It has become quite fashionable today to use the term “minimally invasive surgery.” It is also worth noting that not all minimally invasive surgery and techniques are the same. And not all surgeons are equal. Women who are considering minimally invasive surgery have a lot to choose from and a great deal to consider before making this important decision.
It’s important to emphasize that the first approach to the management of menstrual disorders is not surgical. However, when surgery is required it’s helpful to have a thorough understanding of what’s available today.
Back in the early 1980s when we first started the practice, there were few surgical options available for most menstrual disorders. For women who had failed on various medications—usually a hormone—the only surgical options included a “scraping of the uterine lining” known as a “D and C” (short for dilation and curettage). If the D and C wasn’t helpful—and it usually wasn’t—the next management strategy was a hysterectomy. Until the late 1980s there was no surgical option “in between” the D and C and a hysterectomy. Although hysterectomy is effective at managing menstrual disorders for women who’ve completed their families, it’s still major surgery and carries significant risks—both immediate and delayed. Additionally, the length of recovery following a hysterectomy is measured in weeks and, occasionally, months.
Beginning in the late 1980’s, there was a revolution in gynecologic surgery. Two major changes had occurred: endometrial ablation and newer techniques to perform hysterectomy.
Endometrial ablation (EA)
First—a disclaimer. Although we performed endometrial ablation between 1988 and 1991, we no longer perform endometrial ablation today! Instead, we perform a technique that Dr. Wortman and Amy Daggett invented in 1991 known as ENDOMYOMETRIAL RESECTION (EMR). If you read the section below on EMR, you’ll appreciate the difference.
As we’ve already mentioned, prior to the 1980’s there were no options available to women with menstrual disorders who had failed to respond to hormonal therapy and who would not accept a hysterectomy as treatment. Endometrial ablation became available in the late 1980s.
What is endometrial ablation (EA)?
Endometrial ablation or EA is the selective destruction of the uterine lining. The uterus is mostly composed of muscle (myometrium). The endometrium is the lining tissue on the inside of the uterus and is the part of the uterus that grows and sheds each month in the form of a period. The endometrial growth and shedding is very important for a woman’s reproductive function. However, once a woman has completed her family the endometrium is no longer a critical part of the uterus. Since the endometrium is only about 5% of the uterus its removal or destruction leaves the rest of the uterus intact while removing only that portion responsible for heavy periods.
What are the advantages of endometrial ablation (EA)?
The major advantages of endometrial ablation are that is quite safe (compared to hysterectomy), it can be performed in a physician’s office or hospital outpatient department and is associated with a very short recovery (24-48 hours in most cases). For women with high-deductible insurance plans EA is far less expensive. There are other advantages too. Many women are very concerned about the loss of their uterus and how this will make them feel—emotionally and sexually. EA avoids this issue entirely.
What about the disadvantages of endometrial ablation?
Unfortunately, endometrial ablation is far from a perfect procedure. We know that of all the endometrial ablations performed in the U.S. each year that about 25% of them will fail within 4-5 years and that these women will undergo a hysterectomy. In cases where the endometrial ablation failed, women report that their bleeding never improved or that it improved for a while only to recur. Another issue with endometrial ablation is the post-ablation pain syndrome. In the post-ablation pain syndrome some lining tissue remains and produces menstrual bleeding. However, the menstrual blood may not pass easily through the cervix and this leads to uterine cramps and pain. Many women with post-ablation pain will choose to undergo hysterectomies—particularly if the pain becomes severe or disabling.
How effective is endometrial ablation?
Endometrial ablation is effective in the majority of women who undergo the procedure. Although 25% of women eventually undergo hysterectomies following EA it’s important to remember that 75% avoid hysterectomies! The nice thing about endometrial ablation is that it’s a simple office or outpatient procedure and doesn’t carry with it many risks—especially compared with hysterectomy. It is more effective and has a lower failure rate on women over the age of 45 compared to women under the age of 35. If you are looking for a “perfect result” — no more periods, ever—then you should consider some form of hysterectomy. However, most women are not looking for “perfect” results—they want periods that are tolerable and that don’t control their lives.
What are the endometrial ablation procedures available today?
Although there are as many as 6 different types of endometrial ablation procedures, the following 3 account for the vast majority of EAs performed in the United States today: NovaSure, ThermaChoice Balloon, Hydrothermal Ablation.
In 1988, we performed the first successful endometrial ablation in Rochester, New York. After understanding the limitations of “ablating” or “burning” the uterine lining tissue, we decided to try something different. In an attempt to improve the results obtained with endometrial ablation we invented endomyometrial resection (EMR).
Endomyometrial Resection (EMR)
Learn more about Endomyometrial Resection or view Dr. Wortman’s article on Endomyometrial Resection (EMR) vs. Endometrial Ablation (EA).
It differs from endometrial ablation in 4 important ways:
- Endomyometrial Resection (EMR) removes the lining of the uterus along with a small amount of underlying muscle to a known depth. This eliminates the unpredictable nature of endometrial destruction inherent in EA.
- It achieves a much more reliable outcome of diminished or absent menstrual bleeding compared to endometrial ablation. Overall, about 87-88% of women will stop having periods following an EMR compared to 50% with endometrial ablation.
- Since tissue is removed instead of burned there is a specimen that can be sent to the lab for testing in order to determine whether or not a pre-cancerous or cancerous condition of the uterus exists.
- According to our own data, women who undergo an EMR are less likely to undergo a subsequent hysterectomy than women who undergo an EA procedure. Ultimately, only about 4-5% of women who undergo EMRs undergo hysterectomy.
For many women, a hysterectomy is still a very good method of treating abnormal menstrual bleeding. In many cases, however, it should only be considered after other less invasive methods have been reviewed. The best candidates for this type of approach are women who are well-motivated toward hysterectomy and have completed their childbearing. They should be considered good or acceptable surgical candidates. The best surgical candidates are women who have had few previous abdominal procedures, are not obese and are younger than 40 years of age. Women with extensive fibroids that cannot be removed hysteroscopically are often better served by hysterectomy than any other procedure. Women who have a well-documented history of moderate or severe endometriosis are generally better served by hysterectomy than other surgical approaches.
It is important to distinguish hysterectomy types from hysterectomy techniques as the two are frequently confused.
A hysterectomy is the surgical removal of the uterus. It does not mean removal of the ovaries. Women often hear that a friend or relative had a “complete hysterectomy” and equate this with removing everything—uterus, cervix, tubes and ovaries. A hysterectomy, however, is defined as the removal of only the upper uterus and cervix, which is the lower portion of the uterus. Although tubes and ovaries can be removed at the time of a hysterectomy this is not automatically done. Often for the treatment of abnormal menstrual bleeding the removal of ovaries is unnecessary and unwarranted.
Total hysterectomy—removal of the cervix and uterus BUT NOT THE OVARIES.
Subtotal hysterectomy (also called supracervical hysterectomy) removal of the top of the uterus (fundus) only. The cervix is left in place as are the ovaries.
Total hysterectomy and bilateral salpino-ophorectomy (BSO) is the complete removal of the uterus, cervix, and both tubes and ovaries.
Unfortunately, many women become confused with the types of hysterectomy and the techniques used to perform them. The techniques have evolved over the past 20 years. Some techniques are not meant to be minimally invasive but have other advantages. Some of the oldest techniques—such as vaginal hysterectomy—may be the least invasive! Let’s try and summarize them.
Abdominal hysterectomy– this type of hysterectomy is performed through a larger abdominal incision. Some physicians will use a larger incision if there is reason to suspect uterine, cervical or ovarian cancer. Occasionally, the removal of a uterus with very large uterine fibroids may require a large abdominal incision. In general, however, this type of hysterectomy is used far less frequently than in decades past but there are still cases that require it. With this approach a total or subtotal hysterectomy can be achieved. The ovaries may or may not be removed depending on your individual circumstances. Recovery is generally 6-8 weeks. This is definitely not a minimally invasive technique.
Vaginal hysterectomy – the vaginal hysterectomy is considered by many to be the most cosmetically desirable of all hysterectomies—and it may be the least invasive of all the “minimally invasive” techniques. Its advantage is that all incisions are made in the vagina and there is no abdominal incision. Although once commonly used, vaginal hysterectomy is becoming a lost skill and has largely been replaced with the laparoscopic hysterectomy – also known as laparoscopically-assisted-vaginal hysterectomy (or LAVH). With a vaginal hysterectomy the cervix must be removed and cannot be preserved. Additionally, if the ovaries must be removed it may not always be possible to do so using this technique. Recovery is usually 2-4 weeks. Although vaginal hysterectomy is one of the least invasive of the techniques mentioned it has some disadvantages too:
> The surgeon does not have a good view of the pelvic organs
> The surgeon may be unaware of bleeding in the abdominal cavity
> The cervix cannot be spared
> The physician is often not able to examine the ovaries
For this reason many surgeons prefer another approach
Laparoscopic hysterectomy (LH) or Laparoscopically-assisted vaginal hysterectomy (LAVH) – During a laparoscopic hysterectomy, a lit-telescope known as a laparoscope is placed near the umbilicus (navel). Usually 2 or 3 additional small skin incisions (about ¼”) are made to perform the dissection and removal of the uterus. A laparoscopic approach may be used to perform a total hysterectomy or a subtotal hysterectomy. In addition, the ovaries and fallopian tubes can easily be removed with this approach.
The laparoscopic approach offers several advantages to the abdominal hysterectomy. First, the incisions are smaller allowing a quicker recovery –usually 2 to 3 weeks–and return to work and physical activity. Second, the smaller incisions decrease the likelihood of a wound infection or wound disruption. Third, it is associated with significantly less blood loss than an abdominal hysterectomy. The laparoscopic hysterectomy is definitely considered a minimally invasive gynecologic surgery with recovery generally taking 2-3 weeks.
Laparoscopic hysterectomies require a great deal of skill and this technique has been partially replaced by “robotic hysterectomy”
Robotically-assisted hysterectomy – Robotic hysterectomy is often touted as a minimally invasive gynecologic surgery. When comparing the recovery and outcomes to abdominal hysterectomy this is certainly true. Robotically assisted hysterectomies offer numerous advantages in women with a variety of gynecologic cancers, severe endometriosis and pelvic adhesive disease. There are other factors that may cause a physician to favor the use of robotic assistance compared to other available methods.
Numerous large studies have found little difference in complications and recovery time between laparoscopic and robotic hysterectomy. Without question robotic surgery is far more expensive than laparoscopic hysterectomy.
Other studies have shown that robotic hysterectomy requires the patient to be under anesthesia for longer periods of time. In most cases robotic surgery requires a greater number of incisions than laparoscopic hysterectomy. Although robotic assisted hysterectomy clearly has a place in modern gynecologic surgery it is less clear that it is “minimally invasive” compared to other forms of hysterectomy—such as laparoscopic or vaginal hysterectomy. Further studies are needed before the exact role of robotic-assisted hysterectomy can be determined.
There has never been a time in women’s health care that provided a greater array of choices for the management of abnormal menstrual bleeding. The best treatment or management scheme for you must be individualized to your needs, your overall health and your expectations.
Although second-opinions are expensive and time-consuming, you should consider them if you’re in doubt about what your health care provider is proposing for you. If you’re consulting with a surgeon it might be wise to consider bringing a partner, friend or relative along for the visit. My best recommendation is that you ask your health care provider one question—“is this what you would recommend for me if I was your daughter, wife or other loved one?