SURGICAL MANAGEMENT OF AUB

Times have changed. 50 years ago, AUB was mainly treated by surgical procedures, Dilatation and Curettage which stopped the bleeding temporarily and also shed light on the endometrial curetting hyperplasia, precancerous changes and endometrial cancer. Now there are many minor safe procedures, such as hysteroscopy, removal of polyps, endometrial removal of small sub mucous fibroids others are endometrial ablation, uterine artery embolization, (UAE), and off course Hysterectomy, with or without bilateral removal of tubes and ovaries. These are for cancer, pre-cancer treatment and major pelvic pathology e.g. large fibroids and ovarian cysts. Removal of fibroids is often done as procedure called myomectomy. These are sometimes treated by UAE so they shrink.

Endometrial ablation has come a long way since it started in the nineties. Originally it was done by an electric instrument called Resectascope, for which you required training and practice, as it could cause serious side effects such as injury to the uterus and even the bowel.

Now there is a large array of global endometrial ablation (GEA) tools. The principal mainly applies to destroying the lining of the uterus by radio frequency waves or by Cryo-freezing.  Before we decide to ablate the endometrium, we have to classify the cause of AUB. Making sure there is no intra uterine pathology. A small fibroid 2-3cm can be dealt with GEA. Make sure there is no cancer or pre-cancer pathology. It must be explained to the women that they cannot have any babies.  About 0.7 % of women can conceive after GEA, but it is always disastrous. Some clinicians even do a tubal ligation at the same time. After we have seen all the pros and cons of GEA with the patient, do an ultrasound to exclude any uterine pathology, measure the uterine thickness, made sure there is no pelvic infection, there is no scar in the uterus such as classical caesarean section or myomectomy and cervix is not loose. Every surgeon and the hospital now use the method they are competent with. GEA can be done soon after a period. Measure the length of the uterine cavity. Put the device in, which can be of different types, and once inside it they fit in with the uterine cavity.  Radio frequency waves are passed for 90 seconds while we rotate the device to ablate the total cavity. Remove the device after few seconds so that it cools down to avoid scaring of the cervix. There can be a few serious problems such as uterine perforation. The patient can be given pain relief for a few days.

The latest GEA was approved by FDA in 2015. It is called Minerva. Minerva takes only 3-4 minutes. The device is inserted into the uterine cavity. With this device, the radio frequency is delivered by ionized Argon gas to create plasma. This is controlled by Impedance. The energy is passed for 120seconds.  The other technique is microwaves; the advantage of microwaves is it can be used for a bigger uterus.  Just to name a few, Genesys HTA, Cryo-ablation and heated free fluid and so on.

SURGICAL TREATMENT OF AUB FOR MYOMAS

Myomas are called leomyoma in AUB in FIGO classification. The myomas affect about 50% of women in their life time. Many of these are asymptomatic, the main symptoms they cause are excessive or intermittent bleeding, infertility, and pressure effects due to their size, frequency of urination, constipation, walking difficulty, back ache and so on. If they are a symptomatic there is no need to treat them. Minor problems happen with an endometrial polyp. This can also cause post menopausal bleeding. It can be easily treated on hysteroscopy by removing it. We always send it to pathology as it rarely can be cancerous. The other problems are sub mucous fibroids they can also be removed by hysteroscopy resection. If they are biggish and deep you need a bit more training for this as, you may damage the uterus or rarely adjoining organs. This helps with infertility treatment. A small sub mucous fibroid less than 3 cms can be destroyed at the time of endometrial ablation particularly by the microwave method; however you lose your fertility by GET.

The other method of treating these fibroids is to do what is called uterine artery or fibroid embolization this procedure was first done in 1995. It is done by an interventional radiologist. It is best for fibroids which are within the muscles of the uterus (Intramural). There is some dispute about what is the biggest fibroid you can do it for. General agreement is if the fibroid is bigger than 10cms in size do not do it. When it dies and sloughs it causes problems.  For this procedure you are supposed to stop all your blood thinners, including aspirin and Nsaides (pain relief drugs such as Ibobrufen), several days before. You are prepared like any other operation. It is done under strict sterile conditions. You have to stay in hospital overnight. The operation is performed in the groin on one or both sides depending on the preference of the radiologist. It can be done under local or general, anaesthesia depending on how brave you are.

A small cut is made over the femoral artery in the groin. A small catheter size 1/8 of an inch in diameter is inserted and gradually guided to the uterine artery, embolizing agents are injected. These particles are about the size of sand, the catheter is than guided to the uterine artery on the other side and injected. Some radiologists prefer to use the other side for the uterine artery on the other side.  UAE should not be done if the woman is allergic to contrast media, she is pregnant, has cancer, vascular or bleeding disorders, and recent or severe past pelvic infections.  This procedure gives symptomatic relief in 83% within 6 months. Fibroids decrease in size from 40 to 70 %.   Repeat treatment was required in 15 – 28 %.  This intervention was done by repeat UAE, myomectomy or hysterectomy. Women like to have UAE as it avoids too much time off, major surgery, saves the uterus and saves fertility. The side effects are it can cause infections, damage to ovarian blood supply, problems with future pregnancy. One important side effect is post embolization syndrome. Women run a low grade fever, pain, fatigue, nausea, vomiting and this peaks in 48 hours and then resolves in one week. If it fails to resolve we should look for infection. Sometimes the material from the fibroids gets stuck in the uterine cavity, and then the women require dilatation curettage for this material to be removed.

The final surgical procedures are myomectomy this can be assisted by reducing the size of the fibroids by GnRh analogues or Ultrapristol. Then myomectomy can be performed by laparoscopy or normal laparatomy depending on individual cases. Similarly Hysterectomy can be performed abdominally, vaginal or laparoscopy assisted. It depends on the cases or surgeons preferences. After myomectomy babies need to be delivered by caesarean section.

 SUMMARY ABOUT AUB 

The new FIGO classification of AUB and many current methods of treatment have made a gynaecologists life very interesting. When you have a case of AUB first classify it and   then plan the treatment. Is it urgent, can we manage by medical treatment or she requires surgical options? Always keep few things in mind, patients age, her views, her needs, does she need contraception, future pregnancy, does she have any medical problems, social situations, and always respect her views with your line of treatment.