cools it with a very cold "probe." With endometrial ablation tissue is not removed it's just destroyed.

We've already talked about one kind of endometrial ablation—hysteroscopic endometrial ablation (also called "rollerball endometrial ablation). As we've noted above, with this technique a lit telescope is introduced into the uterine cavity that uses a special electrode called a "rollerball" to cauterize (with electricity) the inner lining of the uterus. However, there are various methods call "Global" methods. These are automated "one size fits all procedures" that require little or no operative skill. The advantage of these methods is that they are designed to avoid complications. The disadvantage of these methods is that they don't work well in situations where treatment needs to be individualized to the patient. Most of these methods cannot be used in women with fibroids and polyps or women with larger than "average" uteri. There are other limitations on these methods that are well beyond the scope of this text. In this article we'll review 5 of these "global" methods.

1) NovaSure endometrial ablation

With this method of endometrial ablation a device (shown above) is inserted into the uterine cavity. Using electrical current the inside of the uterus is cauterized by an array of electrodes that distribute current uniformly through the device and, supposedly, to the uterus. Although the method is quite effective it has several disadvantages. It's a "one size fits all" device. That is to the say that if you have a larger than average or smaller than average uterus it can't be effectively used. Additionally, if there are polyps or fibroids within your uterus this device won't address that problem. Also, since the device leaves no tissue specimen you will likely require an endometrial biopsy prior to the procedure.

The NovaSure endometrial ablation is an office-based procedure. It is not painless and therefore you and your physician should discuss where you'll be having this procedure (hospital or office) and what will be available for pain control. In the drawing below you can see the device as it is inserted into the uterus. In the next drawing it is "unfurled" so that it matches the contour of your uterus. In the third drawing the electricity is turned on and the device causes the tissue to become cauterized. Finally, in the last drawing you can see what the uterine lining looks like after the device is removed. The white area is the area of necrosis (tissue death and destruction)

This area of destruction becomes replaced with scar tissue and in many cases the uterine lining is completely destroyed. In most cases it's partially destroyed and women will generally have light periods as a result.

2) Hydrothermal ablation (HTA)

With this technique a hysteroscope is inserted into the uterine cavity but it is not used to operate inside the cavity. Instead a computer controlled pump allows water into the uterus at relatively low pressure. The water is heated to 194° Fahrenheit (90° C) and allowed to circulate through the uterus for 10 minutes. After 10 minutes the water is drained out of the uterus and the hysteroscope is removed. One of the disadvantages of this procedure is that the uterine lining needs to be "pretreated" with a medication that causes it to shrink. Sometimes an oral contraceptive can be used. At other times a medication called Lupron is used for this purpose. The depth of the "ablation" is between 2-4 mm though this varies from one woman to the next and is not controllable. The procedure is associated with a considerable degree of pain and is best performed in a hospital or outpatient department with I.V. sedation or light anesthesia. Good results from abnormal uterine bleeding are reported and complications are infrequent.

3) The Thermal Balloon--Thermachoice Ablation (TCA)

The Thermal Balloon (Thermachoice) was the first of the so-called Global Endometrial Ablation techniques. This technique depends on inserting a balloon (see right) into the uterus and heating it with hot water until the endometrium (uterine) lining is cooked. This is a very good method of endometrial ablation with several obvious drawbacks. First, it's a "one size fits all" procedure. The balloons come in one size—the uterus doesn't. It doesn't work well for large uteri. Second, it won't work well if a uterus has an odd shape (heart shaped uteri are very common), fibroids or polyps. Also, since no tissue specimen is provided you'll need some form of biopsy prior to the procedure. The results of the Thermachoice ablation system will be summarized in the chart below.

4) Her Option (cryo-endometrial ablation)

This is the fourth method currently in widespread use in the United States. It differs from the other methods insofar as the uterine lining is frozen instead of heated up. The procedure is safe, but again associated with a moderate amount of pain as a very cold probe is inserted into the uterine cavity in order to free it and cause thermal injury. The disadvantages are the same as with other "global methods." It doesn't work well if there are fibroids or polyps present and you'll still need an endometrial biopsy prior to the procedure.

5) Microwave Endometrial Ablation (MEA)

The MEA System is a surgical device that uses microwave energy to heat and destroy the uterine lining. A long slender tube that delivers microwave energy is inserted into the uterus. Treatment typically lasts 3 ½ minutes and is associated with some moderate pain.

During the procedure an applicator is inserted through the vagina into the uterus. A computer is used to deliver microwave energy which causes a rise in temperature where the tip of the applicator meets the tissue. The surgeon moves the applicator in a sweeping motion, blindly, from side to side across the tissue while slowly pulling the applicator out of the uterus. This "painting" of the inside of the uterus with the applicator destroys the endometrium.

    Method

Nova Sure      Number

175    Amenorrhea
rate at one year

40.9% Hysterectomy Rates

No Data published

HTA 187 66% 9%

Thermachoice 188 46.9% 13.8%

Her Option 193 27.6% No data published

Microwave EA 123 10% 21.1%

Hysteroscopic
Endometrial
Ablation 301 44%at 2 years 12.6%

2) ENDOMYOMETRIAL RESECTION (EMR) WITH ULTASOUND GUIDANCE

In 1991 Amy Daggett and I invented and published a technique called hysteroscopic endomyometrial resection (EMR); which is also performed with a resectoscope. EMR has several advantages which will be discussed below. The most important advantage of endomyometrial resection (EMR) is that it provides a tissue specimen for the pathologist to examine. The second advantage is that since it doesn't depend on thermally damaging the tissue (which causes an unpredictable depth of destruction). Instead EMR can be tailored to remove 4-5 mm or more of the lining tissue together with its underlying muscle. The result is greater predictability of the outcome and patient satisfaction; the vast majority of women undergoing EMR have no further periods; this is untrue of any of the other method available today. In 1993 we collaborated with Dr. Steven Goldstein of New York University and began performing EMR procedures under ultrasound guidance. The result is an exceptionally safe procedure that provides a complete specimen of the uterus for examination and produces the great success of any of the minimally invasive procedures.

In 2000, Amy Daggett and I published a paper in the Journal of Laparoendoscopic Surgery, Hysteroscopic Endomyometrial Resection: A review of 304 cases (Vol 4, No. 3: 197-207: 2000). In our study women were followed up to 6 years after their surgery. At one year of follow-up 83.3% of women had no further periods. This number increased to 88.9% at 6 years of follow-up. Most importantly, only 5.6% of women treated with EMR went on to have hysterectomies! In summary, the amenorrhea rates (the number of women without periods at the end of a year) was the highest of any published data in the world and the percentage of women who required hysterectomy was among the lowest published anywhere.

Endomyometrial resection can be combined with many other procedures. For instance we can manage small, medium and large polyps simultaneously along with a variety of fibroids including intracavitary and intramural ones. Since EMR produces a specimen that is sent to the pathology lab a separate biopsy is generally not required. In addition, EMR is the only method that can reliably diagnose adenomyosis without a hysterectomy.

In summary, EMR provides tissue for diagnosis, unsurpassed amenorrhea rates (the percentage of women that have no periods following the procedure) and is the least likely to fail. It is associated with the fewest women requiring a subsequent hysterectomy and is the only method that can be used if an ablation method fails!

    Example of uterus where part of             Example of how the uterus looks without
    lining has been stripped away                 its lining tissue (endometrium)

OFFICE-BASED ULTRASOUND-GUIDED
ENDOMYOMETRIAL RESECTION

Please note that as of July 14, 2009 all office-based surgery as defined by the Department of Health (DOH) requires that it be performed in an accredited facility. We are now awaiting final accreditation from the Accreditation Association for Ambulatory Health Care (AAAHC)

Our latest progress in the management of abnormal period allows us to perform endomyometrial resection (EMR) under ultrasound guidance in an office-setting. In addition, we are equipped to remove polyps and many fibroids in an office-based setting, as well.

Does office-based EMR hurt?

No. While we don't provide general anesthesia in an office setting the use of conscious sedation is very effective in blocking the pain of this minimally invasive procedure. Not all women, however, are candidates for an office-based procedure.

How can I know if I'm a candidate for office-based EMR?

Because of technological advances many of the women that were once managed in a hospital setting for the removal of their uterine lining (EMR) or their fibroids (myomectomy) can now be safely managed in our office. Most women, as long as they are in reasonably good health, can be managed in an office setting. However, the exact determination of whether you are a candidate is something you'll need to discuss with one of your providers.

HYSTEROSCOPIC EMR UNDER ULTRASOUND GUIDANCE: FREQUENTLY ASKED QUESTIONS

What is the length of recovery after hysteroscopic surgery? How does the length of recovery compare with hysterectomy?

The length of recovery for hysteroscopic surgery is a small fraction of the recovery required for hysterectomy. Ninety-five percent of women can return to work within a week of surgery—most within 72 hours. The average recovery for hysterectomy is 6-8 weeks.

How do I know if I should have a hysteroscopic surgery or a hysterectomy? Is there still a place for hysterectomy?

Hysteroscopic surgery is best suited for women who have bothersome periods, have completed their families and cannot or will not accept other medical methods to control their bleeding such as low dose oral contraceptives or the Mirena IUD. You should be willing to accept the fact that you may still have menses after a healing period of 6 weeks. If you would not be happy unless your menses stopped entirely, you would probably be better served by hysterectomy. Women who are poor surgical candidates because of medical problems such as severe asthma, obesity, diabetes, hypertension, previous abdominal surgery or a significant history of alcohol or tobacco use are better served, in general, by hysteroscopic surgery rather than hysterectomy.

Is it possible to have children after hysteroscopic EMR?

The removal of your uterine lining should not be considered unless you have completed your family. In fact, it's important that you not become pregnant after an endomyometrial resection. Although few women have ever become pregnant after an endomyometrial resection it is technically not a sterilization procedure. In some instances you may be asked to consider the insertion of tubal plugs (see hysteroscopic tubal occlusion by Essure above) specifically to avoid an unintended pregnancy.

If I decide on this kind of surgery, what happens between now and the day of surgery?

Should you elect to have hysteroscopic surgery, you may or may not be asked to take a medication for "endometrial suppression." The uterine lining is constantly under hormonal stimulation by your own hormones – estrogen and progesterone. This lining is often thick and lush and may get in the way as we try to remove it. In addition, patients with polyps or fibroids may also need to have their lining "suppressed" so that it does not interfere with their surgery. We generally use one of several agents to suppress your lining. It may be as simple as a birth control pill, a medication called danazol or one called Lupron. This choice will be left to you and your practitioner.

The day prior to surgery you may be asked to come to the office to have a laminaria inserted. This is required in most cases to insure the safe dilation of your cervix so that instruments can be inserted into the uterus without difficulty. You may ask for a sedative for this brief procedure if you prefer.

How will I feel after surgery?

Immediately after surgery, you will feel groggy and sleepy. Additionally, there may be some nausea and cramps. There will be some light to moderate vaginal bleeding lasting up to 4 weeks.

How soon can I return to work, to exercise, and to sexual intercourse?

Most women are able to return to work in 2-3 days, exercise in 7 days, and have intercourse in two weeks. I generally ask that you refrain from intercourse until any heavy bleeding has subsided.

When will I need to see you again?

You will need to see me 2 weeks following surgery. An ultrasound examination will be performed to see how your healing is progressing. Additional follow up will be discussed with you at that time. We recommend annual ultrasound examinations at the time of your yearly pap smears.

3) HYSTEROSCOPIC MYOMECTOMY & POLYPECTOMY WITH
ULTRASOUND GUIDANCE

Fibroids are the most common benign tumors in women. Approximately 30% of women over the age of 40 have fibroids that are detectable on ultrasound examination. The vast majority of them pose no health risk and don't produce any symptoms.

Many women ask the question 'where to do fibroids come from?' Remember that the uterus contains two kinds of tissues—muscular and endometrium (lining tissue on the inside of the uterus)--each of which can give rise to malignant and benign tumors. Fortunately, malignant tumors of the uterus are extremely rare. Benign tumors of the uterine muscle are known as fibroids or myomas, while those that arise from the uterine lining are known as endometrial polyps. Endometrial polyps, since they are comprised exclusively of lining tissue, are only found inside the uterine cavity—hence they are much easier to remove.

Unlike polyps which can only occur in the uterine interior, fibroids can occur inside the uterus (submucous or intracavitary), within the uterine wall (intramural), and on the outer surface of the uterus (subserous or pedunculated). Fibroids are generally multiple and can involve any combination of the 3 basic types.

Of the 3 different varieties of fibroids, the ones that produce the most debilitating symptoms are the submucous (or intracavitary) variety. These generally manifest themselves by producing very heavy periods (hypermenorrhea or menorrhagia). These fibroids may or may not be associated with painful menstrual cramps (dysmenorrhea). Submucous fibroids can also produce spontaneous miscarriages or infertility. Intramural and subserous fibroids generally produce few symptoms unless they cause profound uterine enlargement. Symptoms of large intramural and subserous fibroids may include bladder pressure, frequent urination and heavy menstrual flow.

Location of different types of fibroids Polyps are always inside the uterine cavity

There are many, many treatment options available today some of which I will try to address.

In general, however, both submucous fibroids and endometrial polyps are best addressed by simple excision (removal) using a hysteroscope. During the procedure an ultrasound technician or a nurse trained in ultrasound-guided surgery provides guidance throughout the procedure in order to minimize the risk of uterine perforation.

Ultrasound-controlled hysteroscopic surgery

Intraoperative view of endometrial polyp with ultrasound

The treatment of fibroids is highly individualize. The variations are vast with respect to size, consistency, location and number. Women can have anywhere from a single fibroid to dozens. There is enormous variation in size—anywhere from the size of a pea to a melon! The management of fibroids is dependent on many factors: location, the number of fibroids, their size, your age, your desire for fertility, your motivation and even your predisposition to a particular form of therapy. Twenty years ago most women with heavy vaginal bleeding and fibroids, who had completed their families, underwent a hysterectomy---this is no longer true. Most can be managed by some type of minimally invasive procedure, medication or even an IUD. In some cases the management of uterine fibroids requires a "team approach"—one that includes an expert sonographer, surgeon and even a radiologist.

In 1995, Amy Daggett and I published the largest series in the United States on hysteroscopic myomectomy, a minimally invasive technique for removing selected fibroids that may cause disabling uterine bleeding. Those results were reported in the Journal of the American Association of Gynecologic Laparoscopists.

HYSTEROSCOPIC MYOMECTOMY AND POLYPECTOMY:
FREQUENTLY ASKED QUESTIONS

What is the length of recovery after hysteroscopic myomectomy or polpectomy? How does the length of recovery compare with hysterectomy?

How do I know if I should have a hysteroscopic myomectomy or a polypectomy? Is there still a place for hysterectomy?

If you have completed childbearing and have extensive fibroids accompanied by heavy vaginal bleeding you might, in fact, be better off with a hysterectomy. There still is a place for hysterectomy and this should to be judged on a case by case basis. Most women, however, with heavy vaginal bleeding and fibroids can be treated in a less aggressive fashion. With respect to endometrial polyps there is rarely a place for hysterectomy in removing benign uterine polyps.

Is it possible to have children after hysteroscopic myomectomy?

Hysteroscopic myomectomy can vary from removing a fibroid with a very small attachment point to one that has a much broader point of attachment. The key to future fertility in women with fibroids, who have not completed their families, is to not damage the surrounding uterine lining. Therefore, it's very important to discuss the impact of hysteroscopic myomectomy on your future fertility. In some cases a hysteroscopic approach is not best and other approaches will be suggested in order to optimize your chances of conceiving and carrying a child.

Is it possible to have children following hysteroscopic polypectomy?

Absolutely!

If I decide on this kind of surgery, what happens between now and the day of surgery?

How will I feel after surgery?

Immediately after surgery, you will feel groggy and sleepy. Additionally, there may be some nausea and cramps. There will be some light to moderate vaginal bleeding lasting up to 4 weeks.

How soon can I return to work, to exercise, and to sexual intercourse?

Most women are able to return to work in 2-3 days, exercise in 7 days, and have intercourse in two weeks. I generally ask that you refrain from intercourse until the heavy bleeding has subsided.

When will I need to see you again?

4) UTERINE ARTERY EMBOLIZATION (UAE) OR UTERINE FIBROID
EMBOLIZATION (UFE)

This is a relatively new and somewhat experimental technique whose exact role is still somewhat uncertain. The aim of this procedure is to block the blood supply to the fibroid causing it to slowly degenerate. During the procedure a slender catheter is inserted into a vein in the leg and threaded to the artery that supplies the fibroid. Once the catheter has been placed and its position confirmed polyvinyl particles are injected to block the arterial blood supply—the result is necrosis or tissue death.

Some studies have shown that uterine artery embolization reduces bleeding from fibroids. However, most of the studies are not long term studies and almost none of them compare the results of UAE to traditional myomectomy (the surgical removal of fibroids).

There are clearly concerns over what happens to the dead tissue and therefore UAE is only to be considered under special circumstances where the dead tissue is not likely to end up in the pelvic cavity where it may cause other problems—infection and/or scar tissue. There are situations, however, where UAE might well be considered but those are best discussed with your physician.

The following is reprinted from the Mayo Clinic Website, http://www.mayoclinic.com/health/uterine-fibroids/UF99999/PAGE=UF00021

By Mayo Clinic Staff
March 30, 2007

In uterine artery embolization — also referred to as uterine fibroid embolization — a doctor uses a slender, flexible tube (catheter) to inject small particles into the uterine arteries, which supply blood to your fibroids and uterus. The goal is to block tiny vessels that lead to your fibroids, starve the fibroids and cause them to die.

Uterine artery embolization takes advantage of the physiological changes caused by fibroids. A fibroid uterus has more small blood vessels than does a normal uterus because fibroids stimulate formation of new blood vessels to the tumors. During uterine artery embolization, small particles (embolic agents) follow this increased blood flow to the fibroids and lodge in branches that feed them. Doctors believe that most normal uterine tissue isn't harmed, in part because it gets blood from additional arteries (collateral circulation).

Interventional radiologists — medical specialists who use imaging techniques to insert tiny instruments through small incisions in the skin to diagnose and treat disease — usually perform uterine artery embolization. Some specialists in obstetrics and gynecology also know this technique.

Some studies have shown that uterine artery embolization reduces bleeding, urinary incontinence and abdominal enlargement in about 85 percent to 95 percent of women who undergo the procedure to treat their fibroids. However, many of these studies focused on small groups of women or covered periods of two years or less.

Five years after treatment with uterine artery embolization, more than 70 percent of women maintain symptom control. This percentage equals that of myomectomy, in which the fibroids are surgically removed and the uterus repaired.

What to expect

Catheterization

Using emboli to stop blood flow

A doctor performs uterine artery embolization in a hospital under sterile conditions.

How do you prepare?
On the evening before the procedure, don't eat or drink after midnight. In the radiology procedure room, a staff member places a needle attached to a slender tube into a vein in your arm (intravenous, or IV) to give you fluids, anesthetics, antibiotics and pain medications. A thin tube placed in your urethra (urinary catheter) keeps your urinary bladder empty.

This procedure usually requires sedation, a type of anesthesia that reduces pain, yet allows you to breathe on your own, respond to questions and report any discomfort. It also blocks your memory of the procedure. Alternatively, you might undergo regional anesthesia. In this approach, the doctor injects medication around the spinal nerves that supply your pelvis. This method blocks pain, yet leaves you conscious and able to communicate.

How is it done?
To see your uterus and blood vessels, the radiologist uses a fluoroscope. The device is a pulsed X-ray beam that produces moving images of internal structures and displays them on a computer monitor. The radiologist makes an incision less than 1/4-inch wide (0.635 centimeter) in the skin over your groin, inserts a catheter into your femoral artery and guides it to one of your two uterine arteries. He or she injects a contrast fluid, usually containing iodine, which flows into the artery and its branches and makes them visible on the monitor.

Fibroids "light up" brightly because of their increased blood flow. The radiologist identifies and maps the vessels leading to the fibroids, then injects tiny particles made of plastic or gelatin into those branches. The radiologist injects more contrast and checks images to make sure that blood is no longer flowing to the fibroids. He or she then places the catheter into the other uterine artery and repeats the steps.

After the procedure
In the recovery room, staff members monitor your condition and administer IV medication to control nausea and pain. When the effects of the anesthesia fade, staff members bring you to your hospital room for continued observation.

You must lie flat for several hours to prevent pooling and clotting of the blood (hematoma) at the femoral artery site. Pain is the primary side effect of uterine artery embolization. Doctors believe it's a reaction to stopping blood flow to the fibroids. Some pain may also result from a temporary drop in blood flow to normal uterine tissue.

Pain usually peaks during the first 24 hours. You receive an IV opioid (morphine and related drugs), nonsteroidal anti-inflammatory drugs (NSAIDs) or both. Many hospitals offer patient-controlled analgesia (PCA), a system that delivers a dose of pain medication to your bloodstream through a vein when you press a button.

Post-embolization syndrome — fever, extreme fatigue, nausea and vomiting — is common after uterine artery embolization. Doctors believe that chemicals released by degenerating fibroids stimulate inflammation, causing the syndrome. Although post-embolization syndrome usually resolves spontaneously, it's important to rule out endometritis, a serious complication marked by delayed pain, a rise in the white blood cell count and a pus-like (purulent) vaginal discharge. Doctors treat endometritis with IV antibiotics.

By the next day, oral pain medications usually can replace IV medications. Your urinary catheter is removed, and you're encouraged to walk around. Recovery is generally rapid, and complications are rare.

Major complications
Major complications occur in about 1 percent to 5 percent of women undergoing uterine artery embolization. A degenerating fibroid can provide a site for bacterial growth and lead to endometritis. In extreme cases, infection may require a hysterectomy. Unintended embolization of another organ or tissue could lead to serious illness.

Recovery
Most women return home the day after the procedure with a prescription for oral pain medication. Pain usually ends within a day or two, but in some women it may last up to a few weeks.

Monitor your recovery for potential complications:

Vaginal discharge
You might have a mucus-like vaginal discharge after uterine artery embolization that clears without treatment. In a few women, remnants of fibroids are passed through the vagina. This is more likely if the fibroids are submucosal, but it can also occur with intramural fibroids. The discharge isn't dangerous and usually stops on its own. Rarely, women need hysterectomies after uterine artery embolization treatment to make sure that no remnants remain. You can expect to resume your normal routine in about two weeks.

Infection
Return to your obstetrician-gynecologist or primary care doctor for a follow-up examination within four weeks of the procedure to make sure there's no infection. Signs and symptoms of infection include fever, chills and pain.

You'll likely undergo a series of ultrasound or magnetic resonance imaging (MRI) examinations over the next year to monitor shrinkage or other changes in the fibroids or your uterus. Doctors usually schedule the first ultrasound examination at three months to allow time for fibroids to shrink. Late infections and vaginal discharge have occasionally been reported up to a year after the procedure.

Menstruation and menopause
Your menstrual period will probably resume within a few months. A small number of women, however, enter menopause after the procedure. The risk appears highest among women age 45 and older. Some embolic agents may pass from branches of the uterine artery to branches of the ovarian artery at areas where the two arterial systems connect. The emboli presumably travel through branches of the ovarian artery to your ovaries. Women who are near menopause (perimenopause) are especially vulnerable to a drop in blood flow. Occasionally disruption of blood supply to the ovaries can lead to menopause. If so, you might be at increased risk of entering menopause after uterine artery embolization.

For women who desire future fertility, uterine artery embolization needs to be carefully considered. Although the risk of entering menopause following the procedure is low, subtle ovarian damage may make getting pregnant more difficult. There also may be an increased risk of pregnancy complications, especially involving abnormal placement of the placenta. Still, despite these concerns, many women have had successful pregnancies following uterine artery embolization.

Common concerns about uterine artery embolization

You may have additional concerns about uterine artery embolization, including long-term complications. Discuss any concerns you have directly with your doctor.

Radiation exposure
Uterine artery embolization exposes your ovaries to radiation for imaging, about the same amount as two barium enemas performed to examine your colon. Proper technique is critical to minimize radiation.

Infections and scar tissue
Some doctors who perform uterine artery embolization say that it isn't the best treatment for large submucosal and subserosal fibroids or for fibroids that hang from a stalk (pedunculated). Others report satisfactory results with uterine artery embolization for women with these types of fibroids. Those who are concerned say that a pedunculated fibroid hanging from the uterine cavity could detach from your uterus after treatment, be too large to exit through your vagina and cause infection. Uterine artery embolization for subserosal fibroids may result in the formation of adhesions, bands of scar tissue between pelvic organs. But surgical treatment of fibroids, such as myomectomy, also carries this risk.

Reason to avoid this procedure

Don't undergo uterine artery embolization if you have:

A history of pelvic radiation

A history of kidney failure

When cancer is a possibility

An active, recent or chronic pelvic infection

Poorly controlled diabetes

Inflammation of the blood vessels (vasculitis)

A bleeding disorder

A severe allergy to contrast material containing iodine

Discuss uterine artery embolization with your obstetrician-gynecologist, primary care doctor or an interventional radiologist.

D. HYSTERECTOMY

Definition: Hysterectomy is the removal of the uterus. It does not include removal of the ovaries and does not describe how the uterus is removed. In some hysterectomies the cervix is left behind, a procedure known as subtotal hysterectomy. If an ovary is removed the procedure is known as oophorectomy. Many, if not most, hysterectomies are performed without removing the ovaries.

A thorough discussion of hysterectomy is well-beyond the scope of this chapter. It is important, however, to realize that for some women hysterectomy is the best or only good option available to them when dealing with abnormal menstrual periods. Some examples include

1. Cancer of the uterus

2. Invasive cancer of the cervix

3. A uterus with very large fibroids in a woman who has completed her childbearing, particularly in those cases where the risk of multiple myomectomies is greater than the risk of hysterectomy

4. Some failed endometrial ablation—especially when the patient does not have access to a physician who has the ability to "re-treat" a failed endometrial ablation.

When I trained in the late 1970s there were 2 methods for removing the uterus—one involved an abdominal incision (abdominal hysterectomy) and the other involved removing the uterus through the vagina (vaginal hysterectomy). The latter has become a lost art and few doctors are trained today in the skill of performing a vaginal hysterectomy.

Abdominal hysterectomy Vaginal hysterectomy

In 1988 a colleague of mine, Dr. Harry Reich, performed the first laparoscopic hysterectomy. The beauty of laparoscopic surgery lies with the precision and safety possible if the procedure is carried out by a well-trained and experienced gynecologic surgeon. Laparoscopic hysterectomy is especially advantageous to the patient where a simple vaginal hysterectomy would not be possible because of previous pelvic adhesions (scar tissue). Laparoscopic hysterectomy is not without risks but these risks can be kept to a minimum under most circumstances by an experienced and well-trained surgeon.

If you choose to have a laparoscopic hysterectomy you should be aware that "not all gynecologists are created equal" and that there are few excellent laparoscopic surgeons who "specialize" in this kind of procedure. Our practice does not provide this service but we do refer to a handful of physicians who are highly skilled and have proven over many years to obtain outstanding results for our patients.

The most highly skilled of all laparoscopic surgeons I've known is Joseph Scibetta, M. D., FACOG of Rochester Gynecologic and Obstetric Associates (RGOA) 125 Lattimore Road Rochester,NewYork14620;461-5940; http://www.rgoa.yourmd.com/joseph_scibetta

Disclaimer: Please note that we have no financial interest in Dr. Scibetta's practice or our any of the physicians and practices to whom we refer.

WHAT YOU NEED TO KNOW ABOUT FIBROIDS

INTRODUCTION

As we noted earlier the uterus is made up on two kinds of tissue: muscle and lining. The muscle is the myometrium while the uterine lining is referred to as the endometrium. An overgrowth or tumor of the myometrium is called a myoma or a fibroid.

Uterine fibroids are the most common benign tumor of a woman's reproductive system. As noted above they can attach to the outside of the uterus, grow within the wall of the uterus or within the uterine cavity itself.

As already noted, fibroids can vary from the size of a small pea to the size of a large melon. They can grow as a single tumor or in clusters where they are literally too numerous to count. Fibroids can produce abnormal menstrual bleeding if they are near the lining portion of the uterus. If they cause significant uterine enlargement and grow near the bladder they may produce frequent urination. Generally, fibroids do not cause significant pain unless they undergo degeneration. Rarely, do they cause chronic pain.

These tumors occur in about 25% of all women and are the leading cause of hysterectomy in the United States.

Fibroids are typically stimulated by the hormone estrogen. Although they can show up as early as age 20 they more often show up in a woman between the ages of 30 – 50 years of age. When left untreated, fibroids typically shrink after menopause when the body's own estrogen production diminishes.

Though the exact cause of fibroids is unknown there are several risk factors:

Obesity

Never having given birth to a child

Onset of menses before age 10

African-American heritage (fibroids occur 3-9 times more frequently than in Caucasian women)

SYMPTOMS THAT FIBROIDS CAN PRODUCE

Most fibroids, even large ones, produce no symptoms. Large fibroids can be found during your regular pelvic examination. However, routine bimanual examination (where a doctor or nurse evaluates your pelvis by digital means) performed at the time of your annual exam cannot detect most fibroids. For this reason we advocate routine transvaginal ultrasound as part of your yearly examination.

Most fibroids produce no symptoms and are of no concern. Others can produce heavy or irregular vaginal bleeding (with or without clots). Fibroids can be responsible for infertility, repeated miscarriages, premature labor or a sense of abdominal fullness. Rarely, fibroids produce a sense of frequent urination or constipation. Although many articles discuss the relationship between fibroids and pelvic pain, most do not cause pain. In fact, if a woman has chronic pelvic pain and fibroids it may very well be that the two are unrelated.

TESTS THAT DETERMINE IF YOU HAVE FIBROIDS

1. Physical exam is often a "giveaway" in the 30-50 year old woman with a painless irregular and enlarged pelvic mass that appears to be attached to the uterus. Today, confirmatory tests such as ultrasound are always performed.

2. A transvaginal or abdominal
ultrasound can help identify the number, size, and shape of your fibroids. This test uses sound waves to give doctors an image of your pelvic area. During an abdominal ultrasound a transducer or probe is passed over your abdomen. Abdominal ultrasounds are preferred for large fibroids. Smaller ones are best detected with a probe that is inserted into your vagina.



                           Arrows point to a solitary fibroid on the
                              posterior(back) wall of the uterus

3. A Sonohysterogram is a test that involves performing an ultrasound while the uterus is filled with sterile water or saline. The advantage is simple. Water shows appears black on ultrasound and highlights the tissue surrounding it. For example, a normal sonohysterogram can be seen below. Notice how the uterine cavity appears in black and is smooth and regular in its contour. Compare this to the one on the right which outlines a fibroid.

Hysteroscopy is an exam involving a fiber-optic lens that is passed through the cervix into the uterus. Hysteroscopy can only detect fibroids within the uterine cavity.

4. Laparoscopy is generally not performed for the diagnosis of fibroids, though many have been diagnosed that way while the surgeon was performing the procedure for something else—sterilization, appendectomy, ovarian cysts, endometriosis or unexplained pelvic pain.

In this example seen the uterus cannot even be seen as it is in front of and blocked by this rather large fibroid. Fibroids often have very fine blood vessels on their surface—this is true with either the hysteroscopic or the laparoscopic view.

TREATMENT OF FIBROIDS

Treatment for fibroids depends on your symptoms, the size and location of your fibroids, your age (how close you are to menopause), your desire to have children, and your general health. In most cases more than one option is available to you. The treatment you choose will depend on your own perception of the treatment and what risks you are willing to assume or what level of symptom relief you require.

1. Observation and Medical Treatment

In most cases, treatment is not necessary. Many women have fibroids that produce no symptoms but simply show up as incidental findings on physical or ultrasound exams. Menopausal women with fibroids rarely need any kind of treatment. Fibroids responsible for abnormal vaginal bleeding may be treated using a variety of medications. These medications include oral contraceptive pills, progestins, leuprolide acetate, Danazol and mifepristone. Some of these medications are meant for long term management and can be taken for years while others are designed to be used for one or two months. A variety of articles and websites write of the benefits of non-steroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen or Naproxen. In our experience these medications offer little if any benefit.

2. Surgical treatment

The surgical management of fibroids will depend on factors including your age, the location of the fibroids (intramural, subserous, submucous, intracavitary or pedunculated), your desire to preserve fertility, your overall health and your own predispositions. For instance, given the same set of symptoms and circumstances different women will "insist" on different approaches. This is normal and is an important factor in deciding on the best possible solution to your particular set of symptoms.

For fibroids located inside the uterus (intracavitary or submucous) we often suggest that these be removed hysteroscopically. Special circumstances occasionally prevent this approach and should be discussed with your health care provider. Pedunculated, subserous fibroids, and even some intramural fibroids are best approached by laparoscopy or laparotomy as this provides the best access.

3. Interventional Radiology—Uterine fibroid embolization (see above)

In some instances the use of inert beads to block the artery to a particular fibroid may be warranted. Its use is beyond the scope of this website but can be discussed with your provider.

Here are some useful websites you might wish to visit.

http://www.nlm.nih.gov/medlineplus/uterinefibroids.html

www.nuff.org/index.html

http://www.emedicinehealth.com/uterine_fibroids

http://www.acog.org/publications/patient_education/bp074.cfm

WHAT HAPPENS WHEN TREATMENT FAILS?

When treating most medical problems we generally start with the "treatment" that offers you the least risk with greatest potential for reward and, if necessary, progress in a systematic order to more aggressive treatments.

When it comes to abnormal uterine bleeding the least aggressive treatment is often observation. For many women it's reassuring to know that their symptoms, however disquieting, are not dangerous to them (e.g. cancer) or that their symptoms can be readily explained.

Suppose, however, you've undergone a global method of endometrial ablation or hysteroscopic endomyometrial resection and after a year or even several years of symptoms relief your problem recurs. Consider the following case of a 41 year old woman who underwent a thermal endometrial ablation (by another physician) and it worked for 2 years, but now the problem's back. "What do I do now?" she asks. The answer will depend on many factors including her age, the length of time she was able to achieve symptom relief from her original treatment, her uterine anatomy (as seen on ultrasound) and her own motivation to accept one treatment over another.

With very few exceptions once you've had an endometrial ablation performed by a global method—NovaSure, thermal balloon, hydrothermal ablation, microwave endometrial ablation or cryo-endometrial ablation--another "global" endometrial ablation method will not work. The reasons are complex but involve the fact that all of these methods cause uterine scarring which prevents the tissue, that has re-grown, from being accessible to another "global" (blind) method. In fact, even if you've undergone a hysteroscopic method of ablation or resection very few physicians can manage the problem of "retreatment."

The reality is, as you can plainly see from the chart noted above, that a certain percentage of women will require hysterectomy. Most of these, however, can be avoided by re-treatment. Retreatment, however, is performed by very few gynecologists and always involves operative hysteroscopy under ultrasound guidance.

As endometrial ablation is becoming more common in the United States so is the need for retreatment of ablation-failures. There are several factors that we consider in deciding whether or not a woman is a good candidate for surgical retreatment. Briefly these are:

Your current age
Your age at the time of your initial treatment
How many years of satisfactory results did you achieve from your original treatment? We call this the "latent period."
What was your original treatment?
Are you well-motivated to avoid a hysterectomy?
What are your expectations from re-treatment? For instance will it be adequate for you to have a significant reduction in your periods or will you only be satisfied if your periods stop completely?

Retreatment works best on women over the age of 40 who have enjoyed at least one year of success following an endomyometrial resection and are willing to accept the fact that they may not be amenorrheic (absolutely no periods) but would be satisfied with light and painless periods. If your original procedure was a global endometrial ablation technique (NovaSure, hydrothermal ablation, thermal balloon) we would generally consider you a candidate for retreatment even if the method did not provide any improvement of your symptoms.

In conclusion, we have provided re-treatment to hundreds of women who have seen a reappearance of their symptoms. Retreatment offers appropriate candidates an 80-90% chance of an excellent outcome and avoiding hysterectomy. In those instances when we feel that hysterectomy would be a better choice we will explain why and offer you the best array of options available.

CHOOSING A PHYSICIAN AND A TREATMENT

Let me start out by saying that we live in a wonderful medical community. Along with advanced technology this community is blessed by some very talented and experienced physicians.

Though we have specialized in treating menstrual disorders for over 20 years it is important for you to recognize that no one person, facility or institution can be "all things to all women."

There are procedures we do not offer and there are techniques that are practiced by other physicians who, frankly, do a better job. What we offer is an expertise in a wide variety of menstrual disorders and an understanding of what else is available in the community. If we feel that your particular needs would be better served by another physician we will let you know. Our reputation doesn't depend on being able to offer every kind of expertise available in this vast field. Our reputation depends on being forthright and honest with you and offering you the very best this community has to offer.

For more information please e-mail info@cmdrc.com

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