Understanding

Hysterectomy & Menstrual Disorders

Dr Christine P. West

Published by Family Doctor Publications in association with the British Medical Association

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IMPORTANT

This book is intended not as a substitute for personal medical advice but as a supplement to that advice for the patient who wishes to understand more about his or her condition.

Before taking any form of treatment YOU SHOULD ALWAYS CONSULT YOUR MEDICAL PRACTITIONER.

In particular (without limit) you should note that advances in medical science occur rapidly and some of the information about drugs and treatment contained in this booklet may very soon be out of date.

All rights reserved. No part of this publication may be reproduced, or stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording and/or otherwise, without the prior written permission of the publishers. The right of Dr Christine P. West to be identified as the author of this work has been asserted in accordance with the Copyright, Designs and Patents Act 1988, Sections 77 and 78.

Family Doctor Publications 1999–2007 Updated 2000, 2002, 2004, 2007

About the author

Dr Christine West is a Consultant Obstetrician and Gynaecologist at the Edinburgh Royal Infirmary NHS Trust. She is a part-time Senior Lecturer in Obstetrics & Gynaecology at the University of Edinburgh and has published many articles on problems relating to the menstrual cycle.

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Contents

Introduction

The uterus: structure, function and common problems

Examinations and tests

Drug treatments for menstrual problems

Surgical alternatives to hysterectomy

Different types of hysterectomy

Hysterectomy and your ovaries

Hysterectomy for cancer

Possible complications

Preparation for a hysterectomy

After the operation

Case histories

Questions & answers

Useful information

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Introduction

A frequent problem

Heavy menstrual bleeding and other menstrual problems are very common and one of the most frequent reasons for women to consult their general practitioner. They are the commonest cause of referral to a gynaecologist.

In the past, such referrals frequently resulted in hysterectomy (surgical removal of the uterus), even in cases where the uterus was healthy. Advances in treatment have increased the options available and nowadays most women can be offered medical treatment or minor surgery.

Hysterectomy is only necessary if other treatments have failed or where there is an underlying disease present. Even some diseases of the uterus can be treated without major surgery.

Fifteen years ago, over 20,000 hysterectomies were performed in the year in NHS hospitals in England for treatment of heavy menstrual bleeding. In 2002/3 the number had reduced to under 10,000 (figure). A similar reduction has occurred elsewhere in the UK.

This reduction has occurred because of the availability of simple, safe and effective alternatives. One of these is the Intrauterine System (IUS); a plastic device containing a low dose of a hormone which, when fitted into the uterus, causes thinning of the uterine lining and reduced menstrual bleeding.

The uterine lining can also be thinned out surgically by a minor operation known as endometrial ablation. Both of these treatment methods, together with other medical alternatives will be described in detail in later chapters.

Despite these developments some women will still be advised to undergo hysterectomy. This may be because other treatments have failed or are not suitable or, in some cases, because of uterine or ovarian cancer. Hysterectomy is an effective treatment for many gynaecological conditions.

Even where hysterectomy is the only option, there may be choices. The uterus may be removed through the vagina with no abdominal scar (vaginal hysterectomy) or as a “keyhole”procedure (laparoscopically assisted hysterectomy). Sometimes only part of the uterus is removed (subtotal hysterectomy). The gynaecologist may recommend removal of the ovaries as well as the uterus. Again, all these alternatives will be fully described in later chapters.

The purpose of this book

The objective of this booklet is to describe the causes of heavy menstrual bleeding and other common menstrual disorders. It will explain the various treatment options available, both medical and surgical.

It is designed to provide information that will supplement what you are told by your GP and gynaecologist and the various health professionals whom you will meet. However, even as this booklet is being updated, new developments are taking place and more information is being gathered about existing

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treatments. Thus it can never be a substitute for first hand information from your own hospital and informed discussion with the staff involved with your care.

KEY POINTS

■   Menstrual problems are extremely common

■   There are medical and surgical treatement options available

■   The numbers of hysterectomies carried out for treatment of menstrual problems has reduced by half over the last 15 years

■   The decision to have a hysterectomy may involve more than one surgical option

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The uterus: structure, function and common problems

What is the uterus?

The uterus, referred to since Biblical times as the ‘womb’, is a very remarkable organ, capable of expanding to contain a full-grown baby and of shedding its lining up to 500 times during your life at the time of your monthly period.

The resultant stresses and strains on its supporting structures during pregnancies and the repeated shedding and re-growth of its lining may lead to problems such as prolapse or heavy menstrual bleeding. This chapter describes what the normal uterus and its related structures look like and how they work, and summarises what may go wrong.

When you’re not pregnant, your uterus is approximately pear-sized. It has a thick muscular wall and a central cavity with a lining that is richly supplied with blood vessels. This lining is known as the endometrium and it provides nourishment for the embryo during the very early days of life. Otherwise, the lining of the uterus is shed each month, resulting in a flow of blood lasting for several days. This is known as the menstrual flow, menstruation or the monthly period.

The location of the uterus within the pelvis

The uterus sits centrally in the pelvis supported by strong fibrous structures called ligaments

The uterine muscle wall expands greatly during pregnancy and strong contractions of this muscle wall during childbirth give rise to the pains of labour. You experience similar contractions on a much smaller scale during

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menstruation, and this is the cause of the period pain (dysmenorrhoea) which troubles so many women.

The cervix

The cervix (or neck of the uterus) is the link between the uterus and the vagina (or birth canal) and is found at the top of the vagina. It is a firm, smooth, rounded structure with a central opening which:

■      dilates (opens up) during labour

■      allows menstrual blood to flow through it during your periods

■      allows sperm to travel through it into your uterus during sexual intercourse.

When a doctor needs to look at your cervix, this can easily be done by inserting an instrument called a speculum into your vagina, and most women are used to having this done when their doctor performs routine smear tests.

The fallopian tubes and ovaries

The ovaries are situated on either side of the pelvis and are white, slightly knobbly and grape-sized. They are extremely important because they are the source of eggs and also of the hormones, oestrogen and progesterone (see below), which control the menstrual cycle.

Each month an egg is released from one of the two ovaries in turn by a process called ovulation. This occurs at around day 14 of the menstrual cycle. The egg then enters the adjoining fallopian tube, one of two long, delicate structures attached to the uterus. This is where the egg may meet up with sperm if you have had sexual intercourse, so beginning a pregnancy.

A woman is born with a full supply of immature eggs and, from puberty onwards, these eggs gradually mature so that one is released each month until the egg supply finally runs out at the time of the menopause (see below).

The female reproductive system

The ovaries which contain eggs are situated at either side of the uterus and are connected to it by the fallopian tubes. They produce oestrogen and prgesterone, hormones that control the menstrual cycle.

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Supporting structures

The uterus and cervix sit centrally in the pelvis, at the top of the vagina, supported by strong fibrous structures called ligaments. These ligaments are attached in turn to the bones of the pelvis. They are sufficiently elastic to allow them to stretch considerably during pregnancy and then return to their former size afterwards.

In some women, particularly those who are past the menopause and those who have had children, this elasticity is reduced and the ligaments are weakened, leading to prolapse, or descent, of the uterus and cervix. This causes discomfort, a dragging sensation and an awareness of a swelling or bulge at the vaginal opening.

In front of the vagina and close to the cervix is the bladder, which stores then gets rid of urine through a short narrow passageway called the urethra. Behind the vagina is the rectum (back passage) where the bowel expels faeces. These organs are supported by ligaments and muscles that stretch during pregnancy and childbirth.

The pelvic floor

The ligaments and muscles that support the uterus, bladder and rectum, together with the walls of the vagina, are referred to as the ‘pelvic floor’. When you’re pregnant, you’re taught how to exercise the muscles of your pelvic floor and improve their strength once you’ve had your baby. Women who have a pelvic operation will need to do the exercises too as they help to prevent any weakness developing and so keep the bowels and bladder working properly.

Inside the female pelvis

The female reproductive organs lie in the pelvis. At the lower end of the uterus the cervix leads into the vagina. At the top end two opening lead into the fallopian tubes, which lead to the ovaries.

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The menstrual cycle

For around 40 years (on average, between the ages of 12 and 52), you experience monthly menstrual bleeding from the uterine lining, except for those times when you may be pregnant or breast-feeding.

The average length of the menstrual cycle is 28 days but it is quite normal for it to vary between 24 and 35 days and occasionally longer. Most women find that the bleeding is accompanied or preceded by crampy pain (dysmenorrhoea or period pain), caused by uterine contractions. It may also be preceded by mood changes, bloating and breast tenderness, now referred to as the premenstrual syndrome (PMS) and formerly called premenstrual tension (PMT).

These symptoms are caused by the hormones produced in the ovaries, which act mainly on the uterus but also have effects elsewhere in the body. Different societies vary in their views about menstruation and, within all societies, individual women have vastly different experiences of their monthly periods. However, most look on menstruation as an unwelcome, albeit necessary, process.

Female hormones

Oestrogen is the main female hormone produced by the ovaries and is responsible for the thickening of the uterine lining during the menstrual cycle. It also affects the vagina, breasts, bones and other tissues (for example, walls of blood vessels).

Progesterone, the other female hormone, is produced only after the egg is released at ovulation and acts on the lining of the uterus, thickening it in

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preparation for a possible pregnancy. If you don’t conceive that month, your hormone levels fall and your period starts.

The production of hormones and release of eggs from the ovaries are controlled by a small gland in the brain, called the pituitary gland, which regulates the length of the menstrual cycle.

The menopause

The menopause is the last menstrual period experienced by a woman. It occurs, at an average age of 52 in most Western countries. It happens when the supply of eggs in the ovaries eventually runs out.

It may be sudden or gradual; some women experience increasing irregularity of their periods for months or even years in the lead-up to the menopause (a time of transition known as the “perimenopause”).

As your supply of eggs declines, your hormone levels start to fall and this is what may cause the symptoms of hot flushes, night sweats, vaginal dryness and mood fluctuations that trouble many women. For most women, these symptoms are transient but a few find that they are a serious problem for quite a long time.

If this happens to you, your doctor may suggest treating the symptoms with hormone replacement therapy (HRT). Having your your ovaries surgically removed at the time of hysterectomy is likely to aggravate these problems and this issue is discussed later in the book (see page xx).

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Common disorders of the uterus and menstrual cycle

Given the total number of menstrual cycles experienced by most women, it is not surprising that menstrual problems occur frequently. These comprise painful periods, heavy periods, irregular bleeding and the premenstrual syndrome (PMS). Fibroids and endometriosis are common gynaecological disorders which may cause menstrual problems.

Bleeding problems are particularly common in the lead-up to the menopause (see below). Excessive bleeding is not only inconvenient, uncomfortable and embarrassing, it may also lead to anaemia (shortage of iron caused by blood loss).

Even after the menopause, the problems are not all over because this is the time when many women experience problems with prolapse of the uterus or vaginal walls. In particular, older women are more at risk of development of cancer of the uterine lining, cervix or ovaries, although fortunately these conditions are not common.

Information about the disorders which may affect the uterus and menstrual cycle is outlined below, and you will find more details on several of them in later chapters.

Heavy menstrual bleeding

Most women who seek medical help because of heavy periods have no serious cause for the bleeding and the problem is put down to a disorder of the shedding and re-growth of the uterine lining – so-called dysfunctional uterine bleeding.

Menstruation is a very complex process and one that is not yet fully understood. It is likely that repeated menstrual cycles lead to disorders in this process because periods tend to get heavier and less regular as women get older.

In some cases, the problem is related to changes in the levels of hormones produced by the ovaries in the lead-up to the menopause. Another factor may be that some women become very intolerant of their periods once they have completed their families and are less prepared to put up with the monthly discomfort and inconvenience.

Investigations described in the next chapter may identify a cause for the bleeding. In the absence of an obvious cause, decisions about treatment must depend largely on the severity of the symptoms, the impact they are having on the lifestyle and commitments of the individual woman, and whether heavy bleeding has led to anaemia (a low blood count which must be treated with iron tablets).

You should always be offered medical treatment in the first instance (see page xx). One of the most effective treatments is the Intrauterine System or IUS (see page xx). This may be available at your GP’ surgery, a family planning clinic or the hospital outpatient clinic.

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Endometrial ablation is a minor surgical procedure which is done under local or general anaesthetic in the hospital outpatient clinic or day surgery unit (see page xx).

If these measures fail, removal of the uterus, hysterectomy, albeit rather drastic, will guarantee permanent relief but, as major surgery is involved, the risks as well as the benefits must always be fully considered (see page xx).

Bleeding in between periods

Some women experience unexpected bleeding which occurs in between their normal menstrual periods. If this is heavy, prolonged or persistent it must be reported to a doctor as it may require urgent investigation. It is also important to report any bleeeding which occurs during or immediately after sexual intercourse (post coital bleeding). This may be caused by an infection or abnormality of the cervix.

The most serious cause is cervical cancer athough this is unlikely if you have always had regular smears. Minor bleeding or spotting in between periods is unlikely to have a serious cause. Some women have slight bleeding in the middle of their cycle or in the lead up to each period. If this bleeding is light and regular it is most likely to be due to hormone changes but if in doubt always consult your doctor. Irregular bleeding or spotting may be a side effect of some hormonal treatments such as contraceptives or hormone replacement therapy.

This is known as “break through bleeding. Usually women are warned to expect this in the first few months of any treatment but if bleeding is heavy or fails to settle a pelvic examination and possibly other investigations, described in the next chapter, will be required.

Persistent bleeding in between periods may be caused by hormonal changes or by a polyp (fleshy swelling) or fibroid (see below) attached to the uterine lining. These abnormalities can be detected by ultrasound or hysteroscopy (page xx) and can usually be removed by minor surgery.

Abnormal bleeding and the menopause

It is very common for women to experience changes in their menstrual cycles in the lead up to the menopause (see page xx) and this can cause worry and confusion, particularly if you don’t know whether or when to expect another period.

Many women consult their doctors because of bleeding problems related to the perimenopause (transition time over the menopause) and if these are due to hormonal fluctuations they are usually easy to treat. However diseases of the uterus, including cancer, are also more common as women get older and your GP may arrange referral to a hospital clinic for further investigation.

Any bleeding which occurs 12 months or more after your last menstrual period must be reported to a doctor without delay as it may be a sign of cancer. Fortunately over 80% of women who experience bleeding after the menopause do not have cancer. Common causes of bleeding after the

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menopause include late periods, polyps, thinning of the vaginal wall leading to inflammation (atrophic vaginitis) and bleeding related to HRT.

Uterine fibroids

One of the most common causes of heavy bleeding is enlargement and distortion of the uterus by rounded outgrowths of the muscle wall called fibroids. These are benign (non-cancerous) tumours and vary in size, number and position.

If they are very large they may cause pressure on the bowel or bladder; if small they may not cause any symptoms. They can be detected by abdominal or pelvic examination and confirmed by an ultrasound scan. Heavy periods caused by fibroids may be treated medically (see page xx), but this is less successful if the fibroids are numerous or large because medical treatments will not permanently shrink the fibroids. Similarly, use of an IUS or endometrial ablation may not be possible or is less likely to succeed if there are large fibroids.

A newer, non-surgical alternative is uterine artery embolisation (see page xx). Fibroids can be removed individually without removing the whole uterus (myomectomy - see page xx) if you want to have children in future.

Fibroids will shrink naturally after the menopause but if this is some years away and you are troubled by symptoms such as heavy bleeding or pelvic pressure, hysterectomy will give you the best guarantee of a cure.

Uterine fibroids

Fibroids can grow in the wall of the uterus and they are one of the most frequent causes of heavy bleeding

Menstrual pain

Menstrual pain is caused by a combination of contractions of the muscle of the uterine wall and spasm of the blood vessels supplying the uterine lining. Most

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women experience pain with their periods but the degree of pain is extremely variable for reasons which are not well understood.

In most cases period pain (known as dysmenorrhoea) responds to simple medical treatments, such as pain-killers or the oral contraceptive pill. Severe pain associated with menstruation, which is not relieved by standard medical treatments, may be caused by endometriosis (see below and page xx). Another condition, more common in older women who have had children, is ‘pelvic congestion syndrome’ in which periods are both painful and heavy with a build-up of pain, including backache and painful intercourse, in the lead-up to the period.

Similar symptoms are caused by adenomyosis (see page xx) a condition related to endoemtriosis. Hormonal therapies including the ‘pill’ can be successful by blocking ovulation and the hormone changes that follow.

Hormones can also be used to stop the menstrual cycle altogether. Hysterectomy is a possible option in severe cases. Some women with pelvic pain have underlying problems such as stress or depression which may be aggravating the menstrual problem.

It is important to appreciate that if pelvic pain is not related to the menstrual cycle and is not relieved by hormones, it is not likely to improve after a hysterectomy.

Endometriosis

Endometriosis arises because some women shed a little of the lining of their womb through their fallopian tubes into the pelvis during menstruation. This is more likely to occur in women who have heavy and painful periods. Small patches of uterine lining tissue (endometrium) may grow on the ligaments behind the uterus, on the walls of the pelvis or on the ovaries.

These patches then respond to the hormone changes of the menstrual cycle, giving rise to additional pain before or during menstruation. This may also cause deep discomfort or pain during intercourse and interfere with fertility.

Endometriosis may be detected during a pelvic examination or by a scan but usually a laparoscopy is needed to make a definite diagnosis (see page xx). The symptoms of endometriosis are usually treated successfully with medical treatment (see page xx) or sometimes with minor “keyhole” surgery (page xx) but in the longer term the condition may recur and removal of the ovaries and uterus is a possible long-term solution.

In cases of severe endometriosis, the patches of endometriosis may cause adhesions (scar tissue) in the pelvis, causing the uterus and ovaries to stick to each other and to nearby organs , such as the bowel and bladder. This can make any form of surgery potentially difficult and the endometriosis may be difficult to remove completely.

Severe endometriosis may be a cause of infertility and this may make the decision to have a hysterectomy difficult for those women who are hoping to have one or more children in the future. In this situation, it is particularly important that all alternative options are fully considered.

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Endometriosis

Fragments of the endometrium (lining of the womb) sometimes travel from the uterus into the pelvic cavity via the fallopian tubes. They then may implant on parts of the pelvic organs causing the structures to stick together.

Adenomyosis

This condition causes heavy and painful periods as a result of the presence of uterine lining tissue in the uterine muscle wall, causing the uterus to be tender and bulky. In contrast to endometriosis, which is more common in women who have not had children, adenomyosis usually occurs in women who have had several pregnancies.

It may develop as a complication of endometrial ablation. It can be treated medically but hysterectomy may be recommended if medical treatments are not successful. The diagnosis of adenomyosis is difficult to make on the basis of standard investigations because it is not always visible on ultrasound scanning, and cannot be detected by hysteroscopy or endometrial biopsy. Most cases are confirmed only after a hysterectomy has been performed and the uterus examined by a pathologist.

Uterine prolapse

A uterine prolapse is the descent of the uterus and cervix so that they no longer sit up at the top of the vagina, but can be felt lower down, sometimes as far down as the vaginal opening.

Prolapse of the uterus is caused by weakness of its supporting structures, usually as a consequence of child-bearing. You are most likely to develop it after rather than before the menopause and it is usually accompanied by prolapse of the vaginal walls.

When it happens, you experience a dragging sensation and you and/or your doctor may feel a smooth swelling at the vaginal opening. Some women tolerate a prolapse for many years and come to no harm, but it can be a considerable nuisance and restrict your activities unnecessarily. If it is very

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large, the skin over the prolapse may become irritated by contact with underclothing, leading to discharge and even bleeding.

Minor degrees of prolapse may not require an operation or may be treated by a pelvic floor repair which leaves the uterus intact. However, removal of the uterus through the vagina (vaginal hysterectomy) together with repair of the pelvic floor is usually recommended if the prolapse is large.

When a woman develops a prolapse before she has had all the children she would like, she will usually be advised to delay having surgical treatment until her family is complete. A ring pessary can be fitted as a temporary measure to support the pelvic floor. Ring pessaries are also suitable for the treatment of women who are not well enough to undergo an operation or for those keen to avoid surgery.

Uterine prolapse

In uterine prolapse the uterus is displaced and moves down into the vagina. This normally occurs when the ligaments in the pelvis become weakened, usually as a result of childbirth or after the menopause.

Ovarian cysts and tumours

An ovarian cyst is a collection of fluid within the ovary. Small cysts, measuring between 3 and 5 cm, commonly develop as a complication of the menstrual cycle and normally do not require any treatment because they go away on their own.

Larger cysts can be drained or removed without removing the ovary. If the ultrasound scan shows that the cyst is made up of solid areas as well as fluid, or if there is a solid swelling on the overy (an ovarian tumour), it may be necessary to remove the whole ovary.

If the cyst is very large or if there is doubt about its nature, the gynaecologist may recommend removal of the uterus and the other ovary,

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provided that you do not wish to have any more children. This is especially likely if there is concern that the cyst may be malignant (cancerous). Although most ovarian cysts are benign, there is a greater risk of cancerous changes if it is very large.

Scans and blood tests are helpful in predicting whether an ovarian cyst is malignant. There is also a small risk that a similar cyst may develop at a later stage in the other ovary. More information is given about the treatment of ovarian cancer in a later chapter.

Ovarian cysts

An ovarian cyst is a sac full of fluid that grows on or near an ovary. Surgical removal may be necessary if it is very large or if there is concern that it may be malignant.

Premenstrual syndrome

Most women are aware of changes in mood along with their menstrual cycle. There are also physical changes such as bloating and breast tenderness which commonly occur in the lead up to a period. These are put down to the normal hormone changes of the menstrual cycle but in some women the mood and physical changes are more severe; known as premenstrual syndrome or PMS.

The cause of PMS is not known as women who suffer from this do not have abnormal levels of hormones. Women with other menstrual problems such as heavy or painful periods often find that their PMS improves with treatments such as hormones, the IUS or endometrial ablation but these are unlikely to help if PMS is the only or main problem.

Stress is thought to aggravate symptoms of PMS and some women respond to non medical approaches. Treatment with drugs which alter the level of the chemical serotonin in the brain can also be helpful in severe cases. These drugs are known as SSRIs and are used for the treatment of depression. Examples are fluoxetine (Prozac) and paroxetine (Seroxat). They can be taken cyclically rather than continuously to reduce mood swings of PMS.

Some women with very severe PMS benefit from removal of their ovaries, but this is a very drastic measure and does not guarantee a cure.

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Long-term treatment with hormone replacement therapy (HRT) is essential for women who lose their ovaries at a young age. Some women with PMS are unusually sensitive to the effects of hormones and have difficulty with HRT (for more on medical treatments, see page xx).

KEY POINTS

■   The menstrual cycle is controlled by the hormones oestrogen and progesterone, produced by the ovaries

■   A woman sheds her uterine lining each month during menstruation – up to 500 times in her lifetime

■   Common problems include heavy bleeding, menstrual pain, mood swings (PMS), fibroids, endometriosis and prolapse of the uterus

■   Bleeding disorders are especially common near the menopause because of changes in hormone production by the ovaries

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Examinations and tests

There are a number of ways in which menstrual problems can be investigated. These will depend on the nature of your problem and on your age at the time. You may not need any special investigations other than simple examination, particularly if you’re under the age of 40, when serious underlying problems, such as cancer, are extremely rare. Often your doctor may prefer to try medical treatment to start with and only organise investigations if it doesn’t work.

Pelvic (internal) examination

A simple pelvic (internal) examination will enable your GP or gynaecologist to tell whether your uterus or ovaries are enlarged and whether there are any tender areas. He or she can inspect your cervix by inserting a plastic or metal instrument called a speculum into your vagina and a smear can be taken at the same time. Swabs can be taken from the cervix or vagina to test for infection. A nurse or female chaperone should be present while you are being examined by a male doctor.

A simple pelvic (internal) examination

Ultrasound scan

Ultrasound scanning is a simple painless procedure that can be done either by moving the scanning device firmly over the lower abdomen (abdominal scan) or by placing the device in the upper vagina (transvaginal scan). Women often prefer the transvaginal method because, during the abdominal scan, you have to keep your bladder very full.

The choice of scanning method will vary according to the reason for the scan. If fibroids or an ovarian cyst is suspected, an abdominal scan may give more information; to investigate menstrual bleeding abnormalities, a transvaginal scan gives a clearer picture of the uterine lining (endometrium). Sometimes both methods are used but you will be given the opportunity to empty your bladder after the abdominal scan.

In some hospitals a special type of transvaginal scan may be used which involves injecting a small volume of fluid (saline) into the inside of the uterus through the cervix to identify possible fibroids or polyps inside the uterus. This entails a vaginal examination and insertion of a speculum before the scan but very little additional discomfort.

Ultrasound scan

An ultasound scan produces an echo image using sound waves

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Blood tests

Blood tests are important in diagnosing anaemia and abnormalities of blood clotting. They are also useful if you have symptoms of an overactive or underactive thyroid (which occasionally causes menstrual upset) and for measurement of hormone levels if you are thought to be nearing the menopause.

Endometrial biopsy

Endometrial biopsy involves taking a sample of the lining of your uterus by first inserting a vaginal speculum and then passing a fine tube through your cervix. The sample is then sent to the laboratory for examination under the microscope. This may be necessary if you are having irregular bleeding or additional bleeding in between periods. The biopsy can be taken in the clinic or surgery and takes only a couple of minutes, during which time you will experience mild discomfort, similar to a period pain.

How an endometrial biopsy is taken

An instrument called a speculum is used to hold the vagina open while a thin flexible sampling tube is inserted into the uterus. A small sample of tissue is then drawn into the tube.

Hysteroscopy

Hysteroscopy is an examination of the inside (cavity) of your uterus with an instrument (hysteroscope) which is fitted with a light source and camera so that a view of the uterine cavity can be seen on a screen.

The hysteroscope is passed through the cervix via the vagina, and gas or fluid is used to expand the cavity of your uterus. Once the cavity has been inspected in detail, an endometrial biopsy is usually taken. This technique can detect the presence of polyps and fibroids and if these are small, they can

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sometimes be removed at the same time. Hysteroscopy is usually done in the outpatient clinic but may be done as a day case procedure under a general anaesthetic.

How a hysteroscopy is done

The hysteroscope with its own light source is inserted through the vagina into the uterus. The uterus may be filled with gas to allow the structures to be seen more clearly.

Dilatation and curettage

Dilatation and curettage (D&C) was the traditional method for investigating bleeding problems, but is now rarely used because, unlike the newer methods, it has to be done under a general anaesthetic. It involves first stretching open the cervix (dilatation) and then scraping out the uterine lining (curettage). It is still done, in conjunction with a hysteroscopy, in some women to investigate bleeding after the menopause. It must be emphasised that a D&C has no value in the treatment of period problems.

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How a dilation and curettage is done

Laparoscopy

Laparoscopy may be recommended if your problem is mainly one of abnormal pain associated with your periods. The external surface of the uterus as well as the fallopian tubes, ovaries and the surrounding structures are inspected through a laparoscope, linked up by a fibreoptic light source and a camera to a TV screen.

Laparoscopy involves a general anaesthetic, one or two small abdominal incisions and a short stay in hospital, usually in a day surgery unit (no overnight stay). It is the most reliable way of diagnosing endometriosis. Laparoscopic surgery may be used to treat small ovarian cysts and areas of endometriosis. This is known as keyhole surgery (see chapter xx).

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Measuring menstrual blood loss

One of the difficulties about treating women with heavy periods is that we have no accurate information about the amount of blood a woman is losing each month. Some hospitals measure menstrual blood loss by asking women to collect all their used pads and tampons. This is not a pleasant task but does provide invaluable information. For various reasons this is not done routinely and its use is normally confined to teaching hospitals undertaking research into menstrual problems.

KEY POINTS

■   Pelvic examination by a GP or gynaecologist allows detection of enlargement of the uterus or ovaries and the cervix can be inspected through a speculum

■   Bleeding problems in women under 40 rarely have a serious cause and do not usually require investigation

■   Investigations may involve blood tests, endometrial biopsy, ultrasound scan, hysteroscopy or laparoscopy

■   A D&C does not help menstrual problems and is not usually needed for the investigation of abnormal bleeding

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Medical treatments for menstrual problems

Menstrual problems are often temporary and may improve on their own or after a spell of medical treatment. Some such problems may be caused or aggravated by stress and improve when the cause of the stress is resolved. Menstrual bleeding problems are particularly common in the lead-up to the menopause; the so-called perimenopause. For women in this age group, it makes sense to persevere with medical treatments rather than to undergo surgery for which the benefit, in terms of days of bleeding prevented, may be relatively small.

Drug treatments for heavy or painful periods fall into two main categories:

■   Hormonal

■   Non-hormonal

Non-hormonal treatments are taken only during menstruation (to relieve immediate symptoms) whereas hormonal preparations are taken for much longer in the cycle in order to achieve their effects. However, if bleeding is very irregular, hormonal therapies are more helpful because they can be used to regulate the bleeding pattern. Hormonal treatments are not suitable for women trying to become pregnant.

Medical treatments for heavy and painful periods

Non-hormonal treatments

Non-hormonal preparations are used during the period itself to relieve symptoms: for example, pain-killers such a paracetamol, aspirin or codeine for menstrual cramps or headaches. Similarly there are medications that will help to reduce the amount of bleeding.

Anti-inflammatory drugs

Mefenamic acid and naproxen are members of a group of drugs known as non-steroidal anti-inflammatory agents (NSAIDs). Although most often used for relief of muscle and joint pain, they also reduce menstrual pain and can reduce blood flow by altering the production of substances called prostaglandins which play an important role in menstruation. However, their effect on menstrual flow is only moderate, reducing blood loss by, on average, 25 - 30 per cent, which may be insufficient if periods are very heavy. These drugs are most effective if you start taking them just before the onset of bleeding and so timing may be difficult if your periods start without warning.

You are most likely to benefit from this type of drug if your periods are very painful as well as heavy and your cycle is regular. Mefenamic acid and naproxen are only available on prescription by a GP. Ibuprofen, which is available over the counter, belongs to the same group of drugs and is effective

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in relieving menstrual cramps, but is not usually helpful in reducing heavy bleeding. Drugs in this category may not be suitable for women prone to stomach upsets.

Tranexamic acid

Tranexamic acid acts on the mechanisms in the uterine lining which control blood loss during menstruation. It is available only on prescription from a GP. It reduces menstrual blood loss by an average of 50 per cent and is thus more effective than mefenamic acid or naproxen, although it does not relieve menstrual cramps.

It has the advantage that it is effective if you begin taking it once heavy bleeding has started, so you don’t need to know exactly when that will happen. You need to take two tablets three or four times daily and continue taking them regularly during the days that your period is normally heavy (usually between three and five days). If you stop too soon the heavy bleeding may recur.

Side effects are few although it may cause gastric upsets. It is not recommended for women with a history of thrombosis. If your periods are also very painful tranexamic acid can be taken together with a pain killer or an NSAID.

MEDICAL TREATMENTS FOR MENSTRUAL PROBLEMS

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Hormonal medications

The oral contraceptive pill

The ‘pill’ or combined oral contraceptive pill (COCP) is an extremely effective treatment for the relief of both heavy and painful periods, because the combination of the hormones oestrogen and progesterone not only stops ovulation (egg release), but also causes thinning of the uterine lining and reduces muscle wall cramps. It reduces menstrual bleeding by around 40%. It may also reduce symptoms of PMS.

Unfortunately, many women mistrust the ‘pill’, partly because of bad publicity from the lay press which has tended to sensationalise reports of the risks while overlooking its many benefits. What is often not appreciated is that the ‘pill’ has other benefits besides those of contraception and relief of menstrual problems. Long-term users of the COCP have a significantly reduced risk of both uterine and ovarian cancer and are less likely to develop uterine fibroids or endometriosis.

Hormonally related side effects are common and include bloating, breast tenderness, headaches and mood swings. These can often be relieved by changing to a different brand. Serious side effects, although well publicised, are extremely rare. A minority of women are at greater risk of developing venous thrombosis (blood clots) if they take the ‘pill’.

The COCP may also increase the risk of heart disesase or stroke if prescribed for women over the age of 35 who smoke or have high blood pressure. These complications occur as a side effect of the hormone oestrogen. Pills containing oestrogen are not suitable for women who are significantly overweight, have high blood pressure or a history of thrombosis. Although the ‘pill’ is most often prescribed for younger women, it can be used safely in women of all ages who are non-smokers and have no risk factors for heart or blood vessel disease.

Synthetic progesterone

For women who need to avoid oestrogen, progesterone derivatives, known as progestogens may be helpful and are suitable for women of all ages. In order to reduce heavy periods, these need to be taken in a similar way to the COCP; for 21 days each month, starting on the 5th day of bleeding. The most effective of the progestogens for control of abnormal bleeding is norethisterone.

Taken three times daily in this way it can reduced blood loss by up to 80%. Norethisterone is particularly useful in controlling problem bleeding in

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the lead up to the menopause. The perimenopausal ovary may fail to produce enough progesterone, enabling the uterine lining to thicken up too much under the influence of oestrogen. The period may be delayed and then be unusually heavy and prolonged. In these circumstances, the bleeding can be controlled by taking a 21 day course of norethisterone to balance out the effect of the oestrogen.

Once the initial course of norethisterone is stopped the bleeding will restart as the uterine lining is shed. If this is again abnormally heavy or prolonged, a further 21 day course of the norethisterone can be prescribed and repeated as necessary. If the bleeding does not settle down promptly investigations must be done to exclude a more serious cause. Some women experience side effects with progestogens such as bloating, nausea and weight gain, but serious side effects are very rare.

Synthetic progesterone is also available as a three-monthly injection (depo-provera). This is normally prescribed as a contraceptive, but it can be helpful for the treatment of heavy or painful periods by stopping the bleeding altogether.

The intrauterine system (IUS)

This simple device has revolutionised gynaecological practice by its simplicity and ease of administration. It is a T shaped device which fits neatly into the cavity of the uterus. The stem of the T contains the hormone progestogen (synthetic progesterone). There is one such system currently available, known as Mirena, but other similar systems are likely to be available in the future. It was originally developed as a contraceptive. However, unlike older intrauterine contraceptive devices (coils), Mirena was found to reduce menstrual bleeding dramatically – by over 80 per cent. It is thus more effective than the “pill” or tranexamic acid. Treatment trials have shown that it is as effective as the surgical option of endometrial ablation and can offer a real alternative to hysterectomy.

Although originally devised as a contraceptive the Mirena intrauterine device can help to reduce heavy menstrual bleeding

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How does it work?

It releases the progestogen into the cavity of the uterus where it gradually causes thinning of the lining (endometrium). The uterine lining does not thicken up in response to the normal hormone changes of the menstrual cycle, thus considerably reducing blood loss. This thinning out process can take up to three or even six months and during this time it is common to experience irregular bleeding although this is not usually heavy. However by the end of the first year of use, the majority of women experience no bleeding at all or very light bleeding or spotting. Another advantage of the intrauterine system is that it relieves period cramps.

How is it inserted and removed?

Inserting the device into the uterus is simple, involving the use of a speculum. The cervix is viewed and then usually held with a grasping instrument to steady it while the IUS is inserted. Prior to insertion a biopsy of the lining may be taken or an instrument called a “sound” used to measure the length of the uterine cavity.

The whole process takes a few minutes and usually causes only mild to moderate discomfort. Some women do not feel anything at all! Insertion does not usually require an anaesthetic although a local anaesthetic is sometimes used. Once in place, it can remain in the uterine cavity for up to five years. The device is easy to remove and the effects are reversed as soon as it is removed, so it may suit you if you want to have more children in the future.

The device can be inserted, removed and replaced by your GP or a family planning doctor, or at the hospital. However, some GPs prefer to refer you to hospital for insertion of the device and to enable a more detailed discussion of the various treatment options. Occasionally a general anaesthetic is required for its insertion. This is more likely if you have never given birth.

What are the side effects?

The dosage of the progestogen in the IUS is sufficient to act on the uterine lining but only very small amounts are absorbed into the bloodstream so that hormonal effects elsewhere in the body are very minimal. The IUS does not stop ovulation or normal hormone production so should not affect your mood and the way that you feel generally.

Some women do complain of mild side effects including acne, headaches or breast discomfort but this is not common and usually settles down after a few weeks. There is no evidence that the IUS causes weight gain. The main disadvantage, as mentioned above, is the high liklihood of irregular “breakthrough” bleeding during the early weeks after insertion. This can sometimes persist for several months. If this is a problem, you are usually advised to persevere for a bit longer as this almost always settles down eventually. Some women are concerned about the possibility of infection; a risk with some of the earlier contraceptive “coils”. This is very rare with the

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IUS. The progestogen causes thickening of cervical mucus which acts as a barrier to infection.

The only risk might be at the time of insertion if you have previously been exposed to a sexually transmitted infection. If this is the case you should be offered a screening test (urine and or swab test) before insertion.

How successful is it?

Mirena is the most successful of all the medical treatments for heavy periods; causing a 70-90% reduction in menstrual blood loss. It also relieves menstual cramps. Some women find that it reduces PMS although this is difficult to understand as it does not alter hormone production by the ovaries. It is as effective as the surgical procedure of endometrial ablation and has been shown to reduce the liklihood of a hysterectomy being performed.

Is the IUS right for me?

It is suitable for most women with heavy periods and particularly for those who are concerned about the risks of surgery or loss of fertility. It is particularly suitable for women also needing contraception and is a sensible alternative to sterilisation for women whose periods tend to be heavy. It can be used at all ages, regardless of whether or not you have had children and although its insertion may be more difficult if you have not had children, a local or general anaesthetic can be used if necessary.

It can also be used for the treatment of some abnormalities of the uterine lining such as excessive thickening (hyperplasia) and for treatment of women thought to be at risk of developing uterine lining cancer. For women nearing the menopause, it can be used in conjunction with oestrogen HRT.

It may also be suitable for women with small fibroids although if the fibroids are large there is a chance that the device may be expelled. It is also sometimes recommended for the treatment of the symptoms of endometriosis.

Medical treatments for endometriosis

Endometriosis can cause severe pain during or before the onset of periods and during sexual intercourse (see page xx). The symptoms arise because small patches of uterine lining tissue (endometrium) have become attached to the pelvic lining and/or the ovaries, and is stimulated to grow and shed each month by the hormones released by the ovaries.

Some women find adequate relief of symptoms of endometriosis using non-hormonal treatments such as simple pain-killers such as paracetamol or NSAIDs such as ibuprofen.

Alternative therapies (for example, homoeopathy, herbal preparations) have an important role for some women although their benefits are not scientifically proven.

As the symptoms of endometriosis are triggered by the hormones released by the ovaries, treatments are often prescribed to suppress this hormone production. Similarly, endometriosis is relieved by the natural

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menopause. Hormonal treatments work by causing temporary cessation of the periods. This allows the patches of endometriosis to shrink away.

There are several different forms of hormonal treatment which are described below. All may cause side effects but these differ from woman to woman. They are all effective in relieving pain in the short term but endometriosis can recur in up to 50% of women in the longer term once treatment is stopped. Thus medical treatment may need to be repeated intermittently or continued long term.

While hormonal treatments preserve future fertility, all of them prevent ovulation (egg release) and are thus not suitable for use if you are trying to conceive a baby. Some women with endometriosis require surgery or in-vitro fertilisation (IVF) treatment to help them to conceive.

Hormone treatments containing oestrogen and/or progesterone

Used continuously, high doses of synthetic progesterone (progestogens) gradually shrink and inactivate deposits of endometriosis. They also suppress menstrual bleeding because of a similar thinning effect on the uterine lining. Medroxyprogesterone acetate is the progestogen most often used for treatment of endometriosis. Progestogens have been used for many years in this way and their advantage over newer treatments (see below) is that they can be used for longer. However, side effects may occur, particularly irregular bleeding (spotting), bloating and fluid retention. This is because of the high doses of the hormones.

An alternative is the combined oral contraceptive pill which works best for endometriosis if you take it continuously, without a monthly break. Another alternative which has recently become available is low dose desogrestel (Cerazette), a new type of contraceptive pill which is taken continuously and contains no oestrogen. It differs from the very low dose progestogen-only pills (or minipills) in that it contains sufficient progestogen to stop ovulation but the levels of progestogen are less than in the high dose preparations mentioned above so that side effects are very much less. It has not yet been fully tested for the treatment of endometriosis but is already being recommended by gynaecologists and seems to be helpful for many women.

The Intrauterine System (IUS)

Because the IUS (Mirena) is very effective at shrinking normal uterine lining tissue and in relieving period pain, it is often used by gynaecologists to relieve the symptoms of endometriosis. However it has not yet been fully tested for use in this condition. The potential advantages are that hormonal side effects are much less than they would be with tablets or injections. The potential disadvantage is that unlike the other hormonal treatments used for endometriosis, the IUS (Mirena) does not stop ovulation and may thus be less effective for some women if the endometriosis is primarily present in the ovaries.

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GnRH analogues

Gonadotrophin-releasing hormone (GnRH) analogues are taken by nasal spray (sniff) or by monthly or three monthly injections. They are synthetic versions of a natural hormone known as the gonadotrophin-releasing hormone. They work by blocking the signal which goes from the the pituitary gland to the ovaries, thereby stopping the hormone production from the ovaries. This stops you having periods and deprives the areas of endometriosis of hormonal stimulation.

They are extremely effective in relieving the symptoms of endometriosis but their main disadvantage is that this creates a temporary artificial menopause and you may experience side effects such as hot flushes, night sweats and vaginal dryness.

The other problem is that the the lack of oestrogen caused by GnRH analogues may lead to loss of calcium from bones, leading to an increased future risk of osteoporosis. However, it is possible to take very low doses of oestrogen and progesterone in order to protect the bones and relieve the other side effects if you need to remain on the treatment for a long time. This is known as “add-back” hormone replacement therapy.

Male hormone derivatives

Male hormone derivatives work by suppressing hormone release from the pituitary gland and the ovaries. Unlike the GnRH analogues, they do not cause bone loss or menopausal symptoms, but side effects of weight gain, fluid retention and greasy skin are very common.

The best known of these drugs is danazol which you take in tablet form on a daily basis. A newer alternative is gestrinone which is more convenient in that you take it twice a week rather than every day.

Side effects may include weight gain, fluid retention and greasy skin. There is also a small risk of growth of unwanted body hair and voice changes although fortunately these effects are rare. As a result, although they are very effective at relieving symptoms, they are usually used only in the short term.

Medical treatments for uterine fibroids

Fibroids are extremely common and do not always cause symptoms but, if they distort the cavity of the uterus, they may be a cause of heavy menstrual bleeding. Like endometriosis, uterine fibroids are dependent for their growth on ovarian hormones and so tend to shrink naturally after the menopause.

Treatments that lower hormone levels, such as GnRH analogues, make fibroids shrink in size, but they are less useful for this condition than they are for endometriosis because fibroids almost always re-grow immediately the drug treatment is stopped. They may however be useful if you are very near to the menopause.

Other hormones such as synthetic progesterones, danazol, the oral contraceptive pill or the IUS (Mirena) may be used to relieve blood loss resulting from fibroids, but do not cause shrinkage and are thus not helpful if

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the fibroids are large and causing pressure problems. There is a greater risk of expulsion of an IUS if there are fibroids distorting the cavity of the uterus. If you have smallish fibroids which are causing heavy periods, non-hormonal treatment with tranexamic acid may be very helpful and may cause fewer side effects than hormonal therapies. Bleeding resulting from fibroids may mean you develop anaemia, in which case a short course of a GnRH analogue, together with iron may be prescribed to treat it, but you may ultimately need to have the fibroids treated by embolisation or removed surgically by myomectomy or hysterectomy.

KEY POINTS

■   Tranexamic acid (Cyklokapron) is a non-hormonal treatment that reduces bleeding

■   The oral contraceptive pill relieves heavy bleeding and pain, and helps to protect against ovarian and uterine (endometrial) cancer

■   The Intrauterine System (IUS) is very effective in reducing heavy periods, but irregular bleeding is a problem initially

■   Medical treatments are usually effective in the treatment of bleeding problems that occur in the lead-up to the menopause

■   Medical treatments relieve the symptoms of fibroids and endometriosis but are not a long-term cure

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Minor surgical treatment

In the past, many women underwent hysterectomy, a major operation, even though they didn’t have any significant or serious disease within the uterus. In recent years surgical procedures have been developed in which the endometrium (the uterine lining) is removed or destroyed, leaving the remainder of the uterus and the ovaries undisturbed. This is known as endometrial ablation. This chapter also describes alternative surgical methods of treatment for endometriosis and uterine fibroids.

Endometrial ablation

There are several ways in which this can be performed and they all avoid the need for a surgical incision. The methods used vary in cost and complexity, and the method or methods available in your hospital will depend on the equipment available and the preferences of local gynaecologists.

Most endometrial ablations are carried out under a general anaesthetic although, in some hospitals, it is available under a local anaesthetic. All procedures are carried out via the vagina, by passage of instruments into the cavity of the uterus through the cervix.

Older (First Generation) methods of endometrial ablation

Endometrial resection

Endometrial resection and TCRE (transcervical resection of the endometrium) are terms used to describe the removal of the endometrium (uterine lining) in strips using a fine wire loop through which an electric current is passed (electrodiathermy). This heats up and coagulates the muscle wall of the uterus at the same time as it strips away the lining, thus reducing the risk of haemorrhage.

The wire loop is inserted down the side channel of a hysteroscope so that the surgeon can watch the procedure on a screen. The uterine cavity is continuously flushed through with fluid to open it up and give a good view while simultaneously washing out blood and lining tissue and cooling the uterus down. Endometrial resection is now much less popular than other methods of ablation because it is more difficult to perform and carries a slightly greater risk of complications than the newer methods (see below).

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Roller ball endometrial ablation

This is similar to endometrial resection in that it uses heat generated by electricity (electrodiathermy) but the difference is that the uterine lining is destroyed by contact with the ball which is rolled slowly over the surface. Like endometrial resection, the procedure is done using a hysteroscope with constant fluid irrigation.

Laser endometrial ablation

This destroys the endometrium using heat generated by a laser. The laser beam is passed down the side arm of a hysteroscope and guided by the surgeon over the uterine lining. The laser is in many ways ideal for this task but has the disadvantage of being very expensive and beyond the price range of most NHS hospitals.

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Complications

First generation methods of endometrial ablation are very effective but do carry some risks. As with all operations these include difficulties resulting from the use of the anaesthetic, excessive bleeding (haemorrhage) and infection. These complications are less likely following all methods of endometrial ablation than they are after a hysterectomy.

Other complications that arise only after endometrial ablation or resection are uterine perforation (see below) and absorbtion of the irrigation fluid into the circulation which, if excessive, can put a strain on the heart and circulation – a condition known as fluid overload. Between two and six per cent of first generation endometrial ablation operations have serious complications and the risk of complications is slightly higher with endometrial resection than with other methods. However in hospital that have carried out these procedures for a number of years they are generally very safe and effective.

Newer (Second Generation) methods of endometrial ablation

Endometrial resection and the other first generaton methods described above, although much simpler than hysterectomy, are time consuming to perform, difficult to learn and not available in all hospitals. Recently several newer methods have become available, based on developments in technology, each using a different way of delivering heat to the uterine cavity in order to destroy

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the endometrium. They do not involve fluid irrigation and are much quicker to perform.

Results of clinical trials show that they are equally effective and, most importantly, safer than the first generation methods and endometrial ablation is now available in most hospitals. They are performed in conjunction with hysteroscopy or ultrasound so that the gynaecologist can check that the instrument is placed correctly in the cavity of the uterus before activating the heat source.

Microwave endometrial ablation (MEA)

A probe of suitable size is inserted into the cavity of the uterus, the heat source is triggered and the probe is gradually moved around the cavity for the length of time needed to destroy the endometrium. It is suitable for use where there are small fibroids but may not be suitable for some women who have had one or more caesarean section births because this may result in thinning of the uterine wall and a greater risk of damage due to perforation. If you have had one or more caesareans in the past, an ultrasound scan will be done to measure the thickness of the wall to see if you are suitable for MEA.

Thermal balloon ablation

A small balloon is inserted into the cavity of the uterus and filled with fluid so that it fits the shape of the cavity exactly. It is then heated to a temperature

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sufficient to destroy the endometrium over a set time. This method is not suitable for women who have fibroids within the cavity of the uterus. It is probebly the safest of all the methods of endometrial ablation and is more suitable than other methods for use under a local, rather than a general, anaesthetic.

Other methods

Other methods are being developed all the time. You may read about one of these in a newspaper or magazine, or even on the Internet, only to find that it is not available locally. This is because new treatments have to be thoroughly tested and compared with existing methods before they can be introduced more widely. Some hospitals will prefer existing methods; others may be involved in testing out one of the newer methods.

Complications of second generation endometrial ablation

These methods are safer than the first generaton methods because they do not require fluid irrigation and the risk of haemorrhage is much lower. However technical problems with the equipment may occur, resulting in delay and sometimes rescheduling of the treatment if the problem can’t be sorted out right away.

A rare but potentially serious complication is perforation of the uterine wall by the instrument used to heat the uterine lining. If this is recognised immediately the treatment has to be abandoned. If the perforation isn’t

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spotted immediately and the treatment goes ahead, this can result in damage to nearby structures, including the intestines and large blood vessels, and emergency surgery to repair the damage is then required. Fortunately this is a very rare occurrence.

Other side effects of endometrial ablation

It is usual to experience cramping period-like pain for a few hours after the procedure and pain killers are routinely prescribed both before and after. It is also normal to experience a vaginal discharge for up to two or even four weeks afterwards. This is initially blood stained, then gets progressively more watery. If the discharge becomes offensive or if you develop a temperature and feel unwell this may be a sign that you have developed an infection. This occurs in 2-4% of women after endometrial ablation. You must contact your doctor as a course of antbiotics may be required.

Drug treatment before endometrial ablation

During the menstrual cycle, the uterine lining gradually grows and thickens in preparation for possible pregnancy as described on page x. The older (first generation) methods of ablation are more difficult to carry out and do not work so well if the endometrium is very thick . If these methods are used, it is usual to prescribe drugs to thin the lining in preparation for surgery. Thes drugs – usually a GnRH analogue or danazol – are prescribed for around four weeks before surgery. With the newer second generation methods, these drugs are less often prescribed.

The advantages of endometrial ablation

Although most endometrial ablation operations are carried out under general, rather than local, anaesthetic, they are performed as a day case procedure with no overnight hospital stay and recovery is considerably faster than after a hysterectomy. You will be able to take up your normal domestic activities after a few days and go back to work within one to two weeks – considerably less than the recovery time needed after a hysterectomy!

How successful is endometrial ablation?

In the short term, endometrial ablation has many advantages over hysterectomy but, unlike hysterectomy, it does not guarantee to stop all menstrual bleeding in the future. Survey results indicate that, two to three years after the operation, around 20 per cent of women have no menstrual bleeding and 50 to 60 per cent have reduced bleeding, but up to 25 per cent find that there is no improvement or an actual worsening. Longer-term follow-up indicates that over two-thirds of women treated with endometrial ablation are satisfied with the results and avoid hysterectomy. Women who respond well initially but whose heavy bleeding gradually returns may be treated

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successfully by a second endometrial ablation procedure. This is more likely to be required if you are under the age of 40 when you are first treated.

Is endometrial ablation right for you?

If you have completed your family and are seeking relief of heavy bleeding, do not suffer much menstrual discomfort and wish to avoid major surgery, endometrial ablation is an option well worth considering. However, you should always try medical treatment first.

This form of treatment is not suitable for women who may want to have children in the future. The procedure reduces fertility and, although some women have become pregnant after endometrial ablation, there is a very high risk of miscarriage and later complications.

•        Very painful periods may not be relieved after endometrial ablation.

•        Irregular bleeding may not improve after endometrial ablation.

•        This type of treatment is not usually recommended for women with a uterus containing large fibroids (see below).

You should be aware that insertion of an IUS may be as effective as endometrial ablation, is more likely to relieve period pain, preserves fertility and avoids the potential risks of surgery.

Treating uterine fibroids

If medical treatment or endometrial ablation has failed or is not suitable, there are two other procedures which you may be offered which do not involve removing the uterus itself. These will not be appropriate for everyone.

Myomectomy

If you have not had children or want to have more in the future, it may be possible to remove the fibroids and preserve the uterus – an operation known as myomectomy. This is not easy to do from the surgeon’s point of view, particularly if there are several fibroids, and in some cases they may be very numerous. It is normally done by open surgery unless the fibroids are within the uterine cavity (see below). Laparoscopic (keyhole) methods may be used in some very specialised hospitals.

An operation to remove large fibroids may be complicated by heavy bleeding, so that a blood transfusion is necessary. In extreme cases, an emergency hysterectomy may have to be done, but this is fortunately rare. After a myomectomy, there is no guarantee that you can still become pregnant or that heavy bleeding will be cured and there is still a chance that further fibroids will grow in the future.

Is myomectomy right for you?

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For the reasons outlined above, it does not make sense to opt for a myomectomy rather than a hysterectomy unless you are anxious to retain your uterus so that you can have children at some time in the future. However, if you have strong objections to hysterectomy for personal or cultural reasons, most gynaecologists will be sympathetic, provided that you fully understand the risks and limitations.

An operation to remove fibroids should be done only if the fibroids are causing symptoms such as pressure or heavy bleeding, not just because they’re there. Rarely, fibroids may be a cause of recurrent miscarriages, in which case they should be removed. However, most women with fibroids who conceive go on to have successful pregnancies. Similarly fibroids do not usually cause infertility although they are more common in women who have not had children.

Hysteroscopic myomectomy

Some women have fibroids that are situated within the uterine cavity, so-called submucous fibroids. If so, it may be possible to remove them with the aid of a hysteroscope, using methods similar to those described above. However, it is best for such procedures to be carried out in a hospital that specialises in hysteroscopic surgery because removal of fibroids in this way is difficult and requires considerable experience.

Fibroid embolisation

This is a new treatment that does not involve a surgical scar or a general anaesthetic. It is done by a radiologist and involves the use of X-rays. These show up the blood supply to the uterus (uterine arteries)by dye injected through a very fine plastic tube inserted into one or both groins.

Once the arteries (blood vessels) supplying the fibroids have been located, a special material is injected that blocks off (embolises) the blood supply. Initially, this causes as much pain as an operation. This is usually treated by an infusion of a strong pain killer such as morphine and it is necessary to stay in hospital for one or two days. Following embolisation most women are able to return to work within two weeks.

How successful is it?

Embolisation results in gradual shrinkage of the fibroids by up to 60% over the first year after treatment but they do not disappear altogether. Preliminary results suggest that the procedure relieves symptoms of heavy bleeding and pelvic pressure in around 80% of women but the long-term success of the treatment is not known. If the fibroids are very large or numerous, a 60% shrinkage may still leave you with symptoms of discomfort or pressure.

Are there any risks?

Following the procedure some women feel feverish and develop flu-like symptoms which settle within a few days. Rarely these symptoms persist due

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to the development of infection in the uterus. In very severe cases (around one per cent), this may necessitate a hysterectomy.

The main problem, experienced by up to one third of women, is a vaginal discharge which in some cases can persist for several weeks. There is also a very small risk of developing an early menopause. This would be a disaster if you plan to have children. However most women who have become menopausal immediately after embolisation have been over the age of 45. Overall the procedure seems to carry a low risk of complications and certainly fewer complications than hysterectomy or myomectomy.

Is embolisation right for me?

The most effective cure for fibroids is hysterectomy but this involves major surgery and loss of fertility. If you are approaching the age of the menopause and medical treatment is not appropriate or has been unsuccessful, embolisation is a sensible alternative to hysterectomy. It is also a realistic alternative for younger women who wish to avoid surgery.

The effects of the treatment on fertility are not known. Only a relatively small number of women have had pregnancies after fibroid embolisation and although the outcome has generally been successful, embolisation may not be recommended to women who plan to have children in the future unless their symptoms are very severe or the only other treatment option would be a hysterectomy.

Not all fibroids are suitable for embolisation and it is usual to assess suitability by performing a more detailed scan, known as an MRI scan, before any arrangements are made. Occasionally the procedure cannot be completed due to technical problems. Embolisation is not available in all hospitals and if you are keen to have this procedure you may need to be prepared to travel.

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Treating Endometriosis

The diagnosis of endometriosis is usually made by laparoscopy and some gynaecologists will offer to treat small areas of endometriosis while they’re doing the diagnostic laparoscopy operation. This can be done using

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electrodiathermy (direct heat generated by electrical energy), by laser or by other similar methods.

If the endometriosis is more extensive, a second operation may be required to remove areas of endometriosis, possibly after a course of treatment with one of the drugs described on page xx. Endometriosis that has resulted in the formation of ovarian cysts containing altered blood (endometriomas or chocolate cysts) usually requires surgical treatment, and this is best done by laparoscopy rather than by open surgery, unless the cysts are very large. Surgery may be particularly beneficial for women who are trying to conceive a baby as hormonal treatment would not be suitable in this situation.

The disadvantage of surgical as opposed to medical treatment to relieve the symptoms of endometriosis is that not all areas of endometriosis are visible and thus the surgery may not relieve the discomfort altogether. Often a combination of medical and surgical treatment is the most effective. For women with severe endometriosis who want children, in vitro fertilisation (IVF) may be the best option and this can be combined with spells of medical treatment to relieve symptoms in between cycles of IVF.

Symptoms of endometriosis clear up during pregnancy and may be considerably improved thereafter, although a successful pregnancy does not guarantee a long-term cure of endometriosis

KEY POINTS

■   Endometrial ablation (removal or destruction of the uterine lining) is helpful in up to 70 per cent of women with heavy periods, but rarely stops bleeding altogether

■   Endometrial ablation is not suitable for women who have not completed their families and may not relieve pelvic pain

■   Endometriosis can be treated surgically without removal of the uterus or ovaries, but symptom relief may be only temporary

■   Myomectomy is an operation to remove fibroids that preserves the uterus in women who hope to have children

■   Embolisation is a new non-surgical treatment for fibroids which seems promising in the short term but its long term effectiveness is not yet known

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Different types of hysterectomy

Hysterectomy is the only treatment for menstrual problems that guarantees complete relief of menstrual bleeding. Once it has become clear that a hysterectomy is going to be the best form of treatment for your particular problem, there are further decisions to be made.

A hysterectomy may mean removing all or part of the uterus and does not necessarily mean that your ovaries will be removed at the same time. For each woman, the method selected will depend on the reason why the hysterectomy is being done, her medical and surgical history, the findings of the gynaecologist when he/she carried out a pelvic examination and her own preferences.

Abdominal Hysterectomy

The uterus is removed through an abdominal incision, usually made low down, at or just above the top of the pubic hair line – the so-called ‘bikini line’. If you have previously had an operation with a vertical scar (from just below the belly button to the hairline) this may be re-opened. If the uterus is very large (for example, because you have large fibroids) or if there is a very large ovarian cyst, a vertical scar may be necessary.

A vertical scar heals just as well as a bikini line scar, although it is more uncomfortable initially and is more visible. It is also potentially weaker in the long term because it cuts right through the centre of the muscle sheath that supports the abdominal wall. Both types of abdominal incision involve going through the muscle layer as well as the skin and it takes time for this to heal and recover its strength afterwards.

Various methods are used to close the abdominal incision, including removable clips and staples, dissolving sutures (stitches that dissolve under the skin), and a single or a series of removable sutures. Healing occurs in the same way regardless of which method is used but, if you have encountered any problems with scars in the past and have any anxieties, it is important to let the hospital staff know.

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In general, an abdominal hysterectomy involves a hospital stay of three to five days and a recovery period varying between six and twelve weeks, depending on your general health, whether you develop any complications, your family commitments and what sort of job you do.

Total abdominal hysterectomy

This is the most common operation and involves removal of the uterus and the cervix (neck of the womb), leaving a scar at the top of the vagina as well as the one on the abdomen. It does not necessarily include removal of the ovaries (see page xx). The advantage of removing the cervix is that it makes it impossible for abnormal cellular changes to arise which might lead on to the development of cancer. Any such changes are detected when you have a cervical smear.

Having a total hysterectomy means you’ll never need another smear, providing that your cervix was entirely free of abnormal cellular changes when examined by the pathologist after the hysterectomy. If you have had treatment for abnormal cells in the past or who want to avoid having to go for smear checks in future you should have the cervix as well as the uterus removed.

On the other hand, if you have always had regular smears and they have always been negative, your chances of developing cervical cancer are very low and you may be suitable for a subtotal hysterectomy (see below).

Subtotal abdominal hysterectomy

This involves removing the uterus but not the cervix and is a shorter, simpler and safer operation because the removal of the cervix tends to be the most difficult part of the operation. It may be recommended if the gynaecologist is

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concerned that removal of the cervix may be difficult (for example, if you have had a number of caesarean sections).

The disadvantage is that you may still be at risk of abnormal cellular changes so you must continue to have regular cervical smears. Another potential problem is that leaving the cervix may also leave a fragment of the womb lining and some women experience continuing slight bleeding after subtotal hysterectomy.

One of the main reasons for leaving the cervix behind used to be that this was thought to be important for sexual enjoyment and orgasm. However there is no scientific evidence that the type of hysterectomy makes any difference to a woman’s sex life after the operation.

Vaginal hysterectomy

This is the method used for treatment of a prolapsed uterus. It can be combined with a pelvic floor repair if the walls of the vagina have prolapsed as well. Both the uterus and cervix are removed through an incision at the top of the vagina and so you aren’t left with an abdominal scar. Both the hospital stay and the total recovery time is shorter than with abdominal surgery. You can expect to be in hospital for two to four days and recovery is usually complete six to eight weeks after the operation.

If you’re having your uterus removed because of menstrual problems, you may be offered vaginal hysterectomy, but this method is not suitable for everyone. It is very difficult to perform if there are large fibroids or an ovarian tumour. It is less likely to be offered to women who have had no children, those who have had previous pelvic operations or those who have had only caesarean section births.

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The gynaecologist who will be performing the surgery is the best judge of whether the operation can safely be carried out vaginally. When in doubt it is best to opt for an abdominal operation rather than run the risk of complications from a difficult vaginal operation.

Laparoscopically assisted hysterectomy

This uses methods that have become known as ‘keyhole’ surgery. The laparoscope is a viewing instrument which is inserted into the abdomen through a small incision below the umbilicus (belly button). It is connected to a camera and a fibreoptic cable, which allows the uterus and pelvis to be viewed on a screen. Two additional small incisions are made on either side of the abdomen for insertion of the instruments used to carry out the surgery.

Usually the upper part of the uterus is divided from its supporting structures through the laparoscope and then the uterus and cervix are removed through the vagina (laparoscopically assisted vaginal hysterectomy). This makes it possible also to remove the ovaries if this is necessary.

Laparoscopically assisted hysterectomy requires special equipment and training and is not available in all hospitals. It takes longer to perform than the standard methods and there is a slightly greater risk of complications. The advantage is that there is a much smaller scar than for an abdominal hysterectomy and thus recovery should be quicker.

KEY POINTS

■   A total hysterectomy involves removal of the uterus and cervix, but does not automatically include removal of the ovaries

■   A subtotal hysterectomy preserves the cervix, but regular smears are still necessary afterwards

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■   Hysterectomies may be carried out abdominally, through the vagina or with the assistance of laparoscopy

■   Recovery is quicker after a vaginal hysterectomy, but not all women are suitable for this type of operation

■   Hysterectomy is the only treatment for menstrual problems that guarantees complete long-term relief of menstrual bleeding

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Hysterectomy and your ovaries

Removal of the ovaries is not an automatic part of most hysterectomies, although it can be done at the same time and through the same surgical incision (scar). This should never be seen as a matter of convenience, just because you are having an operation done anyway. The question of whether your ovaries should be removed is very important and must be given very careful and separate consideration.

There will be some situations – for example, the treatment of endometriosis or certain forms of cancer – where removal of the ovaries is an important part of the treatment of the underlying problem. This does not apply to most hysterectomies carried out for the treatment of fibroids or menstrual problems.

What your ovaries do

The main function of your ovaries is the monthly release of eggs to enable you to conceive a baby. The ovaries also produce the two hormones, oestrogen and progesterone, which prepare the lining of the uterus for pregnancy and control the menstrual cycle. Thus, if you are certain that you have had all the children you want, you may feel that your ovaries are no longer required. This is a long way from the truth. The hormone oestrogen produced by the ovaries has many other functions apart from its actions on the uterine lining.

Loss of the ovaries brings on the symptoms of the menopause (see below) and causes bone loss, increasing the risk of osteoporosis in later life. It also causes thinnning and dryness of the vaginal walls, making sexual intercourse painful. If you decide to keep your ovaries after the uterus is removed, the ovaries will continue to produce the same amount of oestrogen for the remainder of their natural lifespan. It is sometimes stated that the

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ovaries fail earlier after a hysterectomy but recent research has not confirmed this.

Symptoms after ovary removal

Symptoms such as hot flushes, night sweats, vaginal dryness and occasionally mood disturbances may start abruptly after removal of the ovaries. These symptoms vary in severity from woman to woman; some scarcely notice them whereas others are severely troubled for months or even years. However, onset of these symptoms can be prevented by the use of hormone replacement therapy (see below).

Hormone replacement therapy (HRT)

If your ovaries have been removed, oestrogen can be prescribed by your doctor in the form of hormone replacement therapy (HRT). There are many different types of HRT, available as tablets, skin patches or skin gel. It is sometimes given as an implant (a small pellet inserted under the skin), although there are disadvantages to this method and some doctors do not use it. Unlike women prescribed HRT who still have a uterus, women who have had a hysterectomy normally need only one of the two hormones normally produced by the ovaries (oestrogen but not progesterone).

Is HRT suitable for everyone?

As HRT is designed to replace hormones normally produced by the ovaries, it is suitable for most women . However, if you have had treatment for breast cancer or are having a hysterectomy for uterine lining cancer (endometrial cancer), it is not advisable to take HRT. It is also not suitable for women with a strong history of thrombosis (blood clots) or heart disease.

There are some medical conditions for which additional health checks are required if HRT is taken. The most common of these is high blood pressure. However, as HRT has to be prescribed by a doctor, you will be asked a series of questions about your health before HRT is prescribed and this will give an opportunity to raise any concerns that you may have.

Does HRT have any side effects?

Side effects may occur with HRT but most of these are similar to the symptoms that women often experience along with their monthly cycle. The most common are sore breasts, headaches, bloating and fluid retention, but it is unlikely that you would experience all of these. Side effects can often be relieved by prescribing a lower dose of HRT or trying a different preparation.

HRT may cause bleeding problems but this is not relevant if you are taking HRT after a hysterectomy. The main concern raised by women starting HRT is whether they will gain weight. Again this varies and HRT can certainly aggravate an existing weight problem. Any initial weight gain is temporary when you first start HRT and does not usually continue.

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What about the risks of HRT?

Women are naturally concerned about potential risks with HRT. On balance, it is felt that the health benefits of HRT outweigh any risks for women who have their ovaries removed before the natural menopause. Not only does HRT treat menopausal symptoms such as sweats and vaginal dryness, and improves the way that you feel, it also protects against bone loss and osteoporosis.

The main disadvantage of taking HRT is that there is an increased risk of breast cancer. However, this risk applies only to women who start taking HRT over the age of the natural menopause (around 50) and take it for five years or more. If you start HRT in your 30s or 40s, it is normally recommended that you take it until you reach the age of 50. HRT causes a slight increase in the risk of venous thrombosis (blood clots in the leg veins) and also increases the risk of heart disease and stroke.

However, these risks apply mainly if you are already at higher risk – for example, if you are overweight or have high blood pressure. Women who are not suitable for HRT patches or tablets may be able to use oestrogen pessaries or cream for the relief of vaginal dryness or painful intercourse. All women are individuals and have different concerns and health factors. It is helpful to discuss the subject with a doctor who is interested in the menopause. For more information readers are referred to the companion booklet in this series, Understanding the Menopause & HRT.

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Ovarian disease

If your ovaries are diseased, this may be the major reason for the hysterectomy operation. For example, if you have severe endometriosis or if ovarian cancer is suspected, the best treatment is removal of the uterus and both ovaries.

The other main reason why gynaecologists recommend removal of the ovaries is to prevent the later development of ovarian cancer. This is a very serious condition that is hard to treat, although it is not common.

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Some women are at increased risk of developing ovarian cancer because they have a strong family history of this condition. You may also be at increased risk if you have no children, have never been on the oral contraceptive pill or have a history of infertility. If you have concerns about any of these factors you should discuss them with the gynaecologist.

Removal of healthy ovaries

If the reason for your hysterectomy is heavy menstrual bleeding or fibroids and your ovaries are healthy, removing them is not a necessary part of your treatment. Few gynaecologists would suggest doing so if you are under the age of 45 because it is generally believed that the disadvantages outweigh the advantages.

If you are already menopausal or very near the menopause, it may be suggested that you should have your ovaries removed, even if they are healthy, on the basis that they are no longer functioning adequately. However, the decline in hormone production during the natural menopause is much more gradual than the sudden fall that occurs after surgical removal of the ovaries. If you decide to have your ovaries removed you should be well informed about HRT and feel happy about taking it.

If you suffer from severe PMS or PMT, removal of both your ovaries may be recommended on the basis that the symptoms are triggered by the hormonal changes of the menstrual cycle. However, this is a particularly drastic approach to the problem and does not always work. Even worse, you may then find that HRT does not suit you.

By giving a course of medical treatment that stops the production of hormones from the ovaries (a GnRH analogue – see earlier chapter) and then later adding in some HRT, it should be possible to predict which women may benefit from removal of their ovaries.

When should HRT be started?

After a hysterectomy with removal of the ovaries, the symptoms of sudden hormone loss may start almost immediately, although they may be masked by other changes related to the operation. Feelings of being very hot and sweaty may be confused with symptoms of a fever and changes in mood with the stress of surgery.

Hormone lack may contribute to feelings of anxiety and low mood after the operation, and thus there are advantages in starting HRT early on in order to prevent these symptoms. This should not be before you are fully mobile – usually around the time that you are due to be discharged home. The HRT may be supplied by the hospital or you can arrange for your GP to do this.

There may be medical reasons for delaying the start of HRT or you may prefer to wait and see whether you really need it. Not everyone experiences symptoms after removal of their ovaries and the symptoms may be milder if you are already going through the menopause anyway. However, if you are under 45 or have additional risk factors for developing osteoporosis in later

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life, HRT is usually recommended. If wish to discuss HRT in more detail, ask your GP for advice and look out for leaflets which are available in surgeries and hospital clinics. You’ll find more information about HRT in the companion booklet in this series (Understanding the Menopause & HRT).

What type of HRT should you be taking?

As indicated above, after a hysterectomy HRT containing only oestrogen is usually prescribed. You would need to take combined HRT which also contains progesterone if you have had endometrial ablation because some remnants of the uterine lining usually remain.

Combined HRT is also recommended after a subtotal hysterectomy because the upper cervix may contain uterine lining tissue. Some women who have had a hysterectomy with removal of their ovaries for the treatment of severe endometriosis require progesterone along with oestrogen to ensure that there is no reactivation of any small areas of endometriosis which may still remain. This will be discussed with you before you are discharged from hospital.

Hysterectomy and your menopause

The term ‘menopause’ is used to describe natural failure of the ovaries and you know it has happened when your periods stop. For those who no longer have a uterus, this change is rather meaningless because you are no longer having periods, so there is no easily recognised sign that your ovaries have stopped functioning. It used to be said that ovaries fail earlier after a hysterectomy but this has been disproved by recent research.

You will most probably become aware that you are going through the menopause because you start to experience symptoms such as hot flushes or night sweats. If you are in any doubt, it can be confirmed by measurement of hormone levels in your blood. You can then discuss the need for HRT with your doctor.

KEY POINTS

■   Removal of the ovaries is not an automatic part of a hysterectomy and may have serious implications for future health

■   The hormone oestrogen, produced by the ovaries, has an important function in preserving the health of the bones and vagina

■   Recent research has shown that, if ovaries are left behind, they do not fail any sooner after a hysterectomy

■   If the ovaries have to be removed, hormone replacement therapy (HRT) is suitable for most women

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■   HRT can be taken as tablets, skin patches or implants under the skin

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Hysterectomy for cancer

Most hysterectomies are carried out to relieve problems that are troublesome or debilitating but not life threatening, so you are able to weigh up the pros and cons beforehand. When cancer of the uterus, cervix or ovaries is diagnosed, the decision about treatment usually has to be made very quickly and there may be no alternative to a hysterectomy. Nevertheless, it is still important that you fully understand the proposed treatment, whether you have any choices and what will happen afterwards. Ask a relative or friend to come to the hospital with you to help you remember what is said and write down what questions you want to ask.

Hysterectomy may be only one part of your treatment and several specialists are likely to be involved in deciding the best course of action, including the gynaecologist, a pathologist who is responsible for examining tissue specimens and an oncologist (cancer specialist) who will advise about the necessity for additional treatment, such as radiotherapy or chemotherapy. There are often specialised nurses attached to such a team and they can be a great help in providing explanations, reassurance and support.

Cancer of the endometrium (uterine lining)

Endometrial cancer is most common after the menopause and is extremely rare in women under the age of 40. It causes abnormal bleeding after the menopause or prolonged and irregular bleeding in younger women. The diagnosis may be suspected by the presence of abnormal thickening of the uterine lining on a scan and is confirmed by examination of a sample from the lining (endometrial biopsy – see earlier).

The endometrial lining is surrounded by the thick muscle wall of the uterus so it is rare for this type of cancer to spread beyond the uterus, and a hysterectomy therefore gives a very good chance of a complete cure. The ovaries are also removed to minimise the risk of any cancer spread. If the pathologist who examines the uterus and ovaries after the operation has the slightest suspicion that the cancer may have spread beyond the uterus, a course of radiotherapy (X-ray therapy) will be recommended to destroy any cancer cells that may have entered the surrounding tissues with the object of achieving a complete cure.

The hysterectomy is normally performed through an abdominal incision, although occasionally the gynaecologist may decide that a vaginal or laparoscopically assisted approach is appropriate. Whatever method is used, it is likely that it will take a little longer than usual to recover fully afterwards, because the women concerned tend to be older than those having hysterectomies for other reasons.

As most women with cancer of the endometrium are already menopausal or beyond their fertile years, the decision to perform a hysterectomy is rarely a difficult one for the woman herself although there will

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always be exceptions to this, particularly for women who have never had children. Unfortunately, this form of cancer is more common in childless women. As cancer of the endometrium may be caused by high oestrogen levels, oestrogen-containing HRT cannot usually be prescribed. However all cases are different and if menopausal symptoms are a problem after the operation, this should be discussed with the gynaecologist or oncologist.

Cancer of the cervix

This form of cancer affects the neck of the uterus and is usually prevented from developing by early detection of abnormal cells through the cervical smear programme. If a smear test shows up pre-cancerous cells, they are removed by a procedure called colposcopy, which involves a detailed inspection of the cervix through a magnifying system (colposcope). This enables the removal of abnormal cells by simple treatments which leave the uterus and cervix to function normally. This pre-cancerous condition is known as cervical intraepithelial neoplasia (CIN) and must not be confused with cervical cancer itself.

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Despite the effectiveness of the smear programme, some women still develop cervical cancer, sometimes at a relatively young age. If the tumour is fairly small, it can be treated by hysterectomy but, if it has started to spread, it cannot all be removed by hysterectomy and radiotherapy will be necessary, either as well as or instead of hysterectomy. Both these forms of treatment will result in loss of fertility, although a hysterectomy for cervical cancer does not usually involve removal of the ovaries. Theoretically, a woman who has a hysterectomy but still has her ovaries could have a child with a partner, but only with the use of in vitro fertilisation (IVF) and with the help of another woman willing to carry that child for them (a surrogate mother). Radiotherapy stops the ovaries from functioning so there is no prospect of future fertility. However, methods of retrieving and storing small pieces of an ovary are currently being researched and may become available in the future. Therefore, any young woman with cervical cancer faced with loss of fertility should have the opportunity of discussing the implications and any available options before treatment is started.

A hysterectomy for cervical cancer is a very major operation because it involves removal of additional tissues besides and below the cervix, and also removal of the lymph nodes in the pelvis to which cancer may spread. In particular the bladder and bowels may take longer to return to normal. Loss of the ovaries or of their function after treatment of cervical cancer can be compensated for with HRT because this form of cancer is not influenced by hormones.

Ovarian cancer

This condition is less clear than the others described above because there are many different types of ovarian cancer and it is not always possible to diagnose its extent or even its presence in advance of an operation. A woman may therefore face uncertainties about the precise nature of an operation to remove the cancer until after it is over. Nevertheless, a woman’s desire to retain her fertility will always be taken into consideration and is likely to influence decisions about her treatment.

The symptoms of ovarian cancer are very vague and varied, usually abdominal discomfort or swelling, possibly vague ill-health and weight loss. It may come to light because the woman herself or her doctor has felt a swelling in her abdomen. The suspicion is then confirmed by the results of an ultrasound scan. Blood tests may give additional information and sometimes a more detailed type of scan (computed tomography [CT] or magnetic resonance imaging [MRI] scan) is performed. Sometimes it is possible to be fairly confident about the diagnosis of cancer, but often there is uncertainty which can be resolved only by removal of the ovary and having it examined by the pathologist.

If a woman with suspected ovarian cancer has completed her family and is near to or through the menopause, she will most probably be advised to have both ovaries and the uterus removed in order to avoid the need for a

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second operation and to minimise the risk that the disease may come back. Even a benign tumour may develop in the other ovary in the future. If there are visible signs that the cancer has spread beyond the ovary, these areas are removed as well.

Ovarian cancer more commonly affects older women and is fortunately rare in women under 40. Its treatment in younger women always involves weighing up the risks of spread of the cancer against the risk that fertility will be lost, and the wishes and opinions of the woman herself are always taken into consideration. It may be possible to remove only the affected ovary and leave the uterus and remaining ovary if the woman is anxious to retain her fertility, unless there is obvious spread of the tumour. Treatment of ovarian cancer in young women will usually involve chemotherapy (use of drugs that destroy cancer cells) and there is a risk that this may also damage the egg-producing cells in the remaining ovary, although it is usually possible to select drugs that minimise this risk.

Further treatment

Hysterectomy for cancer may be followed by additional treatment with radiotherapy or chemotherapy, depending on what is found during the operation and the results of the pathologist’s tests on the tissues. As mentioned above, recommendations regarding further treatment are made by a team of specialists. Even if additional treatment is not required, further visits to t