Various procedures have been developed in recent years which aim to destroy the endometrium in women experiencing excessive bleeding that is resistant to control by drug therapy. The heavy or prolonged bleeding may be caused by fibroids, adenomyosis, postmenopausal hormone therapy or drugs designed to thin the blood (anticoagulant therapy). These procedures do not appear to be helpful in relieving pain associated with menstruation.
The destruction process is carried out using a hysteroscope, an instrument described previously in this chapter. A fibre optic camera threaded through the hysteroscope records the view which is seen by the surgeon on a video screen. The surgeon, who needs good hand-eye coordination, watches the image on the screen, enabling him or her to guide various instruments in the confined space of the uterus. These instruments can include a ball heated by an electrical current (called a rollerball), an electrically heated wire loop (called a resectoscope) or a laser. The procedure is referred to as an endometrial resection when the electrically heated ball or wire loop is used to produce electrocoagulation (also called diathermy) of the endometrium, and an endometrial ablation when heat from a laser is used. The rollerball method of endometrial resection destroys the endometrium by rolling the coagulating ball over it like a paint roller, the electrocoagulation loop removes or ploughs several furrows in it, and the laser vaporises it. In the case of endometrial ablation, light from the laser passes down an optical fibre inserted into the hysteroscope and the surgeon moves the tip of the laser to draw a fine beam of light across the endometrium. In radiofrequency ablation, high energy radio frequency waves are applied to the endometrium instead of the high energy laser beam. A thermal method of removing the endometrium which involves passing hot water into the uterus is also being developed. Early studies suggest it is just as effective as methods using laser or electrocoagulation and may have advantages over them in terms of safety.
Comparisons of the resectoscope and the laser suggest that the former is cheaper, more readily available in hospitals, faster to use, takes less time for doctors to become competent with, is more robust and results in fewer complications. As the techniques alter, however, claims to superiority may be short-lived. A study comparing the newer ablation technique of radiofrequency with endometrial resection claims the former is simpler to perform, less time-consuming and possibly safer. However its cost is higher and the success rate is comparable.
Women having these procedures can receive either a general anaesthetic or a local anaesthetic with light sedation, although, for the laser treatment, a general anaesthetic is currently the norm. A few women bleed heavily immediately after the operation; but, for most, light post-operative bleeding gradually turns into a light discharge that disappears completely over about four to six weeks. Periods may continue, and in most cases they are light. Most women are in hospital for a day or overnight, and many have resumed work within a week or two. A year after an endometrial ablation or resection, about 85% of women report having reduced their use of sanitary pads or tampons by more than half; some have no bleeding at all, while for others heavy bleeding is still a problem. Looked at over a ten-year time frame, there is still a dearth of data.
The endometrium is well-known for its regenerative powers, provoking speculation that removing the endometrium is just ‘one more operation of doubtful value* that women are being encouraged to have. One study of more than 400 women who had endometrial resections for fibroids, endometriosis or adenomyosis found that about 20% developed a recurrence of heavy bleeding within four years, in some cases within a few months of the procedure.10 Some of these women chose to have the procedure repeated but, after a second try, about 40% of this group were still having bleeding problems. Overall, about one in every eight women who had an endometrial resection ended up having a hysterectomy within four years. Women who had a repeat resection were even more likely to resort to hysterectomy, with more than one in three such women eventually having the operation.
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