New treatment for menorrhagia
BY CHRISTINE HANSEN, MD
BOULDER WOMEN'S CLINIC
Menorrhagia, or heavy menstrual bleeding, is one of the most common complaints encountered by primary care physicians and gynecologists. The condition severely impacts quality of life. The traditional primary treatment for menorrhagia caused by submucosal myomas or endometrial polyps involved major surgery, with menorrhagia responsible for almost 20 percent of U.S. hysterectomies. Morcellator hysteroscopy is at the forefront of what will become a new, less-invasive standard of care for treating menorrhagia caused by myomas or polyps.
Between 5 and 10 percent of all U.S. women complain to their doctors about menorrhagia1, which affects more than 10 million annually2. Menorrhagia is defined as menstrual loss of more than 80 mL. This translates to menses that continues for more than seven days or the use of more than 10 pads or tampons per day. It is most commonly associated with perimenopause3.
Although menorrhagia is not fatal, it can cause chronic anemia, pelvic pain and cramping. The condition also severely impacts quality of life by disrupting work, social functioning and family life2.
Menorrhagia can have hormonal or non-hormonal causes. Uterine fibroids, or myomas, are a common non-hormonal cause3. Clinically, there are three main types of myomas, classified according to their location in the uterus:
- Intramural myomas grow within the uterine wall.
- Subserosal myomas develop in the outer portion of the uterus.
- Submucosal myomas grow just under the lining of the uterine cavity and near the endometrial cavity.
It's this last group of myomas, the submucosal, that have the most effect on menorrhagia4,5. Because of their location on the endometrium, these myomas place pressure on the uterine lining that builds with each menstrual cycle. This, in turn, can cause heavy bleeding. Even very small submucosal myomas may cause very heavy bleeding.
Endometrial polyps are another non-hormonal cause of menorrhagia. These hyperplastic overgrowths of glands and stroma form a mushroom-like fold that projects into the uterine cavity. They can be single or multiple growths.
SHORTFALLS OF CONVENTIONAL HYSTEROSCOPY
Only a few years ago, the primary way to treat menorrhagia caused by myomas or polyps involved major surgery, including the often ineffective Dilation and Curettage (D&C) and the very invasive hysterectomy. Although these are still widely used treatments-with menorrhagia responsible for almost 20 percent of U.S. hysterectomies and 40 percent of D&Cs3-there are now other less-invasive options.
In recent years, hysteroscopic treatment has become an effective option. Hysteroscopic myomectomy is a major advancement for treating submucosal myomas6, and hysteroscopic polypectomy for endometrial polyps7.
Conventional hysteroscopic treatment typically uses a resectoscope equipped with a wire-loop electrode. The resectoscope is passed into the uterine cavity by way of the endocervical canal, and the uterine cavity is distended with a non-electrolyte solution. The surgeon then removes the intrauterine lesions using an electro-surgical technique.
Even though conventional hysteroscopic treatment is a less invasive means of removing intrauterine lesions compared to older treatments, it still has some weaknesses. During conventional hysteroscopic treatment, the surgical instruments must be removed periodically so that an active suction can be inserted to clear debris from the visual field. The surgeon must pass both the hysteroscope and resectoscope in and out of the uterine cavity numerous times to remove excised tissue. This process is very time consuming and increases the risk of puncturing the uterus.
Also, when a resectoscope is used, the surgeon must rely on electrolyte-free solutions for distension and irrigation. These fluids have been known to cause sodium imbalances and fluid overloading. There is also some risk of thermal injury.
QUICKER, SIMPLER, SAFER LESION REMOVAL
Morcellator hysteroscopy is the most recent innovation in hysteroscopic treatment, delivering several advantages over conventional techniques for the removal of submucosal myomas and endometrial polyps. Only a handful of U.S. surgeons currently offer the procedure.
Approved by the FDA in 2004, morcellator hysteroscopy uses a probe with a "uterine shaver." Once placed inside the uterine cavity, the device shaves off and immediately suctions out any excised tissue that might impair visibility. The ability to remove and instantly suction out tissue fragments means the hysteroscope and morcellator are inserted only once, for initial entry. This is a huge advantage from both the physician's and the patient's point of view.
For the physician, the immediate removal of tissue through the probe makes surgery much simpler to perform and requires less surgical time. A recent study showed that this new method cuts average operating time in half8. For myomas, the mean morcellator operating time was 16.4 minutes compared to 42.2 minutes for resectoscopy. For polyps, mean morcellator time was 8.7 minutes compared with 30.9 minutes for resectoscopy.
The advantage for the patient is a much safer treatment. Shorter operating time means less exposure to general anesthesia and puts the patient at less risk of fluid overloading. There is also a reduced risk of puncturing the uterus from multiple entries of surgical instruments.
There are other advantages as well. Since the morcellator does not rely on electro-surgical techniques, the surgeon can use a saline solution for distension and irrigation instead of an electrolyte-free solution. This minimizes the risk of sodium imbalance and thermal injury.
Morcellator hysteroscopy is at the forefront of what will become the new standard of care for treating menorrhagia caused by submucosal myomas or endometrial polyps. The new procedure (1) shortens operating time by quickly removing tissue, which reduces the patient's exposure to anesthesia and risk of fluid overload; (2) requires only a single entry of surgical instruments, reducing the risk of puncturing the uterus; and (3) uses a non-electrosurgical technique to avoid the risk of thermal injury and reduce the risk of sodium imbalance.
Drs. Hansen and Ryan are two of only a handful of U.S. surgeons currently offering the procedure. They can be reached at 303-444-5110.
FOOTHILLS HOSPITAL DESIGNATED AS REGIONAL TRAINING SITE
Boulder Community Foothills Hospital has been designated as the Rocky Mountain area's first regional training site for physicians wishing to learn how to perform morcellator hysteroscopy using the Smith & Nephew Operative Hysteroscopy System. The hospital joins training centers in Boston, Chicago, Dallas and Houston. Drs. Hansen and Ryan will be part of the training team.
1. Centers for Disease Control and Prevention: Office of Women's Health. Helping Women Understand Bleeding Disorders, Health Matters for Women Newsletter, Summer 2002.
2. National Women's Health Resource Center. Survey titled Majority of Women Do Not Seek Treatment for Health Condition Affecting 1 in 5, November 15, 2005.
3. Warren M. The Need For Proper Diagnosis and Treatment of Menorrhagia. Menopause Management, November/December 2002.
4. National Uterine Fibroids Foundation. Uterine Fibroids, August 27, 2004.
5. Mayo Foundation for Medical Education and Research. Uterine Fibroids: Signs and Symptoms, March 2006.
6. The National Guideline Clearinghouse. Surgical alternatives to hysterectomy in the management of leiomyomas, accessed online April 2006.
7. Preutthipan S, Herabutya Y. Hysteroscopic polypectomy in 240 premenopausal and postmenopausal women. Fertil Steril. 2005 Mar;83(3):705-9.
8. Emanuel MH, Wamsteker K. The Intra Uterine Morcellator: a new hysteroscopic operating technique to remove intrauterine polyps and myomas. Journal Minim Invasive Gynecol. 2005 Jan-Feb;12(1):62-6.