This document discusses the surgical management of menorrhagia (heavy menstrual bleeding). It begins by providing background information on menorrhagia, including that 12% of referrals to specialist clinics are for menorrhagia. It then discusses various causes of menorrhagia and guidelines for initial evaluation and treatment. The document focuses on different surgical treatment options for menorrhagia, including endometrial ablation techniques, myomectomy, and hysterectomy. It provides details on various ablation devices and techniques, and compares outcomes of ablation to hysterectomy. The document concludes by discussing potential future treatments for menorrhagia such as embolization of fibroids and medical therapies.

1. Dato Dr Aruku Naidu
MD(UKM) FRCOG(LONDON) CU(JCU),AM
Consultant Obstetrician & Gynaecologist &
urogynaecologist
Department of O & G, Ipoh Hospital
aruku-naidu.blogspot.com
Surgical management of
Menorrhagia

2. Menorrhagia
• 12% of referrals to specialist clinic
– Coulter ’91 (A)
• >80mls/ month anaemia
– affects 11% of menstruating women ,
Hallberg ‘66 (A)
• 50% don’t have menorrhagia
objectively Cameron ‘90 (A)
• 60% referred have hysterectomy
within 5 yrs Coulter ‘91 (A)
• Correct diagnosis essential
• Management directed to the specific
cause

3. Menorrhagia
• Dysfunctional(DUB)
• Fibromyomata
• Endometriosis
• Adenomyosis
• Carcinoma
– Endometrial
– Sarcoma
• Non-gynaecological pathology( Blood
disorders, Thyroid disease)

4. NZ Guidelines for Menorrhagia
Refer for USS assesment, endometrial sampling
+/- specilaist referral
No success
refer to specialist
Medical Therapy
NO
Normal Abnormal
Specialist
Endometrial sampling, USS
Yes
High risk
Assess for risk of hyperplasia
Regular Heavy Cycles
Irregular Cycles, IMB, PCB,
Abnormal exam, Cx or uterus> 12 weeks
anaemic
Full history, exam, FBC
Woman presents with Menorrhagia

5. Investigation
None (barring clinical examination)
PBLAC ( Pictorial blood loss assessment charts )
specificity /sensitivity >80%
FBC +/- endocrine function ( Haematin: research tool)
Cervical smear
Ultrasound: Sonohysterography
• Endometrial sampling
– Pipelle sampler, Vabra
• Hysteroscopy
– Outpatient vs inpatient
• MRI, CT scan

8. Oral Treatment Agents
• Anti-fibrinolytics- 50%  Bonnar ‘96 (A)
• Progestogens (cyclical)- 80% in loss Irvine ‘98 (A)
• Combined o/c pill- 40% in loss Fraser ‘91 (A)
• Mefenamic acid - 25%  in loss Bonnar ‘96 (A)
• Danazol- 80%  in loss Chimbria ‘79(A)

9. Surgical Alternatives
 Ablation: FEAT & SEAT
– Laser vs diathermy vs cryotherapy vs radiofreq
– Rollerball vs wire ( FEAT )
– Intracavity thermal devices ( SEAT )
• Thermachoice
• Cavatherm
• Microwave Endometrial Ablation(MEA)
 Myomectomy
Laparotomy vs laparoscopy vs hysterscopic resection
 Hysterectomy
Abdominal vs vaginal vs laparoscopy Hysterectomy
 Others: newer developments

10. ENDOMETRIAL ABLATION
• FEAT: FIRST GENERATION
ENDOMETRIAL ABLATION TECNIQUES-
TCRE (RESECTOR LOOP), ROLLERBALL
• SEAT: SECOND GENERATION
ENDOMETRIAL ABLATION TECHIQUES
(BALLOON ABLATION, MEA, BIPOLAR
TECNOLOGY, DIODE LASER,MONOPOLAR
ENERGY, RADIO-FREQUENCY,
CRYOTHERAPY & PHOTODYNAMIC
THERAPY).

11. Surgical Alternatives: Ablation
Pro’s: quick, avoids major surgery, cheaper
C/I:carcinoma, scars, previous myomectomy
S/E:minor, pain discharge, entrapment in long
term, missed carcinoma.
Risks: perforation, bowel, bladder,
infection,fluid overload
Suitability: DUB, Submucous fiborid<2cm,
completed fly

12. FIRST GENERATION
ENDOMETRIAL (FEAT)
TCRE(RESECT
OR LOOP),
ROLLERBALL

13. ROLLERBALL AND TCRE

14. RESECTION OF
FIBROID POLYP

15. FEAT
• INDICATIONS: DUB, submucous fibroid less than 2 cm
• COMPLICATIONS: fluid overload(~4%), uterine
peroration(0.65-2.47%), bleeding, infection, subsequent pregnancy
( morbidity 3%, mortality 2/10000)
• OUTCOMES:
AMENORRHOEA RATE: 20-50%
Patients satisfaction rate: 85%
retreatment or hysterectomy rate: 5-10%
• MISTLETOE study: 10500 operations, 690 surgeons,
18 month’s f/up: SAFE, surgical skill-little impact on CX and
otcome

16. SECOND GENERATION
ENDOMETRIAL ABLATION
TECHIQUES (SEAT)
• Uterine Thermal Balloons: ThermaChoiceTM,
CavethermTM , MenotreatTM
• Hydrothermal Ablation(HTA):
hydroThermAblatorTM , EnablTM
• Microwave Endometrial Ablation: MEATM
• Cryoablation: CryogenTM , SapranoTM
• Electrode: Mesh-VestaTM , Balloon-NovasureTM ,
• Interstitial Laser: ELITTTM ,
• Photodynamic Therapy: No licence product

17. BALLOON ABLATION
Thermachoice HTA
Cavetherm

18. ThermaChoice

19. MEA System & Applicator

20. MEA: HEAT

21. MEA vs. TCRE
• 260 patients randomised, F/U 2 yrs
• Outcomes the same in terms of satisfaction
• Shorter operating times with MEA
• Less complications
• Shorter stay in hospital
Cooper et al 1999

22. CRYOABLATION: FREZEE
ADVANTAGES:
• LA, Anesthetic effect
• Small probe:< 8mm
• Slow: 20-30 min

23. Comparison of various endometrial destructive
techniques
Device hysteroscopy Diam
(mm)
RX
(Time)
F/up Ameno
(%)
ReRx
(%)
Hyst
Ablat/
resect
YES 8-10 - 4-6yrs 20-50 5-10 5-10
Therm
Choice
No 4.5 8 12mth 15-20 20 4
HTA YES 8 10 12mth 50 NA NA
MEA No 8 1-6 36mth 37 6.9 9.3
Cryo No 4-6 10 NA NA NA NA

24. Endometrial Ablation Trials Group BJOG
1999, Aberdeen
• RCT of hysterectomy
vs TCRE / ELA
• Questionnaire at 4 -
6 yrs (median 5.1)
• Case note review
Satisfaction
• Ablation 80%
• Hysterectomy 89%
(ns)

25. Other surgical options:
With FEAT & SEAT,
anticipated decline in
Hysterectomy rate not
occurred

26. MYOMECTOMY

27. Hysterectomy
• Hysterectomy (hystero- & ektomè):
– 1768 Cavallini, “the uterus could be plucked with impunity”
• Australia: 20% of women before age
50 Santon „92 (B)
• USA- 2nd most common operation Lalonde „94
• UK- 90,000/ year Smith „94 (B)
• 40% of hysterectomies for
menstrual disorders SA figs ISACC „99

28. Evaluate Hysterectomy Study
Health Technology A 2004
• Randomised trial comparing
VAGINAL, ABDOMINAL(AH)
AND LAPAROSCOPIC
HYSTERECTOMY(LH)
• LH a/w higher major
complications, longer to
perform, but less pain,
quicker recovery, better
short-term QOL than AH
• VH under-power for any
comments

29. Success of Hysterectomy
Satisfaction Rates
– 95% at 2 yrs Crosignani „97 (A)
– 96 % at 2 yrs O‟Connor „97 (A)
– 89% at 4 yrs Aberdeen Endometrial Resection Trial
Group „99 (A)

30. What of the Future?

31. Future Treatments
• Embolisation of fibromyomata
• MRI guided Laser destruction of
fibromyomata
• Medical therapy
– Different dosages of LNG-IUS
– Specific receptor modulators for the
endometrium
• Day Case hysterectomy

32. EMBOLIZATION OF FIBROID

35. Conclusion
• Decide who needs further investigation or
referral to a specialist
• Medical therapy if used properly is
successful
• If treatment fails after 2-3 months
consider alternatives or further
investigation!
• There are some excellent options other
than resorting to hysterectomy
• Some women will always want hysterectomy
by choice and satisfaction rates are high
in the long term

36. “Evidence from Scandinavian
countries points to the
effectiveness of the hormone
releasing intrauterine device
as a first line of treatment of
menorrhagia”
Dep't of Health, Effective Care Bulletin, UK „95

37. The Demise of the General Gynaecologist?
What meteor?

38. THANK YOU