Gynecological Surgeries
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| Hysteroscopy & Endometrial Ablation |
This set of procedures is usually used when women have too much bleeding with their periods-either the periods are too heavy, they come too often/unpredictably, or both. There are a few reasons why this can happen, including irregular ovulation, endometrial atrophy, endometrial polyps, fibroids, endometrial hyperplasia, and endometrial cancer. You've probably heard these terms before; and if you talk with your friends and family, someone will either have experienced one of these or know someone who has.
What happens in a normal period? Regular periods happen because the ovaries give a signal to the uterus once a month, essentially saying, "it's time to prepare for a pregnancy!" The inside lining of the uterus (the endometrium) responds to these hormones by getting thick and fluffy, and by making sure there's a really good blood supply in case a pregnancy tries to implant. Well, if pregnancy doesn't occur, then the ovaries send a different signal to the endometrium, and all the thickened, fluffed up tissue with a great blood supply slides off and out of the uterus. There's some bleeding that goes with this-and we call it a period!
Irregular ovulation : this means just what it sounds like. For various reasons, some women do not ovulate on a regular basis. One woman may have a condition called PCOS (polycystic ovarian syndrome); another may have diabetes; and another woman may be close to menopause and won't ovulate on a regular basis, and so forth.
Endometrial atrophy : "atrophy" means thin and puny. Most women who have bleeding after menopause have endometrial atrophy, sometimes associated with a polyp or two (see below). There's usually nothing bad about having endometrial atrophy, but the irregular bleeding or spotting can be a real nuisance and make the patient worry.
Endometrial polyps : polyps are finger-like growths of endometrial tissue. They are almost always benign (not cancer). Polyps bleed very easily and irregularly, even if the ovaries are not sending a signal that it's time for a normal period.
Fibroids : fibroids are firm and usually smooth balls of tissue that can be as small as an apple seed or be as large as a volleyball! If you look at the picture below, you can see that they are roughly in one of three places-subserosal (or just under the outer skin of the uterus. They can even come out on a stalk), intramural (stuck in the muscle wall of the uterus), or submucosal (right underneath the endometrium). It's very uncommon for these to have cancer in them. Depending on their location and size, they can cause a little abnormal bleeding, a lot of very heavy and irregular vaginal bleeding, and even pressure and pain when the fibroids are large enough.
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Endometrial hyperplasia : this is a condition when the lining of the uterus (endometrium) grows too thick, usually because there's too much estrogen in the bloodstream. There are essentially three types of hyperplasia, and your doctor will talk to you in detail about this if you have it.
Endometrial cancer : this is a condition that usually comes from endometrial hyperplasia if the hyperplasia has been there for a long period of time. The endometrium grows thicker than it should, and the usual checks and balances that tell it to stop when it has grown enough are turned off. The cells that make up the endometrium start to look abnormal (under the microscope, that is) too. Obviously, your doctor will talk with you in depth about this condition if it ever applies to you.
Is there a conservative way to fix this? Usually, there is! You've just reviewed the most common causes of abnormal bleeding. A lot of times, your doctor will order a pelvic ultrasound-and that really helps narrow down the possible causes. Occasionally, your doctor may want to put a small amount of saline inside of your uterus while the ultrasound is being done. This can give even more details about what might be causing the problem.
To get a really good idea of why a particular patient has this abnormal bleeding, your doctor will likely want to do an endometrial biopsy . It's sort of like a Pap test with a few cramps. With the speculum in the vagina, a thin, flexible tube is passed through the cervix and into the uterine cavity (where the endometrium is). He or she then applies a tiny bit of suction to the tip of this tube, and that gets a few wisps of tissue. This specimen gets sent to a lab, and the pathologist looks at it under the microscope. The pathologist sends a report to your doctor with the diagnosis.
Many times, after you've had an endometrial biopsy and ultrasound, your doctor will suggest hysteroscopy. He or she may recommend a D&C and/or an endometrial ablation. These are pretty easy to understand, very low risk, and the patient gets to go home about two hours after the procedure is finished. Under most circumstances, these procedures are done as outpatient surgery. The patient is under general anesthesia during the procedure ("completely out of it"), but these procedures can sometimes be done under IV sedation.
It takes the doctor 15 to 45 minutes to do the procedure, depending on what he or she finds inside the uterus. There are no incisions, and patients tend to get back to work and their daily activities by the next day. Many years ago, if you had one of these conditions, your options were either to live with it or have a hysterectomy. Hysteroscopy and endometrial ablation can fix the problem in most cases, and hysterectomy is avoided!
Hysteroscopy : literally means "look in the uterus". A long, thin metal scope is inserted through the cervix (which was dilated a little bit first) into the uterine cavity. There's a camera attached to the scope, so images are projected for your doctor to see on a monitor in the operating room. Saline is put into the cavity to make seeing the whole uterine cavity easier. The doctor will likely take pictures, and that way you'll get to see what was found after the procedure.
Resection of a polyp or fibroid: While your doctor is doing hysteroscopy, he or she may want to remove a polyp or fibroid if it's sticking up from the endometrium. This is something that can be done easily through the same scope that is already in the uterus.
D&C: this means "dilation and curettage". "Curettage" is a French word that means "gently scrape". After the doctor has looked around and removed any polyps or fibroids, he or she will likely use a small spoon-shaped instrument to gently scrape away some of the endometrial lining. This not only provides a lot of tissue for the pathologist to analyze (and confirm the initial diagnosis), but it also prepares the inside of the uterus for an ablation.
Endometrial ablation: This means that heat is delivered to the lining of the uterus. It is treated with this heat, usually for an average of 90 seconds, so that no matter what signals the ovaries send to the uterus, the lining of the uterus won't be able to build up, get thick, and bleed. Over half of women who undergo this procedure never have another period; and of the women who do continue to have periods, they are much lighter and more regular. So after all is said and done, more than 9 out of 10 women say they're satisfied with the results.
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