Recently I’ve written about the most common causes of abnormal menstrual bleeding and the options for managing abnormal bleeding with medication. If you are not a candidate for medication or it is not working for you, then you may want to consider a surgical option. Many of the surgical techniques gynecologists use to treat abnormal menstrual bleeding today are minimally invasive, can be performed in your surgeon’s office or in a hospital and allow a quick recovery and return to daily activities.
Earlier I discussed anatomic or structural abnormalities that may cause abnormal bleeding, such as polyps and fibroids. If you have been diagnosed with a polyp or fibroid that is inside the uterus, in many cases it can be removed with a hysteroscope. A hysteroscope is a small device that is inserted into the uterus allowing your surgeon to see and remove the polyp or fibroid. Your surgeon may be able to perform this in the office. If the growth is larger or more complex, it may require a visit to the operating room for removal. This can usually be done as a same-day surgery. Most people will only need to take a day off work and will be able to resume normal activities within a day or two. Most of these procedures are uncomplicated, but if you have a large fibroid, then the experience of your gynecologist is very important and you should have a thorough discussion about the success of hysteroscopic surgery to treat your condition.
If you have a normal uterus (specifically, the inside cavity of the uterus) and no particular reason can be found for your abnormal bleeding, then your provider may suggest an endometrial ablation. An ablation works by destroying the lining of the uterus (called the endometrium), which results in decreased bleeding. There are several methods available to achieve this and your gynecologist can review which option is best for you.
Most endometrial ablations can be performed as office surgery if you have no major medical problems, a relatively normal-sized uterus and do not need a general anesthetic. Otherwise, endometrial ablations can be performed in the operating room. Endometrial ablation provides an option for controlling abnormal bleeding without the need for a hysterectomy. It also allows for a quick recovery and return to normal daily activities within one to two days. Most patients go home the same day and very few, if any, report any significant side effects.
Endometrial ablations control heavy bleeding around 90% of the time. That means that up to 10% of the time an endometrial ablation may not work. I typically break the success rate down as follows:
- one third of patients will stop having periods;
- one third will have decreased or light periods; and
- one third will go back to having a normal period after an endometrial ablation.
The procedure is less effective in younger women or if you have fibroids. I encourage all patients to have a thorough talk with their gynecologist to determine if they are a good candidate for this procedure. Before an endometrial ablation is performed, it is important to make sure the lining of your uterus is normal, specifically to rule out any evidence of precancerous or cancerous cells. This is done by performing an endometrial biopsy, which is done at an office visit.
If you may wish to become pregnant in the future, an endometrial ablation is not an option for you. In fact, it is of the utmost importance to make sure you have a reliable form of contraception (birth control) before having an endometrial ablation. If you become pregnant after having one, there could be significant complications and you should alert your provider as soon as possible.
If your provider has recommended a hysterectomy, you should know that there are new options in how the hysterectomy is performed that vary widely in terms of hospital stay, recovery time and risk of complications. Today, hysterectomies can be performed vaginally, abdominally or laparoscopically.
Vaginal hysterectomy offers the advantage of no abdominal incisions, which means a shorter recovery, less blood loss and a prompt return to work and activities. The uterus is removed through the vagina. Depending on the reason for a hysterectomy, you may be a good candidate for this option. If you have been diagnosed with a large uterus, have never had a child or have a history of multiple pelvic surgeries, your gynecologist may not recommend this approach. Vaginal hysterectomy typically requires a one-day hospital stay. The recovery is usually very good and varies between two and four weeks.
Abdominal hysterectomy, sometimes called “open” hysterectomy, used to be the most common way of removing a uterus in the United States. Unfortunately, it is still the most common in some communities. It also is the most invasive and requires the most time off from work or daily activities. In an abdominal hysterectomy, the same type of incision is made in the abdomen as for a cesarean section. This usually requires two to three days in the hospital and four to eight weeks of recovery.
Fortunately, most patients can benefit from a laparoscopic approach to a hysterectomy and avoid the large abdominal incision and longer recovery times. Laparoscopic hysterectomy is becoming more and more popular as the method of choice when it comes to hysterectomy. Most laparoscopic hysterectomies can be performed as same-day, outpatient surgery with recovery times of two to three weeks. In this approach, the uterus is removed through small abdominal incisions with the aid of a laparoscope (small camera that is inserted into the abdomen). Studies report the benefits of laparoscopy to be a faster recovery, less blood loss, greater visibility for the surgeon during surgery and less need for pain medication. In my measured experience, about 85% of my patients go home on the same day of surgery. In addition, if you are a good candidate for a laparoscopic hysterectomy to begin with, there is a very small chance (1%) that the surgery would need to be converted to traditional abdominal or open hysterectomy.
Laparoscopic hysterectomy can be challenging, especially if you have conditions such as larger fibroids, cysts and endometriosis. You should have a thorough discussion with your gynecologist about this option and their experience performing this surgery. If you desire a minimally invasive approach, ask about a potential referral if he or she does not perform laparoscopic hysterectomies.
In my next blog, I will review the different forms of laparoscopic hysterectomies in more detail and review the most frequently asked questions.
Dr. Liberato Mukul is a board-certified OB/GYN physician and fellowship-trained minimally invasive surgeon who sees patients at Northwest Gynecology Center, Peterkort.