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Surgical procedures Hysteroscopy Hysteroscopy is a procedure which allows direct visual examination of the uterus. Although it is often done under a general anaesthetic, many gynecologists now carry out hysteroscopy as an out-patient procedure using a local anaesthetic. The procedure generally takes about ten minutes in the doctor’s office or outpatient section of the hospital, and may involve some discomfort. Usually the woman lies in the lithotomy position, with knees bent and feet apart. The doctor inserts a narrow telescope-like instrument through the vagina and cervix into the cavity of the uterus (endometrial cavity). Gas or fluid is then passed into the uterine cavity so that the walls of the uterus are held apart, allowing them to be examined. The doctor looks through the protruding end of the hysteroscope into the uterus. |
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 This procedure shows whether there are any problems such as fibroids, polyps, or scar tissue in the uterine cavity. Some problems can be treated with operative hysteroscopy which involves placing instruments through the scope. Hysteroscopy can be done alone or at the same time as dilation and curettage (D & C). Sometimes areas of abnormal tissue or growths can be missed during D & C or endometrial biopsy. Hysteroscopy may detect these missed areas. D&C (Dilatation & Curettage) This operation was the standard treatment for heavy bleeding, and is still offered to many women even though more effective and modern treatments are available. D&C is usually done as a day case under general anaesthesia, although it may involve an overnight stay in hospital. The cervix, which is normally tightly shut, is opened slightly to allow a spoonlike instrument into the uterus. The lining of the uterus (endometrium) is scraped away. After the operation, there is often bleeding for a few days. It is advisable to arrange your day so that you are able to rest after your D&C. If possible, have someone come with you to the hospital and take you home afterwards. The main purpose of the D&C is to investigate the causes of heavy menstrual bleeding and to screen for endometrial cancer. Endometrial cancer becomes more common in women over 40 but is extremely rare in women under 35. Even for women over 40, many doctors now question the widespread use of D&Cs for investigation when less invasive procedures (such as endometrial aspiration mentioned below) can be used just as effectively. The first menstrual period after a D&C may be lighter but generally periods become heavier again. Some women do find that a D&C helps but it is hard to know whether this is because of the operation or is a coincidence. General anaesthetic carries some risks and with a D&C there is also a slight risk of perforation of the uterus (a chance of between 1 in a 100 and 1 in a 1000) and possible weakening of the cervix. Even though rare, these must be considered since there is doubt about the value of the D&C in treating heavy bleeding. Endometrial aspiration This is a simpler procedure than D&C for getting a sample of the uterine lining. Studies have shown that results are as reliable as from a D&C. Endometrial aspiration can be done in the gynaecologist's office. A narrow tube is put through the cervix into the uterus and a specimen is sucked out. The procedure often causes cramps which can be painful. The advantage of endometrial aspiration is that it doesn't involve staying in hospital, having general anaesthesia or dilating the woman's cervix. TCRE (Transcervical Resection of the Endometrium) TCRE is a procedure in which the lining of the uterus is removed (also called resected or ablated) with a wire loop, roller ball or laser. The choice of instrument depends on the preference of the surgeon. The operation is performed using a hysteroscope, an instrument like a telescope which allows the surgeon to see the inside of the uterus. Special instruments can then be passed along the hysteroscope so that surgical procedures can be carried out.  After TCRE, periods usually become much lighter and in some cases stop altogether, depending on how much of the uterine lining has been removed. The choice is left to the woman to have either a partial resection, where some of the lining is left alone, or a total resection. The effects of TCRE are long term so it is not a method that women who want any or more children should choose. If you have a TCRE you should still discuss contraception with your doctor as some women may still conceive following TCRE and there may be an increased risk of an ectopic pregnancy (pregnancy occurring outside the uterus, in the tubes leading from the ovary). Some doctors may suggest having a tubal ligation (sterilisation) at the time of the operation. In the weeks leading up to the surgery, doctors may prescribe drugs to "thin" the lining of the uterus. These are usually GnRH agonists (see the section on these drugs on the previous page). The drugs make it easier to carry out the resection. TCRE can be carried out under general or local anaesthetic. Some doctors prefer to use a mixture of sedation and local anaesthetic. Women may be offered the choice. Once sedated or asleep, the legs are placed in stirrups. An internal examination will be done and the cervix will be opened slightly, just as it is for a D&C. The hysteroscope will then be inserted in the uterus and a watery solution will be used to distend the uterus so the doctor can see the inside more clearly. After checking for any possible problems, the lining of the uterus will be systematically removed. TCRE usually involves no incisions, stitches, drains or bladder catheters. Sometimes an intra venous drip may be needed and a balloon catheter may be left inside the uterus for a few hours. This may be necessary if bleeding is heavier than usual. There is a 6-7% incidence of complications during TCRE, such as injury to the cervix, perforation of the uterus, or absorption of the fluid used to distend the uterus, leading to a fluid overload in the body. If local anaesthetic is used, you will probably be allowed home in a few hours but some women stay in hospital overnight. There will be some vaginal bleeding but this normally becomes light within 24 hours. Some women experience slight lower abdominal discomfort. Rest is recommended immediately after TCRE. Normally, women will be able to resume usual activities, including return to work, within 1 2 weeks. The vaginal bleeding will gradually change (usually within 10 days) to a discharge which will continue for several weeks to a month. Women will be asked to return to the hospital for a six-week post op check. As the cervix is not affected, regular smear tests will still be necessary. Not all women can have TCRE. Sometimes there may be technical difficulties (such as where the uterus is severely tilted) and sometimes the tissue in the uterus may be found to be diseased and other treatment may be necessary. Balloon therapy Balloon therapy is a relatively new procedure to treat heavy periods. Like TCRE it removes the uterine lining, but a balloon filled with hot water is used to achieve this rather than manual removal using a laser, rollerball or wire loop. Because it does not rely so heavily on the skill of the doctor, complications during the procedure are rare. The recovery time after balloon therapy is quicker than after TCRE. The procedure is done under local anaesthetic and you usually go home the same day. Hysterectomy Hysterectomy is the most common major operation performed on women. 90,000 hysterectomies are performed every year in England. Half of these are carried out as a treatment for heavy menstrual bleeding. Ideally, the decision to undergo any major operation is based on a two way discussion involving the doctor's expertise and advice and the woman's feelings and wishes. In the case of hysterectomy as a treatment for heavy bleeding, the surgery is usually 'elective'. That is, the woman is not suffering from an illness for which surgery is necessary to save her life, but is in a situation where she should be free to choose whether or not she wants to have surgery. The decision should be based on how the heavy bleeding is affecting her quality of life, rather than by the fact that she has heavy bleeding. Although hysterectomy is common, it is still major surgery with all the risks such procedures involve. Some women feel fit two months after the operation, others need a longer time to recover (nine months to a year for many women). Women who have been experiencing severe problems in coping with heavy bleeding find that their quality of life improves dramatically. |
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All original illustrations © Michelle Forster unless otherwise indicated |
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