Transcervical Resection of Endometrium

Review Article

INTRODUCTION

Dysfunctional uterine bleeding is defined as heavymenstrual uterine bleeding not due to any recognizablecause and is therefore a diagnosis of exclusion. Otherconditions such as uterine fibroids, endometrial polyps andsystemic diseases should be excluded by appropriateinvestigations. In the adolescent, investigations for acoagulopathy should be performed. The pathophysiologyof DUB is largely unknown but occurs in both ovulatoryand anovulatory menstrual cycles [1]. Heavy menstrualbleeding is clinically defined as greater than or equal to 80mL of blood loss per menstrual cycle [2]. Heavy menstrualbleeding (HMB) is a significant health problem inpremenopausal women; it can reduce their quality of lifeand cause anemia [3]. Various treatment modalities areavailable for the management of DUB.

MEDICAL MANAGEMENT

This has been traditionally been the first-line therapy.Medical treatments include nonsteroidal anti-inflammatory drugs or antiprostaglandins, tranexamicacid, the progesto-gen releasing intrauterine device,combined oral contra-ceptive pills, and other hormonaltherapies. As no medical treatment is superior to another,each woman should be individually assessed as toappropriate management [1].

The LNG IUS (MIRENA, PROGESTASERT) resultsin a smaller mean reduction in menstrual blood loss than

endometrial ablation [2]. Women with an LNG IUSexperience more progestogenic side effects compared towomen having TCRE for treatment of their heavymenstrual bleeding [2,4].

Studies show that surgery reduces menstrual bleedingat one year more than medical treatment alone [4].

Studies have shown that medical management alone isusually insufficient for treating DUB [5]. Cooper KG, etal in there study found that only 10% of those randomizedto the medical arm still used medical treatment, at 5 yearfollow up. While 77% had undergone surgical treatmentlike endometrial ablation and 18% a hysterectomy [5]. Inthe surgical group, only 27% women allocated totranscervical resection of the endometrium hadundergone further surgery, and 19% required ahysterectomy [5].

At five years women initially randomized to medicaltreatment were significantly less likely to be totallysatisfied or to recommend their allocated treatment to afriend. Bleeding and pain scores were similar in bothgroups and highly significantly reduced. Significantlymore women in the transcervical resection of theendometrium arm had no bleeding or very light bleedingand they had significantly less days of heavy bleeding [5].

HYSTERECTOMY

Hysterectomy is obviously 100% effective in stopping

121 Apollo Medicine, Vol. 7, No. 2, June 2010

TRANSCERVICAL RESECTION OF ENDOMETRIUM

Geeta Chadha* and Surpreet***Senior Consultant, **Registrar, Department of Obstetrics & Gynaecology, Indraprastha Apollo Hospitals,

Sarita Vihar, New Delhi 110 076, India.

Correspondence to: Dr Geeta Chadha, Senior Consultant, Department of Obstetrics & Gynaecology, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India.

e-mail: geeta_chadha@hotmail.com

Dysfunctional uterine bleeding (DUB) is the major cause of heavy menstrual bleeding and impacts onwomen’s health both medically and socially. First-line therapy has traditionally been medical therapy but this isfrequently ineffective. On the other hand, hysterectomy is obviously 100% effective in stopping bleeding but ismore costly and can cause severe complications and affect the quality of life. Endometrial ablation is lessinvasive and preserves the uterus and has shown to improve the quality of life indices.

Key words: Dysfunctional uterine bleeding.

Apollo Medicine, Vol. 7, No. 2, June 2010 122

Review Article

bleeding but it cause severe complications like urinaryincontinence, psychosexual ailments and it affects thequality of life.

It is associated with prolonged hospital stay, morechances of anesthetic complications and pain [3,6].

Allahdin S, et al in there 10 year follow up of patientsundergoing TAH for DUB as compared with TCRE,showed that TAH is associated with a significantlyincreased incidence of hospital referrals for UrinaryIncontinence(UI) , urological investigations and treatmentfor UI as compared to TCRE [7].

Women’s fears about sexual function afterhysterectomy might not be unfounded. The psychosexualproblems like (i) libido loss, (ii) difficulty with sexualarousal, and (iii) vaginal dryness may return and/ordevelop with time. The removal of ovaries at the time ofhysterectomy is associated with greater deterioration ofself-reported sexual function. Surgical menopausesignificantly impairs sexual wellbeing despite hormonereplacement therapy (HRT) [8]. McPherson K, et alreported that five years after surgery for DUB, the crudeand adjusted prevalence of psychosexual problems washigher after hysterectomy than after TCRE [8]. So the roleof hysterectomy for DUB should be reserved for therecalcitrant cases of endometrial ablation who do not getrelief from symptoms with the less radical procedures[3,8].

ENDOMETRIAL ABLATION

Endometrial ablation is less invasive and preserves theuterus, although long-term studies have found that thecosts of ablative surgery approach the cost ofhysterectomy due to the requirement for repeatprocedures. A large number of techniques have beendeveloped to ‘ablate’ (remove) the lining of theendometrium. The gold standard techniques (laser,transcervical resection of the endometrium and rollerball)require visualization of the uterus with a hysteroscopeand, although safe, require skilled surgeons. A number ofnewer techniques of ablation include microwaveendometrial ablation (MEA) and thermal balloonendometrial ablation (TBEA) have been developed forheavy menstrual bleeding (HMB) [1,3,6,9,10].

TCRE, has been the gold standard of the endometrialablation techniques for DUB and has been shown to beeffective and achieves high rate of patient satisfaction(88.8%) [9]. The procedure is also known asHysteroscopic Endometrial Ablation or HysteroscopicEndometrial Resection. The surgical procedure isperformed under general anesthesia using a

hystereroscope after gently dilating the cervix to 10 mm. Aroller ball coagulation at the fundus and cornual region isdone while resection of the cavity walls is done using anangled cutting loop, with 1.5% glycine solution asdistending medium [9]. TCRE affords reasonable long-term effectiveness in the treatment of dysfunctionaluterine bleeding, even without any preoperative hormonalendometrial preparation [11].

TCRE is also an effective and safe method for themanagement of benign intracavitary pathology likesubmucous myomas or polyps [12]. TCRE for treatmentof heavy menstrual loss achieves higher levels ofsatisfaction, better menstrual status, and greaterimprovements in health related quality of life than medicaltreatment [5]. In addition, transcervical resection of theendometrium is safe and does not lead to an increase in thenumber of hysterectomies [5].

TCRE did not lead to any alteration of uterine andovarian haemodynamics per se [13], but patients who hadrelapse of menorrhagia at 1 year after TCRE had a lowerResistant Index (RI) at all levels of uterine arteriescompared with those who had persistent improvement[13]. Pregnancies after TCRE although rare, areassociated with increased risk of ectopic pregnancy.Surgical termination of pregnancy after TCRE ispotentially a difficult procedure and should be carried outunder ultrasound guidance [14].

Fluid overload, uterine perforation, hematometra eventhough rare, is the main complications associated withTCRE. Post operative infections are rare [3].Studies showthat in 70% of the patients post TCRE, even with apostoperative amenorrhoea, a residual endometrium canbe found. For the prevention of a hematometra due toTCRE , the cervix should be spared during endometriumablation and a hormone replacement therapy can be usedalongside [15].

Fluid overload and equipment failure were higher forthose women having laser treatment as compared withTCRE [3]. Comparison between newer techniques likeMEA and TBEA and TCRE do not show significantdifference. All the techniques achieve significant andcomparable improvements in menstrual symptoms, andhealth-related quality of life [9].

In conclusion TCRE should be considered as themainstay of treatment for DUB, it can be supported withhormonal replacement. Hysterectomy should be reservedfor recalcitrant cases of DUB.

REFERENCES

1. Farrell E. Dysfunctional uterine bleeding. Aust Fam

Review Article

123 Apollo Medicine, Vol. 7, No. 2, June 2010

Physician. 2004; 33(11): 906-908.

2. Lethaby AE, Cooke I, Rees M. Progesterone orprogestogen-releasing intrauterine systems for heavymenstrual bleeding. Cochrane Database Syst Rev.2000;(2): CD002126.

3. Lethaby A, Hickey M, Garry R. Endometrial destructiontechniques for heavy menstrual bleeding. CochraneDatabase Syst Rev 2009;(4): CD001501.

4. Marjoribanks J, Lethaby A, Farquhar C. Surgery versusmedical therapy for heavy menstrual bleeding. CochraneDatabase Syst Rev. 2006;(2): CD003855.

5. Cooper KG, Jack SA, Parkin DE, Grant AM. Five-yearfollow up of women randomized to medical managementor transcervical resection of the endometrium for heavymenstrual loss: clinical and quality of life outcomes.BJOG. 2001;108 (12):1222-1228; Comment in BJOG.2003; 110 (1): 87.

6. Duggal BS, Wadhwa RD, Sunder Narayan, Tarneja P,AB Chattopadhya. Transcervical Resection ofEndometrium Will it edge out Hysterectomy MJAFI,2003; 59 (3).

7. Allahdin S, Harrild K, Warraich QA, Bain C.Comparisonof the long-term effects of simple total abdominalhysterectomy with transcervical endometrial resection onurinary incontinence. BJOG. 2008; 115(2): 199-204.

8. McPherson K, Herbert A, Judge A, Clarke A, Bridgman S,Maresh M, Overton C. Psychosexual health 5 years afterhysterectomy: population-based comparison withendometrial ablation for dysfunctional uterine bleeding.Health Expect. 2005; 8(3): 234-243.

9. Sambrook AM, Bain C, Parkin DE, Cooper KG. Arandomized comparison of microwave endometrialablation with transcervical resection of the endometrium:follow up at a minimum of 10 years. BJOG.2009;116(8):1033-1037.

10. Garside R, Stein K, Wyatt K, Round A, Price A. Theeffectiveness and cost-effectiveness of microwave andthermal balloon endometrial ablation for heavy menstrualbleeding: a systematic review and economic modeling.Health Technol Assess 2004; 8(3).

11. Molnár BG, Kormányos Z, Kovács L, Pál A. Long-termefficacy of transcervical endometrial resection with nopreoperative hormonal preparation. Eur J ObstetGynecol Reprod Biol. 2006;127(1):115-122.

12. Stamatellos I, Koutsougeras G, Karamanidis D,Stamatopoulos P, Timpanidis I, Bontis J; Results afterhysteroscopic management of premenopausal patientswith dysfunctional uterine bleeding or intrauterinelesions. Clin Exp Obstet Gynecol. 2007;34(1): 35-38.

13. Liu Y, Cheong Y, Li TC, Xia E, Zhang D, Ma Y. Impact oftranscervical resection of endometrium on uterine andovarian haemodynamics. Reprod Biomed Online. 2007;15(1): 57-62.

14. Xia E, Li TC, Yu D, Huang X, Zheng J, Liu Y, Zhang M.Theoccurrence and outcome of 39 pregnancies after 1621cases of transcervical resection of endometrium. HumReprod. 2006;21(12): 3282-3286.

15. Römer T. Hormone substitution following transcervicalendometrial ablation. Zentralbl Gynakol. 1997;119(5):229-231.

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