What's New in Surgical Treatment of Menorrhagia?

What's New in Surgical Treatment of Menorrhagia?

What''s New in Surgical Treatment of Menorrhagia?

"Patients should be properly counselled and educated about the options. The era of the only choice being a hysterectomy has passed"

Dr David Parkin, Aberdeen Royal Infirmary, Scotland

Menorrhagia - the bare facts

Excessive menstrual bleeding, or menorrhagia, is clinically defined as a flow that lasts more than seven days a month or saturates a pad or tampon in one to two hours. From the onset of menstruation to menopause, menorrhagia is most often due to hormonal imbalances or uterine fibroids. It needs to be diagnosed by a doctor to rule out a variety of potentially serious underlying conditions that sometimes cause increased menstrual bleeding.

The following interview was conducted with Dr Lee Keen Whye, Consultant Obstetrician and Gynaecologist at Gleneagles Hospital.

Interviewer: Dr Lee, what proportion of the female population in Singapore suffers from menorrhagia, also known as heavy periods?

Dr Lee: Menorrhagia or excessive menstrual loss affects about 5% of women in the reproductive age group in Singapore.

Interviewer: What has been the traditional method of curing menorrhagia?

Dr Lee: Traditionally, we try conservative treatment using hormones and iron vitamins, often with diagnostic uterine curettage (DAC) to exclude cancer. The ultimate surgical cure for menorrhagia is a hysterectomy, which is the removal of the uterus. But hysterectomy itself has its own morbidity and complications. The question then is to find an alternative to hysterectomy to avoid removal of the womb whilst solving the problems of menorrhagia.

Interviewer: Does such an alternative exist?

Dr Lee: A simple answer is to destroy or ablate the endometrium which is the lining of the uterine cavity that is shedding or bleeding periodically. This is possible in a uterus without any other significant pathological problems like multiple fibroids or cancer.

The gold standard which all gynaecologists regard as the best ablative surgery of the endometrium is TCRE (transcervical resection of endometrium). This involves cutting out the endometrial lining with a electro-surgical loop of wire. But this process requires a lot of skill and training to adapt to special hysteroscopes, and it can be potentially risky in untrained hands. Hence, different alternatives have been invented to replace manual TCRE in simpler cases, thus avoiding the risk of TCRE and the difficulty of learning TCRE.

Interviewer: What are these alternatives?

Dr Lee: The newer methods currently available and proven safe for general usage are:

1) Uterine balloon therapy (Thermachoice) - USA
2) Microwave endometrial ablation (MEA) - UK

Thermachoice uses hot water in a balloon to scald the endometrium and MEA uses microwave energy to ablate the endometrium. Both methods are done as day surigical procedures and require local or regional anaesthesia.

Interviewer: What if the patient still prefers to undergo hysterectomy?

Dr Lee: If the option is for hysterectomy and she is suitable for laparoscopic removal of the womb in total or partially (subtotal), then I may consider using the Harmonic scalpel. It is the latest ultrasound surgical technology acquired by Gleneagles Hospital. With this instrument, suitable patients will be assured of less surgical risks compared with electrocautery or laser. However, there is a small premium to pay in using this range of disposable instruments.