Heavy%20menstrual%20bleeding Treatment

Treatment

Considered in cases where patient does not desire future pregnancy, or in the presence of pelvic disease (ie uterine fibroid tumors)

Endometrial Ablation (EA)

Aims to destroy or remove the endometrium and the superficial myometrium which reduces or completely stops menstrual blood loss
Should be considered in women who have a normal or ≤10-week pregnancy-sized uterus, those with <3-cm uterine fibroids, those wherein medical treatment has failed, who completed child-bearing or who are not candidates for major surgery
After endometrial ablation, women are advised to avoid subsequent pregnancy and the need to use effective contraception, if required
Results in faster return to normal activities compared with hysterectomy but is associated with a 22% reintervention rate
Divided into 1st- and 2nd-generation methods, depending on whether direct visualization is needed or not

Hysteroscopic-Guided Endometrial Ablation

First-generation methods, eg transcervical resection of the endometrium (TCRE), rollerball EA (REA)
Performed through a hysteroscope
Recommended in patients who will also undergo hysteroscopic myomectomy
Involves distending the uterine cavity with fluid and then resecting the tissue with an electrosurgical loop (TCRE method) or burning the tissue with a heated rollerball (REA method)
Takes more time to perform, requires regional or general anesthesia and is technically more difficult than 2nd-generation methods
Not suitable for patients with cardiac or renal disease due to 4% risk of fluid overload

Non-Hysteroscopic Methods

Second-generation technologies, eg thermal balloon endometrial ablation (TBEA), microwave EA (MEA), hydrothermablation, bipolar radiofrequency EA, endometrial cryotherapy
Used when there is no structural or histological abnormality identified
Not done under direct visualization of the uterine cavity
Easier to learn and safer to use
- Risks of complications are fewer and anesthetic requirement is lesser than hysteroscopic ablation

Hysterectomy

Appropriate for women who have completed their family, have failed or are contraindicated for other treatment options, do not want to retain their uterus, fertility or menstrual bleeding, and are willing to assume the risks of surgery
3 main routes: Abdominal hysterectomy (AH), vaginal hysterectomy (VH) and laparoscopic hysterectomy (LH)
- Choice of route depends on the size or mobility of the uterus, size and location of uterine fibroids, size and shape of the vagina, presence of other gynecological conditions and history of previous surgery
- VH is the preferred route; contraindicated in patients with large uterus, presence of pathology and low uterine mobility

Possible unwanted outcomes include infection and less commonly, intraoperative hemorrhage, damage to other abdominal organs and urinary dysfunction
Bilateral oophorectomy is not recommended if patient has healthy ovaries

Myomectomy

Recommended for women with >3-cm uterine fibroids who want to retain their uterus and fertility
May be performed via an abdominal approach, laparoscopically, or hysteroscopically
Possible unwanted outcomes include adhesions (which may result in pain and/or impaired fertility), infection, perforation and recurrence of fibroids

Uterine Artery Embolization (UAE)

Advised in patients with >3-cm uterine fibroid who want to retain their uterus and fertility and avoid surgery
Done by an interventional radiologist through injecting particles in the uterine arteries causing blockage and then shrinkage of the fibroids
Studies showed that effect on HMB that is associated with uterine fibroid is similar to hysterectomy and myomectomy

Magnetic Resonance-Guided Focused Ultrasound Surgery (MRgFUS)