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Heavy Menstrual Bleeding (HMB) – Part 2: Conservative Surgical Management

Case 1
A 43 year old Nigerian mixed race stock broker presented to her Family Physician about 3 to 4 years ago with history of soaking 2 tampons every 4 hours for consecutive menstrual cycles. She was not a known diabetic. She had a normal pap smear done 9 months earlier. She was pale with a haemoglobin level of 8.3gm/dl. Ultrasound scan showed a normal uterus with a slight thickening of the inside of the womb (endometrium).
The physician prescribed Primolut tab which initially decreased the blood loss but for only 7 weeks and the bleeding continued unabated. She reported back to her physician and a progestogen hormone impregnated IUCD was inserted in the womb. Blood forming tablets was prescribed. She had a temporary relieve for about 6 months when the bleeding started all over again. After one and a half years of battling with this intermittent but heavy bleeding, the lady reported again to her gynaecologist.
The consultant gynaecologist saw the lady and a repeat scan noted once again the thickness of the endometrium. The woman was counselled for a hysteroscopy (camera visualisation of the inside of the womb). During hysteroscopy, several tiny little growths (polyps) were found and were uneventfully removed. All removed tissues were sent for microscopic examination (histology). The result found no evidence of cancer but a benign condition called uterine or endometrial polyps.

Case 2
Mrs. FYB was a 35 year old baby specialist doctor who reported several months of heavy menstrual flow. She has 3 children all alive and has completed her family. She was assessed and found to have a normal uterus and ovaries on ultrasound, her pap smear was normal but this bleeding that trickles unannounced was a source of concern to her. She has been on a combined oral contraceptive and a clot forming pill, all to no avail. She was advised by the gynaecologist to have an endometrial biopsy using a thin flexible plastic syringe as an office procedure. The histology result was non-cancerous. A hysteroscopic endometrial resection or destruction was planned and carried out uneventfully. Her bleeding was subsequently ameliorated.

Case 3
The 3rd case is Mrs. VA, a 33 year old Nigerian teacher who has no problem falling pregnant but she lost the pregnancies on 3 different occasions and therefore has no children – a cause of major emotional trauma in Africa. She has been consulting her general practitioner for heavy menstrual flow. She was subsequently referred to her gynaecologist for a 3cm diameter submucoid fibroid by a radiologist.
The lady was terrified when she had of surgery to remove the fibroid and she went spiritual. A year later, her bleeding and childlessness persisted. She came back to the gynaecologist who offered her laparoscopy and or hysteroscopy. Hysteroscopy was performed with removal of the submucosal fibroid uneventfully.

The women who have an underlying problem of growths like fibroid or polyps are best treated by removing the pathology as in Ms. VA above. Mrs. FB needed to have her endometrium (the source of her bleeding) destroyed surgically. Many methods of achieving this abound. The method can only be used by those women who have completed their families as a significant woman will not be capable of further conception.
The options for destroying the endometrium includes balloon heating, roller ball ablation or thermal endometrial resection, where the whole lining of the womb is removed, burnt or vaporised. This method of destroying, or ablation of the endometrium is a minimally invasive procedure that surgically destroys or ablates the uterine endometrium. Radio frequency/ ultrasonic/ microwave ablation also works at destruction by mostly vaporising the endometrial cells.
It is important to rule out conditions that may lead to cancer especially in women who are perimenopausal. In this condition your gynaecologist will not perform conservative surgery but a total hysterectomy. All three women whose history appeared above had a permanent solution to their heavy bleeding after three years of follow up.
Generally, in the women who have endometrial ablation, 90% returns to normal bleeding and reduction of painful period, 95% recommends the treatment to their friends, 96% are satisfied and 35% stop their menstruation. Your gynaecologist will always choose the option that particularly suits your condition. In many situations, medications can be used as a first line option but in most instances, hysteroscopy or endometrial biopsy especially in the perimenopausal, are needed to rule out conditions that may lead to cancer.




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