Endometrial ablation as an alternative to hysterectomy for heavy periods

When endometrial ablation was introduced in the 1980's it was all the rage, and I was one of the few gynaecologists to start using this surgical treatment in Singapore for the treatment of heavy periods and fibroids in the endometrial cavity of the womb. Endometrial ablation involves in simple terms removing and ablating the lining of the the womb similar in the way an enlarged prostate is removed surgically in a man. It involves introducing an intrument through the cervix and stripping the lining of the endometrium and then with the aid of electrocautery ablating whatever remnant of the lining. It is a minimal invasive procedure with the patient going back the same day. For those patients who desired keeping their womb and were averse to surgical hysterectomy, this offered a good surgical alternative. However over the last 20 years of use, studies have shown that in about 20%, the heavy periods will recur as the endometrium has a tendency to grow back after several years. So most will go on to have repeated ablations and some end with hysterectomies. The types of ablation have evolved to include freezing, high thermal, and microwaving. Certainly endometrial ablation has a place in intractable menorrhagia (heavy periods) but not for everyone.

Endometriosis and Adenomyosis

I recently operated on a 28 year lady with both endometriosis stage III and with significant adenomyosis. Although endometriosis is a rather common condition in women especially those in there 30s and 40s who have few or no children, this was unusual in that here was a relatively young lady, getting married, in the best reproductive years of her life with extensive endometriosis and adenomyosis. Endometriosis is a generalised pelvic condition in which there are blood cysts scattered throughout the pelvis but mainly in the folds between the womb and the bladder in front and the rectum and intestines behind. There is also a predeliction for the ovaries as well. In stage III endometriosis, there are large blood cysts involving both ovaries and extensive adhesions of the surrounding structures. The disease acts almost like a cancer attaching and invading surrounding tissue although it is not malignant. It is simply distructive to the structures and can significantly affect her fertility. She presented with heavy irregular and painful periods. Very often there may be no symptoms other then infertility and found during investigation for such. In addition she had adenomyosis. This is blood cyst mixed together with a fibroid and is present and invades the muscle of the womb. Pain during the period comes from the bleeding from all these blood cysts. If the cysts are large they may even rupture during the period.

In her case I obviously had to be as conservative as possible. She was offered the alternatives of medication in the form of danazol for 9 months or a gnrh agonist lucrin. Both would induce a semi-menopausal state and allow the shrinkage of the cysts. This would however not be ideal as it would be impossible to shrink away the disease and cysts totally. She was therefore offered surgery as the better alternative followed by medication as the better choice.

Such extensive disease is unusual and requires careful considerate surgery to restore her fertility. Endometriosis and adenomyosis is thought to be an immune disorder and is related to backflow of menses through the fallopian tubes allowing the cells to implant on the pelvic structures. It should be suspected especially if periods get increasingly painful. Diagnosis early in stage I would prevent further progression with medication or use of laparoscopic laser surgery (key hole). Regular gynaecological checkups with ultrasound scanning from an early age is the key.

Uterine Prolapse

A few days ago, I performed a vaginal hysterectomy on a patient with uterine prolapse. She had a 3rd degree uterine prolapse with the entire uterus hanging out of the vagina!. It is actually quite unusual to see these cases nowadays with women having only a couple of children. In the olden days when women tended to have large families this was very much more common, and when I was working in the UK, a vaginal hysterectomy for prolapse was one of the most common operations performed. These women would come with the complaint of pressure below, a lump appearing or tell the doctor that she was turning into a man!.

Prolapse is a gradual process and results from damage to the supporting tissues at childbirth. As a woman ages especially in her 40s and 50s, there is increased laxity of the collagen due to decreasing female hormones, oestrogen. The prolapse then worsens. 1st degree and 2nd degree prolapse are less severe, but 3rd degree prolapse or procidentia can result in damage to the kidneys due to kinking of the ureters between the kidneys and the bladder, ulcers and cancerous change of the cervix due to the constant rubbing on underwear. My patient did indeed have swollen kidneys before surgery but an xray after the hysterectomy showed that the kidneys had reverted back to normal size. A 3rd degree prolapse and hysterectomy can be prevented if prolapse is detected in the earlier stages and supportive surgery performed. A sensation of heaviness, constipation, difficulty with urination or leakage of urine on excercise or coughing may indicate uterine prolapse.