Endometrial resection/vaporization: a patient-friendly first-option treatment for menorrhagia in rural areas

Introduction

Excessive menstrual bleeding is a common presenting symptom in women attending gynaecological consultation. Many of them eventually undergo hysterectomy. ¹ Hysterectomy, being a major surgical procedure, is not always an acceptable procedure for women from rural areas who attend small hospitals. In northeast India, where the population includes people from tribes who have a variety of traditional isolation practices for women during the menstrual period, hysterectomy has an even poorer acceptance rate. Near total endometrial resection/vaporization offers a procedure that is more acceptable and which controls menorrhagia. The procedure can be carried out using standard urology instruments (i.e. 27 F resectoscope manufactured by Karl Storz).

Patients and methods

Forty-eight patients who presented to Burrows Memorial Christian Hospital at Silchar, Assam in northeast India, from April 1999 to December 2001 with heavy menstrual bleeding (27), irregular and heavy menstruation (10), uterine polyp (8) and postmenopausal bleeding (3) underwent endometrial resection/vaporization. Forty-one preferred to undergo hysterectomy. Eighteen of those who underwent endometrial resection/vaporization were available for follow-up five years later in 2006.

All patients received prophylactic perioperative antibiotics. They were placed in the lithotomy position after being given a spinal anaesthesia. The endometrial resections were carried out with a urological resectoscope after the cervix had been dilated; 1.5% amino acetic acid (glycine) was used for irrigation. Usually a bit of endometrium near the fundus was left unresected so that the women were able to continue to have menstruation but with a much reduced blood loss. From March 2001 the endometrium was vaporized using special electrodes after resecting a small piece for biopsy.

The cervix was dilated using Haegar's dilators to 30 F or more as the size of the resectoscope is 27 F. The standard cutting loop with the electocautery setting of 150 W was used to resect boat-shaped pieces of endometrium and the bleeding points were coagulated. The vaporization technique uses a special vaporizing electrode and a setting of 400 W cutting current is used. There is hardly any bleeding and the endometrium is vaporized by the intense heat generated at the tips of the electrodes.

The results are show in Tables 1–4.

Discussion

In the tribal area in northeast India a variety of isolation techniques are practiced and women feel uncomfortable about undergoing hysterectomy because they are unable to take part in these practices. They are considered to be unclean during the menstrual periods and remain isolated at such times. Hysterectomy is a major surgical procedure which involves a long absence from home and considerable expense for the family. Endometrial resection/vaporization offers an alternative treatment for these women. It is a safe and effective procedure and the patients can return home a day after the procedure.

Studies ² have shown that hysteroscopic surgeries have less morbidity and significantly shorter recovery periods. The procedure has gained popularity – 42 endometrial vaporizations were carried out in 2002. However, after the patients became aware that many of them might subsequently require a hysterectomy it became less popular. Some studies ^2,3 reported a brownish discharge per vaginum, persistent menorrhagia and need for repeat procedures.

Laparoscopy-assisted vaginal hysterectomy then became the procedure of choice. Patient satisfaction was significantly higher with hysterectomy. ² However, endometrial resection/vaporization is a friendly procedure that is acceptable even to those who are averse to hysterectomy.

In this series, patients with postmenopausal bleeding who initially refused hysterectomy underwent an endometrial resection. They only agreed to undergo hysterectomy after the biopsy reports were available. Of the two procedures endometrial vaporization is considered a better option. ⁴ It is a patient-friendly procedure that is better indicated for patients with milder symptoms who do not warrant hysterectomy or who refuse hysterectomy. It can be comfortably carried out using standard urology instruments. Unlike the laparoscopic or open hysterectomies, it is a simple procedure which even the junior doctors are able to easily learn and perform.