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Operations associated with functional gynaecology


Hysteroscopy

What is a hysteroscopy ?

A hysteroscopy is a procedure to look at the inside of the uterus (womb) using a small telescope (hysteroscope). It is common for a biopsy (removing a small piece of the lining of the womb) to be performed at the same time.
Your gynaecologist has recommended a hysteroscopy, as it is good for finding out the cause of abnormal bleeding from the womb especially heavy periods and bleeding after the menopause. However, it is your decision to go ahead with the procedure or not. This document will give you information about the benefits and risks to help you make an informed decision.
If you have any questions that this document does not answer you should ask your gynaecologist or any member of the healthcare team.

Why do I need a hysteroscopy?

Your symptoms suggest you may have a gynaecological problem but the exact cause has not been found so far. A hysteroscopy will find out if you have one of the following conditions:

  • Fibroids, where the muscle of the womb becomes overgrown
  • Polyps- a polyp is a small skin tag that looks like a small grape on a stalk.
  • Endometrial cancer (a malignant growth in the lining of the womb) can be diagnosed.
  • Abnormally shaped womb, which is sometimes associated with abnormal uterine bleeding or miscarriages.

If your gynaecologist finds the cause of your symptoms, they will discuss appropriate treatment with you.
It is common not to find a problem. You can then be reassured that there is nothing seriously wrong. Other treatment can then be considered.

What are the benefits of a hysteroscopy?

A hysteroscopy will normally allow your gynaecologist to find out the cause of your problem and decide on the best treatment for you.

Are there any alternative to a hysteroscopy?

It may be appropriate to try to find the cause of your symptoms using a scan and by performing a biopsy using a small tube placed through the cervix (neck of the womb). Sometimes it is not possible to place the small tube in to the womb, or to get enough tissue. Your gynaecologist may recommend a sono-ultrasound (Also called sono-hysterogram) where an ultrasound device is placed in your vagina and your womb is filled with saline solution.
It is important to realize that these alternatives cannot identify all conditions and a hysteroscopy may still be recommended even if your results are normal. Your gynaecologist can discuss the options with you.

What will happen if I decide not to have the procedure?

Your gynaecologist may recommend a scan and biopsy to find out more information. However, this may not accurately find out the cause of your symptoms. Choosing not to have the procedure may make it more difficult for your gynaecologist to decide on the best treatment for you.

What happens before the procedure?

Your gynaecologist may ask you to go to a pre-admission clinic. They will carry out several tests and checks to find out if you are fit enough for the procedure. If you have any questions about the procedure, you should ask a member of the healthcare team at this visit.
Your gynaecologist may ask you to have a pregnancy test to make sure you are not pregnant. The test is usually performed using your urine sample.
Sometimes it may not be possible to perform the hysteroscopy if you are bleeding. Let a member of the healthcare team know if you are likely to be bleeding at the time of the procedure.

What does the procedure involve?

The healthcare team will carry out a number of checks to make sure you have the procedure you came in for. You can help by confirming to your gynaecologist and the healthcare team your name and the procedure you are having.
A hysteroscopy can be performed under local or general anaesthetic, or without any anaesthetic. The procedure usually takes less than 10 minutes.
Your gynaecologist may examine your vagina. They will pass the hysteroscope along your vagina, through your cervix and in to your womb. Your gynaecologist will inflate your womb using gas (carbon Dioxide) or a fluid so they can have a clear view. They can use instruments to perform a biopsy to remove polyps and small fibroids.

What should I do about medication?

You should make sure our gynaecologist knows the medication you are on and follow thier advise.
You may need to stop taking Warfarin, Clopidogrel, oral contraception or hormone replacement therapy (HRT) before your operation. Your gynaecologist may not perform a biopsy or remove any tissue.
If you are a diabetic, it is important that your diabetes is controlled around the time of your operation. Follow your gynaecologist advice about when to take your medication. If you are on Beta Blockers to control your blood pressure, you should continue to take your medication as normal.

What complications can happen?

The healthcare team will try to make your procedure as safe as possible. However, complications can happen some of these can be serious and can even cause death (risk: less than 8 in 100,000).
The possible complications of a hysteroscopy are listed below. Any numbers which relate to risk are from studies of woman who have had this procedure. Your doctor may be able to tell you if the risk of a complication is higher or lower to you.

  • Complications of anesthesia

Your anaesthetist will be able to discuss with you the possible complications of having an anaesthetic

  • Complications of a hysteroscopy
  • PAIN the healthcare team will try to reduce your pain. Pain after a hysteroscopy is usually mild (similar to period pains) and is usually controlled by simple painkillers
  • FEELING OR BEING SICK, which is common after the operation. Most women have only mild symptoms and feel better within 24 hours without needing medication
  • BLEEDING, which is usually mild (similar to a period), settling within 7 days. It is important to use sanitary pads not tampons
  • INFECTION, which may cause an un-pleasant smelling vaginal discharge or persistent bleeding. Infection is easily treated with antibiotics
  • BLOOD CLOTS in the legs (deep vein thrombosis), which can occasionally move through the bloodstream to the lungs (pulmonary embolus), making it difficult for you to breathe. The healthcare team will asses your risk, nurses will encourage you to get out of bed soon after surgery and may given you injections, medication or special stockings to wear.
  • MAKING A WHOLE IN THE WOMB WITH POSSIBLE DAMAGE TO NEARBY STRUCTURE this happens if one of the instruments makes a small hole in the womb or cervix (risk: less than 8 in1,000). If this happens you may need to stay in hospital overnight for close observation in case you develop complications. Sometimes a further operation is needed (risk less than 1 in 1,000)
  • FAILED PROCEDURE where it is not possible to place the hysteroscope inside the womb. You should discuss these possible complications with your doctor if there anything you do not understand.

How soon will I recover?

  • In hospital – you should be able to go home the same day. However, your doctor may recommend that you stay a little longer. If you do go home the same day, a responsible adult should take you home in a car or taxi and stay with you for at least 24 hours. You should be near a telephone in case of an emergency. A member of the healthcare team will tell you what was found during the hysteroscopy and will discuss with you any treatment or follow up you need/ if you are worried about anything, in hospital or at home, contact a member of the healthcare team. They should be able to reassure you or identify and treat any complications.
  • Returning to normal activities- you should not drive, operate machinery (this includes cookers) or do any potentially dangerous activities for at least 24 hours and not until you have fully recovered feeling, movement and co-ordination. If you have had a general anaesthetic or sedation, you should also not sign legal documents or drink alcohol for at least 24 hours. Most women are able to return to normal activities the day after the procedure. You may experience some period like cramps and mild bleeding. If this happen, you should rest for the first 1-2 days and take painkillers as you need then. If you develop any problems such as a temperature, pain in your lower leg, bleeding or a discharge from your vagina, breathing difficulties, or if your pain does not go away or increases and is not eased by your medication, you should tell your doctor.
  • Lifestyle changes- if you smoke, stopping smoking will improve your long-term health. Try to maintain a healthy weight. You have a higher chance of developing complications if you are overweight. Regular exercise should improve your long-term health. Before you start exercising, ask a member of the healthcare team or GP for advise.

SUMMARY

A hysteroscopy is usually a safe and effective way of finding out if you have a problem with your womb and in some circumstances, treating your symptoms. However, complications can happen. You need to know about them to help you make an informed decision about the procedure. Knowing about them will also help to detect and treat any problems early.

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Dilation and curettage

Dilatation and curettage is more commonly known as the SCRAPE.  It is done to help diagnosis and is not a cure to your problem.

It is minor surgery and is performed under a general anaesthetic

After the operation it is normal to bleed from your front passage. There is not a normal length of time for this as each woman is different. The loss will gradually decrease and then you will start a period, unless you are menopausal then the bleeding will just stop. Providing the loss is no more than a normal period there is nothing to be concerned about. To minimise the risk of infection you should avoid intercourse until the bleeding has stopped.

If you are worried in any way, you may either contact the ward for advice or go to your doctor.

A follow-up appointment (if you require one) will either be given to you on discharge from the ward or posted to you.

You may experience discomfort similar to period pains, which can be eased by taking two panadol or paracetamol tablets if necessary.

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Laparoscopy

Gynaecologists can look inside the abdomen during the procedure. The objective is to inspect the internal organs. This procedure can greatly help in diagnosing certain conditions and can be used to treat conditions like scar tissue, endometriosis and ovarian cysts. This operation is often called minimal access surgery, keyhole surgery, or ‘endoscopy’, which means ‘to look inside’. You may hear your gynaecologist use these terms. Thin telescopic instruments called endoscopes are used in laparoscopy. A video camera is fitted to the endoscope so the gynaecologist and surgical team can view the images on a video monitor.

In laparoscopy the endoscope is inserted in to the abdomen through a small cut in the abdomen or navel.  Sometimes a small piece of tissue (biopsy) is taken for further analysis. Surgery to treat many gynaecological conditions is performed safely and effectively during laparoscopy. Compared to laparotomy (surgery through a larger incision in the abdomen), laparoscopy has significant benefits, which include:
  • smaller less visible scars
  • less pain and discomfort during recovery
  • Usually quicker recovery after surgery and an earlier return to daily activities

Length of stay: It is generally performed as a day only procedure but 1/40 patients have to stay overnight.

The procedure

A thin hollow needle is inserted in to abdomen (usually through a small cut in the navel), and carbon dioxide gas is passed into the abdominal cavity. The gas gently inflates the abdomen, raising the abdominal wall above the uterus, bowel and other organs so they can easily be inspected. The bladder will be emptied with a urinary catheter placed in the urethra temporarily.

The laparoscope is then inserted. If necessary, special instruments may be inserted through 1 to 3 incisions, usually near the pubic hairline. The gynaecologist uses these instruments to move the pelvic organs to get a clear view of the area. The instruments may also be used to perform surgical treatment, as discussed with your gynaecologist. An instrument is usually placed in the uterus through the vagina, so pelvic organs can be manipulated during the procedure.

When the instruments are removed, the carbon dioxide gas is released from the abdominal cavity. A stitch may be used to close each of the small cuts.

Conversion to open surgery (laparotomy): in some cases, the gynaecologist may find that is not safe to continue the laparoscopy due to unexpected or life threatening problems. The gynaecologist may have to continue treatment through laparotomy, which is open surgery through a larger incision in the abdomen

A woman may be disappointed that she has had open surgery instead of laparoscopy, but it is done in the interests of her safety and wellbeing. The decision to convert to open surgery should be considered sound judgement. Before you sign the consent form, it is best to discuss the possibility of open surgery and its benefits

Recovery after laparoscopy: following laparoscopy your recovery will depend on the amount of surgery performed during your procedure. If you have general anaesthetic, do not drive for at least 24 hours and do not make any important decisions for 2 days. Although some women feel able to return to work the next day, others take 1 or 2 days of work. Shower and bathe as normal. Tampons may be used and changed regularly. Expect to remain off work for at least 3 days

After your operation you may experience some symptoms that may last several days:
  • Tiredness
  • Mild nausea
  • Muscle pain
  • Pain or discomfort at the site of the incision
  • Pain in 1 or both shoulders that may extend to your neck. This thought to be caused by the carbon dioxide gas used during the procedure.
    This pain may last a few days. Lying down often helps improve it
  • Cramps similar to period cramps
  • A little vaginal discharge or bleeding may last a few days
  • A sensation of swelling in the abdomen

Pain relief

Paracetamol is usually sufficient to relieve pain and discomfort. If you need stronger pain relief ask your gynaecologist.

Resumption of normal activities

Normal physical and sexual activities can be resumed once any bleeding and discomfort have disappeared, and you are feeling well enough. Risks
1/500 Bowel injury
1/2000 Vessel injury
1-2% Conversion rate (Laparotomy)
2% Infection
Uterine perforation (rare)

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Mirena®

The IUS (Intrauterine system) is a small plastic T-shaped device containing the progestogen hormone. It is fitted into the womb where it releases the hormone slowly and steadily over a period of at least five years. The IUS currently available in the UK is called the Mirena®. The Mirena® IUS is like many other types of Intrauterine Contraceptive Devices (IUCD's or coils) in that it is fitted by a doctor and remains in the womb for a fixed amount of time, after which it must be changed. It is different, however, in that it is much more effective than usual IUCD's and avoids many of the side effects that put women off this choice of contraception.
  • The IUS was developed as a contraceptive, but it is also very effective at reducing menstrual bleeding.  
  • For this reason, it can be used as a treatment for heavy periods and helps many women to avoid surgery to remove the womb (hysterectomy)
  • The IUS can also be used in Hormone Replacement Therapy (HRT) to provide the progestogen needed to protect the lining of the womb (endometrium)
  • It is licensed for 5 years after which it must be removed and may be replaced with a new device

How does the IUS work?

The hormone in the IUS makes the lining of the womb very thin. This means there is very little to come away at period time.

The IUS as a Contraceptive.

As with all IUCD's, if it does fail, there is a higher risk of ectopic pregnancy (a pregnancy located outside the womb, usually in the tube). If you felt pregnant or had a positive pregnancy test, it is important to see your doctor to rule this out. Overall, however, compared to women not using any contraception, the risk of ectopic pregnancy is greatly reduced (around 2 per 10,000 women each year [1]) because the IUS is such a good contraceptive.

If a pregnancy does occur with an IUCD, it is advisable to remove the contraceptive if possible - this reduces the risk of bleeding, infection and miscarriage. Because failure is so rare, there is little information available on the effects on an ongoing pregnancy with the Mirena® still in place.
  • The failure rate is 1 in 500 women per year, compared to female sterilisation 1 in 200 per year
  • It works because it thickens cervical mucus so that it is difficult for sperm to get through to reach the egg
  • IN some women it stops the ovaries from releasing an egg

How effective is the IUS at reducing period blood flow?

Most IUCD's make a woman's periods heavier, but the Mirena® actually makes periods much lighter than usual. Because of this, it is frequently used as a treatment for heavy periods, even in women who don't need contraception. In the Mirena®, however, a much lower dose is released than when you take the Pill (about 1/7th strength), and it goes directly to the lining of the womb, rather than through the blood stream where it may lead to the common progesterone-type side effects (see below).
  • In the long term, most women notice a significant reduction in their menstrual flow. In addition the number of days of bleeding is reduced
  • Some women find their periods stop altogether. This is more likely to happen as you approach the Menopause and is nothing to worry about
  • After 5 years 35% of women will be period free and 56% will only have occasional bleeding
  • Around 2 out of 3 women will avoid surgery such as hysterectomy
  • Period pain is often reduced
  • In some women the IUS will help reduce symptoms of PMS
  • The IUS may also shrink some Fibroids
  • If the IUS is removed, your periods will return to their previous pattern unless you have become menopausal
  • The IUS can help prevent and treat endometriosis

Painful periods

Although the IUS isn't primarily used for painful periods, two studies have found that it does help in many cases (as often as 80% of the time). If painful periods persist, it is usual to rule out any other problems with an investigation called a laparoscopy.

Fibroids

Large fibroids are a common cause of heavy periods. If they are so large, or in such a position that they make the inside of the womb an abnormal shape, it is unlikely that the Mirena® will remain in place, and would not be helpful as a treatment. With small to moderate size fibroids, it is quite reasonable to use the IUS and one study has found that fibroids are less common in women who use the Mirena® . A further paper has found that in the 5 women studied, a Mirena® actually reduced the size of their fibroids. This is only one report, of course, and the IUS cannot be recommended as a treatment for fibroids based

Premenstrual syndrome (PMS)

PMS is a syndrome that is thought to be caused by the varying hormones of the menstrual cycle. There have been suggestions that the IUS may be useful as it will allow a continuous dose of hormones to be given (oestrogen) without the worry of excessive stimulation of the lining of the womb. Usually oestrogens are combined with a course of a progestogen to prevent this, but many women experience PMS-like symptoms with progestogens. At present there is little published in the medical literature about the use of the Mirena® in this way, but for severe cases, where hysterectomy is being considered as the only remaining alternative, it would certainly be reasonable to consider this.

Hormone replacement therapy (HRT)

There is a growing experience with the use of the IUS for women who require hormone replacement therapy, but who have either bad PMS-like symptoms or erratic bleeding on normal HRT preparations. The IUS with continuous implants, tablets or patches of oestrogen provides good symptom relief with minimal side effects. As its use in this way is not generally established in the UK, this would normally be prescribed under the care of a gynaecologist. In other countries (eg. Finland) the IUS is licensed for use in this way and can be routinely used for up to 5 years.

Ectopic pregnancy

Women who have experienced an ectopic pregnancy are at a greater risk of this happening again in future pregnancies. For this reason, they are advised to choose a type of contraception that does not increase this risk any further - in particular they are encouraged to avoid IUCD's, as these are known to increase this risk. The risk of ectopic pregnancy is very much lower with the IUS than in women not using any contraception (60 times lower, in fact). Although perhaps not a first choice, the IUS may be considered when other contraceptives are really not suitable. As with most decisions in medicine, it is about the balance of risk.

Can IUS be used for HRT?

Oestrogen, the main hormone used in HRT makes the lining of the womb thicker. A progestogen is needed to stop this happening and the Mirena® does this very effectively. Bleeding is uncommon after one year and the oestrogen can be taken by any favoured route.

Fitting the Mirena® IUS

Before it is inserted, the doctor will do an examination to make sure the womb is a normal size and there is nothing else unusual to find. If there is some discharge, swabs will be taken to rule out infection before it is placed. The IUS is inserted within a week of beginning a period - this helps to reduce the chance of expulsion and irregular bleeding (as the womb lining is already quite thin at this time). It may be inserted immediately after surgical termination of pregnancy, but should be deferred until 6 weeks after delivery of a baby.

A speculum is placed in the vagina, like when you have a normal smear test, and the Mirena® is placed into the womb through the cervix. Because it contains the storage of hormone, the stem is slightly wider than in normal IUCD's. This can occasionally lead to difficulties with fitting, especially if you have not had a baby before. In this situation, it would be helpful to use some local anaesthetic. It should be fitted by someone who has been trained and has experience in fitting IUCD's.

It is a good idea to take some painkillers a couple of hours before the fitting - this will help reduce any discomfort. A good choice is Ibuprofen 400 mg, which can be bought over-the-counter at a chemist. Most women do not find the insertion procedure very uncomfortable - usually much less than expected.
Once the IUS is in place, you won't be able to 'feel' it in your womb. Your doctor will show you how to check for the strings, and it is very unusual for your partner to be aware of it during intercourse. After fitting, a further appointment should be made for six weeks later to check the strings can still be seen. Yearly checks are advised after this appointment.

Removing the Mirena®

It is much easier to remove than insert! Removal involves a speculum examination again and the IUS is removed by pulling on the strings. This is only uncomfortable for a second or two as it comes out. The hormone effect on the lining of the womb is reversed within a month and normal periods and fertility returns.

Are there any disadvantages when using Mirena®

It is usual to have irregular bleeding, spotting and prolonged lighter periods during the first 3 months. This settles down by 6 months.
Red or brown spotting can occur but this is normal and nothing to worry about.
Occasionally women may experience breast tenderness, which will resolve in time. It may be helped with Evening Primrose oil, or additional short-term treatment may be required. Other side effects may include slight weight gain, greasy skin or mood changes. These are common to all progestogens but are less likely to occur with IUS.

It’s your body

Don’t be afraid to ask questions. Consider taking someone with you to the consultation to help you to keep on track of the facts and think carefully about your options. If you are unsure about your diagnosis and the treatment prescribed do not be afraid to ask for clarification.

Written information is always given to you prior to any significant medical or surgical treatment.
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Endometrial ablation is a treatment for heavy bleeding.

Endometrial ablation is the removal or destruction of the endometrium (lining of the uterus or womb).  Ablation is an alternative to hysterectomy for many women with heavy uterine bleeding who wish to avoid major surgery.  After a successful endometrial ablation, most women will have little or no menstrual bleeding.  Patient selection and physician experience is essential to a good outcome. Make sure your consultant is both trained in this procedure and regularly performs it on the NHS.

Who should consider endometrial ablation?

Women who have menstrual bleeding that is impacting on their life, and do not have other problems that require a hysterectomy, should consider Endometrial ablation.
  • You limit your activity because of your periods
  • Bleeding is causing you to be anemic and tired
  • Bleeding limits your intimate time with your partner?
  • You do not desire to retain fertility

Who shouldn't have an endometrial ablation?

Since an endometrial ablation destroys the lining of the uterus, endometrial ablation is not for anyone who desires to keep her fertility.  Women who have a cancer or pre-cancerous condition of the uterus are not candidates for ablation.  Women who have severe pelvic pain, unless the pain is coming from a fibroid within the womb, may be better served by alternative treatments.  Although pregnancy is unlikely after ablation, serious complications could arise.  It is essential for to use reliable contraception after an Endometrial ablation.

What are the alternatives?

Endometrial ablation may be recommended if non-surgical treatments, such as taking medicines (such as the combined oral contraceptive pill) or an intra-uterine system (a coil in the womb - Mirena®®) don't help reduce heavy bleeding or you decline these treatments after careful consideration. Endometrial ablation is not usually recommended if you have growths in your womb (fibroids) or if you want to have children in the future, because it affects fertility.

A good gynaecologist will discuss the pros and cons of all options and explain which are the best for your particular circumstances.

What is a "balloon ablation?"   What about other devices?

Thermachoice™ balloon uses a balloon placed in the uterine cavity through the cervix.  Hot water is circulated inside the balloon to destroy the lining of the womb. It is very safe, with the machine either not activating or switching off if there is a risk that the temperature is getting too high or there is a hole in the womb.

macThe treatment fails 15% of the time but the other 85% of patients have lighter or no periods.
Another new device, the Novasure System™, is now available, and has a number of advantages over other systems.  It only takes a few minutes and has an excellent safety record.

Risks of endometrial ablation

As with any surgical procedure, there are risks, which should be compared to the risks of things we do in everyday life.  A number of things can be done to reduce these risks.  Some of the risks of endometrial ablation procedures are perforation of the uterus, bleeding, and infection. Abnormal bleeding should be evaluated whether or not you have had an ablation.

A small percentage of properly selected women having an ablation will still eventually need a hysterectomy, but the vast majority will not.  Having done endometrial ablation since 1985, I can often identify women who will have a successful ablation and those who would be better off with other treatment.

Who can help me decide if an endometrial ablation is for me?

It is helpful to see a gynecologist who is familiar with, and who is able to provide all of the alternatives for the treatment of your problem.  A doctor who does not do endometrial ablation on a regular basis is unlikely to have the experience to help you make the best decision.  The gynaecologist should consider non-surgical treatments, as well as discussing the advantages and disadvantages of all the options available.  While the gynaecologist can provide you with information, the decision is ultimately yours.

What does the procedure involve?

Endometrial ablation usually takes about half an hour. A telescope called a hysteroscope is passed through the vagina and cervix so that your surgeon can see your womb. Special instruments are then used to remove the womb lining as a biopsy is essential to rule out cancer. A balloon-like device is then tested, placed in the womb and filled with fluid. The fluid is heated to destroy the womb lining and it stays there for 8 minutes. The balloon is then emptied and removed once the fluid has cooled down.

What to expect afterwards?

If you have a general anaesthetic, you will need to rest until the effects of the anaesthetic have passed. You may need pain relief to help with any discomfort as the anaesthetic wears off. You will need to wear a sanitary towel as you will have some vaginal bleeding. You will usually be able to go home when you feel ready. Your nurse may give you a date for a follow-up appointment.  You will need to arrange for someone to drive you home. You should try to have a friend or relative stay with you for the first 24 hours.

Recovery from endometrial ablation

Most women are able to go home within a few hours after the Endometrial ablation  There may be mild cramping, which can usually be relieved by ibuprofen and/or paracetamol.  Occasionally stronger medicine may be needed.  The anaesthetist will prescribe regular pain relief medication – take this even if you do not have pain to prevent the pain from developing. It is normal to be tired for a few days, but most women are able to return to most normal activities in 3- 5 days.  Intercourse and very strenuous activity is usually restricted for 2 weeks.  It is normal to have an increased discharge for 2 to 4 weeks afterward, as the lining is shedding. 

You shouldn't use tampons for at least one month after having an endometrial ablation, to help lower your risk of infection. If you develop any of the following symptoms contact your GP or Consultant as you may have developed an infection:
  • prolonged heavy bleeding
  • vaginal discharge that is dark or smells unpleasant
  • severe pain
  • pain that lasts for more than 48 hours.
  • high temperature

It can take up to three to six months to see whether the operation has been