Menstrual Disorders - Surgery

Heavy bleeding, often from fibroids, is the reason for about two-thirds of all hysterectomies. However, in about half of these hysterectomies, no abnormalities are detected to explain the bleeding. In one European study, women with menorrhagia were more likely to choose hysterectomy over conservative treatment if they also had pelvic pain and were inconvenienced by the heavy bleeding. The number of procedures has continued to increase, but the rise has slowed substantially in recent years.

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In its support, hysterectomy, unlike medical treatments and less invasive procedures, cures menorrhagia completely, and most women are satisfied with the procedure. Less invasive hysterectomy procedures are also improving recovery rates and increasing satisfaction afterward.

Still, in one study in 70% of cases when physicians recommended hysterectomies, they did not give their patients alternative choices or adequate diagnostic evaluations. It should be noted that some evidence suggests that the levonorgestrel-releasing intrauterine system, or LNG-IUS (Mirena, FibroPlant) might help avoid hysterectomy in 80% of cases. Any woman, even one who has reached menopause, who is uncertain about a recommendation for a hysterectomy for fibroids or heavy bleeding should certainly seek a second opinion.

[For more details on hysterectomy, see In-Depth Report #73, Fibroids: Uterine or Report #74, Endometriosis.]

Nerve Destruction Techniques for Treating Dysmenorrhea

There is some evidence that when the pain-conducting nerve fibers leading from the uterus are surgically severed, the amount of pain from dysmenorrhea diminishes. Two procedures, uterine nerve ablation and laparoscopic presacral neurectomy, are used to block such nerves. Small studies have shown benefits from these procedures, but stronger evidence is needed before they can be recommended for women with severe primary dysmenorrhea.

Laparoscopic Uterosacral Nerve Ablation (LUNA). LUNA is a recent approach that uses either laser or cauterization to destroy nerves in a small segment of the ligaments that connect the cervix with the lower back. The ligaments do not appear to provide any structural support. About 30% of patients do not respond to this treatment. There are few side effects from the procedure. The patient does not lose any sensations associated with sexual activity.

Laparoscopic Presacral Neurectomy. Laparoscopic presacral neurectomy uses laser techniques to sever a web of nerves between the lower spine and tail bone that transmit pain from the uterus. The procedure does not affect fertility. Some studies report pain relief in about 90% of women. It has more complications than LUNA, however. They include constipation, diarrhea, and urinary problems. (It should be noted, however, that these symptoms improve after the procedure in as many women.) Although injury can occur during the procedure, it is uncommon.