Surgical treatment is indicated when HMB is due to pelvic diseases that are amenable by surgery e.g. uterine fibroids and endometrial polyps or when medical treatment has failed in the women with HMB due to DUB and or whenever a woman opts for a more permanent fix for the management of her HMB. Such surgeries can be conservative, when the structure and or the function of the womb/uterus are conserved e.g. myomectomy for the management of uterine fibroids or non-conservative when the uterus is removed, totally putting an end to any form of possible bleeding whether normal or abnormal from the uterine endometrium. The surgical process of removing the uterus with or without its appendages is known as hysterectomy. Endometrial ablation, although a conservative surgical procedure, is associated with significant impairment of fertiltiy and complicated pregnancies and as such is indicated only in women with HMB that are not desirous of pregnancy and are ready to accept contraceptive meaures following surgery. In this section we will focus on the surgical management of HMB due to DUB while various conservative surgeries for specific pelvic causes of HMB will be described in sections on this site dedicated to the specific disease.
Surgical treatment in the setting of DUB is normally restricted to women for whom medical treatments have failed. It is important that such women are certain that they have completed their family size and are not desirous of fertility. This is because hysterectomy, a non conservative procedure involved in the removal of the uterus, will render a woman incapable of getting pregnant, while endometrial ablation, a procedure involved in destruction of the uterine endometrium will also render a woman subfertile but in the event of an unlikely pregnancy, is associated with an increased risk of preterm delivery and abnormalities in the placenta formation.
This refers to the removal of the uterus. It is an extremely common procedure in many parts of the world with about 20 per cent of women being reported to have had hysterectomy by the age of 60 in some countries. It can be subdivided into total hysterectomy (TAH) and subtotal hysterectomy (STAH) depending on the exent of the surgery. TAH refers to total removal of the uterus including the whole of the cervix while STAH refers to the partial removal of the uterus leaving behind the lower part of the uterus and or the cervix. Although TAH is often desired in most cases, STAH may be indicated by patient’s preference or by the presence of scar tissues between the cervix and the lower part of the uterus with adjoining structures such as the bladder or the pelvic side walls preventing proper access for its removal, common in women with previous surgeries. Such patients after surgery require cervical screening just like any other women with intact uterus as there remain a potential risk of cervical cancer.
Hysterectomy may be combined with the removal of one or both ovaries and the fallopian tubes in what is termed unilateral salpingo-oophorectomy (USO) and bilateral salpingo-oophorectomy (BSO) respectively. Although removal of both ovaries combined with a total hysterectomy almost totally eliminate any form of genital tract diseases and cancer such as ovarian cancer, ovarian cyst, and endometrial cancer, just to mention a few, performing a bilateral salpingo-oophorectomy will immediately result in a post-menopausal state with all the features of menopause if done for a woman yet to attain menopause. Therefore, a proper counselling of all women must be done before surgery, comparing the pros and cons of leaving or removing the ovaries with that of the symptoms of menopause such as sweating, hot flushes, dyspareunia, mood changes e.t.c. after assessing each woman’s personal risk of developing the female genital tract cancers (ovarian cancer, endometrial cancer and cervical cancer) and that of the pros and cons of hormone replacement therapy for the management of post menopausal symptoms. This is especially important as removal of the uterus and ovaries without a woman’s consent (or without her full understanding of the nature of the procedure) is a recurrent cause of law suites in gynaecology and informed consent may be required separately for each part of the procedure before the surgery.
Hysterectomy may be approached, laparoscopically, abdominally and vaginally depending on presentation, uterine size and expertise of the surgeon. Large sized uterus such as those with huge fibroids are removed abdominally, while small sized uterus remaining in the pelvis can be approached vaginally baring the absence of a previous pelvic surgery. A laparoscopic approach to the removal of the uterus can be done either by an abdominal route only in what is referred to as total laparoscopic hysterectomy (TLH) or in combination with a vaginal approach in what is referred to as Laparoscopy-assisted vaginal hysterectomy (LAVH). In terms of numbers of days of hopsital stay, vaginal and laparoscopic approach have the shortest hopsital stay, while abdominal hysterectomy has the longest hospital stay. In vaginal hysterectomy, the scar is hidden in the vagina, while, one or more tiny small scars may be left on the abdomen in laparoscopic hysterectomy, unlike a long abdominal scar seen in abdominal hysterectomy. Recovery time from surgery is shorter in vaginal and laparoscopic hysterectomy, but longest in abdominal hysterectomy taking about 6 to 12 weeks following surgery.
These are of procedures involved in the destruction of the endometrial lining to sufficient depths deep enough to prevent normal regeneration of the endometrium. With an average of about 90% reduction in the mean blood loss, 40 per cent of all women who have endometrial ablation will become amenorrhoeic i.e. stop seeing their menses, another 40 per cent will have markedly reduced menstrual loss while only about 20 per cent will have no difference in their bleeding. Hence it serves as a worthy alternative to hysterectomy for many women with HMB due to DUB who are reluctant to undergo hysterectomy. Compared to hysterectomy, it is associated with a very short hospital stay (1 day compared to 5 to 7 days for hysterectomy) and even a shorter recovery time.
As mentioned earlier, it must be offered only to women undesirous of future fertility and proper conselling on possible complications during surgery (e.g of perforation of the uterus and electrolyte derangement and fluid overload), success rates of the procdure, post operative symptoms (such as crampy lower abdominal pain for about a day or two after surgery and light bleeding or greyish vaginal discharge for up to a few weeks after surgery), the need for contraception and possible complications of an unexpected pregnancy (preterm labour, retained placenta and morbidly adherent placanta) and alternative treatment such as hysterectomy including the chance of a repeat surgery most especially hysterectomy should be expressed to the woman. For further enquiry on surgical treatments of HMB or for an online consultation on a related issue, kindly CHAT WITH OUR CONSULTANTS.
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