Menorrhagia surgery

Why are there different types of surgery for menorrhagia?

Having surgery is not a first-line treatment. It is an option if the other treatments, for example, medication or an intrauterine system (IUS) do not help or are unsuitable. Surgery can be more effective than medical treatments but does involve more risks.

The operation you may be offered usually depends on the underlying cause of your heavy periods. For example, if you have growths in your womb (uterus) - such as polyps or fibroids - you may have an operation to remove these. This will reduce or stop your heavy bleeding. However, for many women there is no underlying cause for their menorrhagia.

Surgery for heavy vaginal bleeding includes:

• Surgery for fibroids

• Surgery for menorrhagia

Fibroids can be treated by removing them (called a myomectomy) or cutting off their blood supply (called uterine artery embolisation).

Myomectomy

A myomectomy to remove fibroids can be done in different ways depending on the actual location of the fibroid or fibroids. If possible, the operation is usually done by keyhole surgery (laparoscopically). During this procedure your doctor uses thin instruments and a camera to remove the fibroid or fibroids. An alternative approach to this operation is to remove the fibroid (or fibroids) by inserting the instruments through the neck of your womb (cervix) to the inside of your womb (uterus).

Most women who have a myomectomy are able to have children afterwards. Between 10-25% of women who have a myomectomy will need further fibroid surgery, as the fibroids can return (recur).

Uterine artery embolisation (UAE)

UAE is an alternative procedure to a hysterectomy and myomectomy for treating fibroids. It may be recommended if you have large fibroids. UAE is performed by a doctor who has been trained to interpret X-rays and scans (a radiologist). It works by blocking the blood vessels that supply blood to your fibroids, causing them to shrink. During the procedure, a chemical is injected through a small tube (catheter), which is guided by X-ray through a blood vessel in your leg.

Magnetic resonance-guided focus ultrasound (MRgFUS)

MRgFUS is an alternative treatment which uses a combination of MRI and ultrasound to localise your fibroids. Then ultrasound-generated energy is applied which heats up your fibroids and destroys them. This is only offered in some areas. Your doctor will be able to discuss which treatments are available to you in detail.

Endometrial ablation

This treatment destroys or removes most of the lining of your womb (endometrium). It works to reduce your heavy menstrual bleeding or in many cases it actually causes you to stop having any more periods.

This operation is usually done as day surgery. A small instrument is passed into your womb via your vagina. The aim is to remove as much of the lining of your womb as possible.

Endometrial ablation operations vary by the method used to destroy or remove the lining of your womb. The different methods available include:

• Microwave. In this method, a slender wand that emits microwaves is placed into your womb, which works to increase the temperature of the lining of your womb to destroy it.

• Extreme cold. This is also called cryoablation and this method uses extreme cold to create two or three ice balls that freeze and destroy the lining of your womb.

• Bipolar radiofrequency. The instrument that is placed into your womb puts out short waves of energy that destroy the lining of your womb.

• Electrosurgery. This method uses heat to destroy the lining of your womb. A small instrument which can be a roller ball or a wire loop becomes hot. It is then used to carve grooves into the lining of your womb.

• Heated balloon. A balloon device is inserted through the neck of your womb and then inflated with fluid which is heated.

Although endometrial ablation prevents women from having children in the future, it cannot actually be relied on as contraception. This is because there have been some cases of women becoming pregnant after this operation.

Endometrial ablation is not usually recommended if you have large fibroids or if you want to have children in the future, as it can affect your fertility. It can be an option if you have small fibroids however.

Following this type of surgery you may have some discomfort in your lower tummy (abdomen), which is usually eased by taking painkillers. You will need to wear a sanitary towel for a few days after the operation, as it is common to have some vaginal bleeding. You will usually be able to go home on the same day when you feel ready. Most women are able to return to most normal activities in 3-5 days. Having sex (intercourse) and doing very strenuous activities should be avoided for around two weeks following this type of surgery. It is normal to have an increased vaginal discharge for 2-4 weeks after the operation.

You should avoid using tampons for at least one month after having an endometrial ablation, to help reduce your risk of infection. If you develop any prolonged vaginal bleeding, offensive smelling discharge, severe pain or a high temperature (fever), you should contact your doctor as soon as possible. These symptoms may be due to an infection which can be treated with antibiotics.

Hysterectomy

Hysterectomy is an operation that removes your uterus. This is a permanent treatment that cures heavy menstrual bleeding. However, the surgery can have complications and may require up to six weeks for full recovery. Pregnancy is obviously not possible after a hysterectomy.

A hysterectomy is now done much less commonly since the introduction of endometrial ablation. It is usually only considered when all other treatment options have not worked for you.