The smart way to learn. The smart way to teach.

MRCOG PART 2 SBAs and EMQs

Course PAID
notes336
EMQ1502
SBA2115
Do you realy want to delete this discussion?
Forum >>

ESSAY 158 - MENORRHAGIA

Posted by uma M.
Menorrhagia is a common problem in gynaecology clinics.Various medical(hormonal &non hormonal) and surgical treatment modalities are effective in treatment of menorrhagia.But in a 35 year old surgical treatment option is considered only after initial medical therapy, and if it fails to control her symptoms.
Prior to definitive surgery for menorrhagia semi-objective or objective assessment ( using pictoral blood loss assessment charts)of menstrual blood loss is done as upto 50% of women c/o menorrhagia do not have menstrual blood loss >80 ml. Also endometrium should be assessed by either out patient endometrial sampling user pipelle sampler or hysteroscopy guided biopsy to exclude serious conditions like malignancy though rare in this age group, exclude atypia, hyperplasia.
Surgical options in management of idiopathic menorrhagia include endometrial ablation/resection and hysterectomy.
Endometrial ablation /rescetion using LASER/Thermal ball/Microwave/rescection is an option for woman if future child bearing is not a problem for her and has significant blood loss at menses as assessed . This procedure involves destruction of endometrium inducing changes similar to asherman\'s syndrome. She is ideal candidate for this procedure if she doesn\'t expect complete amenorrhoea, as amenorrhoea is only seen in 30-40% of women. she can under gothis procedure as as day case ,assosiated with reduced hospital stay,short post op recovery , reduced minor morbidity,serious complications( like haemorrhage,VTE) compared to hysterectomy for her .These procedures are safe if women who is unfit for major surgery due to some medical reasons, or if she is at high risk for surgery eg -extremenly obese or anaesthesia as these can be performed under LA .She should continue to use contraception as pregnancies can occur after ablation.This is easy to perform effective with reduced menstrual blood loss in 80% .COunsel her prior to procedure that long term satisfaction rate will be around 80%. Around 20% of women undergo hysterectomy in the future 5 years.40% will have reoperation in the form of repeat ablation at 3 years.As fluid over load is potential problem with these Hysteroscopy guided procedures like TCRE/ELA caution if women is at risk due to preexisting ilness like cardiacdisease,chronie renal failure.
Hysterectomy offers definitive treatment for her with 100% amenorrhoea. It is cost effective as it completely eliminates the problem. This is procedure of choise if she desires no future child bearing and expects complete amenorrhoea. But with this procedure she is at risk of significant surgical morbidity including viseral injury,haemorrhage, infection, DVT and mortality .Long hospital stay is required for her. Subtotal hysterectomy may have advantage over total hysterectomy if she is well motivated ,compliant for regular cervical screening as it does not effect sexual function as does total hysterectomy in this 35 yr women.Ovaries should be retained as she is only 35 yrs, unless she is assessed as high risk of malignancy from family ,personal history and genetic testing if necessary. But removal should be only after clear discussion with her and obtaining consent.Route of hysterectomy depends on patient\'s preferrence, presence of any uterine descent , available experetise to perform non descent vaginal /laparoscopic assisted hysterectomy.
Women should be counselled regarding these methods ,risks & benefits explained so that she chooses her option. Provide written information to assist her in understanding .
Posted by Nitin P.
Menorrhagia is defined as menstrual blood loss of >80 mls per cycle. It affects 10% of women and commonest cause is idiopathic or dysfunctional bleeding. It may significantly affect the quality of life, loss of working days and hence needs treatment.
The type of surgical treatment will depend on the presence of associated symptoms in addition to the menorrhagia. History of dysmenorrhoea, abnormal cervical smears, past infection may suggest the need for more radical surgery. If premenstrual syndrome or cyclical mastalgia or migraine is a significant symptom, a discussion regards oophorectomy would be appropriate.
The surgical treatments are mainly in the form of endometrial destruction and hysterectomy. The endometrial ablation/destruction is done by either roller ball, thermal balloon, laser, radio frequency or microwave. The amenorrhoea rate is 30%, satisfaction rate 30% and 30% will not be happy with the result. It is important to counsel regards this, as it may improve the satisfaction rate. 30% may need a further surgery upto 3 years later. The uterus should preferably be normal sized and cervical and endometrial cancer ruled out.
These methods are associated with less post operative pain scores, shorter anaesthesia, shorter operating time. Consequently need for analgesia is less and hospital stay is less. Also there is an early return to work.
The procedure itself carries the risk of uterine perforation and fluid overload. Dysmenorrhoea may improve in some but may arise as a long term complication in others.
Though there is significant improvement in immediate quality of life measures, there may be long term deterioration in these measures necessitating a follow up.
Hysterectomy may be indicated if there is endometrial pathology, cervical pathology or dysmenorrhoea. It may be done Laparoscopically, Abdominally or Vaginally. The risks and complications are operator dependent and hence the method with which the operator is most familiar should be chosen. The VALUE trial suggested that the vaginal route should be preferred, as the pain, operating time and complications were the least.
A subtotal hysterectomy may be discussed in this case. It is associated with shorter operative time, less intraoperative complications, less post operative morbidity and early return to work. However, cervical smear need to be followed up and also there may be persistent menorrhagia from retained endocervical glands.
The ovaries would normally be retained at this age unless there is coexistent pelvic pain, premenstrual syndromes or strong family history of ovarian cancer. If the ovaries are removed, need for HRT needs to be considered.
Hysterectomy is associated with higher intra operative and postoperative complications. The main complications are bleeding, blood transfusion, bladder, bowel or ureteric injury, and need to return to theatre. Yet in the long term there may be better quality of life measures, and a lower risk of ovarian cancer. It is also the method of choice in those wishing complete amenorrhoea.
The patient is given all the non-surgical and surgical options in a non directive manner using lay terms. Leaflets are provided and follow visit arranged to answer any queries.
Posted by salma S.
Various surgical treatments for idiopathic menorrhagia include endometrial ablation and hysterectomy. It is important to discuss likely outcomes and complications with the woman beforehand and provide appropriate written information.
Endometrial ablative procedures are effective in treating menorrhagia. Amenorrhoea rates are 20-40%. It is associated with lower morbidity and quicker recovery compared to hysterectomy with a significant improvement in Hb and quality of life. There is a risk of fluid overload. Long term satisfaction rates are around 80%. These are associated with a re-operation rate of up to 38% at 3 years and10-25% require hysterectomy after 3-4 years. Per-operative counselling and patient selection is vital. Women should have heavy menses and should not expect amenorrhoea. Malignant or pre-malignant endometrial conditions should be excluded and the uterus should be less than 12 weeks size. Pelvic infection should be excluded; the woman should have completed her family and would undergo a hysterectomy if necessary. Women need to continue contraception as there is s risk of pregnancy. The effect on dysmenorrhoea remains uncertain, some practitioners consider dysmenorrhoea as a contra-indication to endometrial ablation / resection. Others suggest that ?true dysmenorrhoea? is significantly improved in most women. Techniques of ablation include laser / diathermy ablation, endometrial resection, microwave endometrial; radio-frequency induced thermal ablation and the use of uterine thermal balloons.
The other surgical option is hysterectomy which is an established effective treatment for menorrhagia. It is important to discuss the route of hysterectomy vaginal or abdominal and their complications. Important points to be considered in this regard include presence of any coexisting prolapse, any associated medical conditions and available expertise. Total abdominal hysterectomy has the advantage of easy access and good vision of structures and affords easy oophorectomy. The patient however may incur other intra or postoperative morbidity including cosmetic effects of a scar. Cost to NHS due to prolonged hospital stay and prolonged pain relief are relevant. The risks of hemorrhage, thromboembolism and infection cannot be ignored. Laparoscopic vaginal hysterectomy enables abdominal hysterectomy to be transformed into a vaginal hysterectomy or a difficult vaginal hysterectomy into an easy one. Although operation time is prolonged it compares favourably with vaginal hysterectomy in terms of patient recovery, time, reduced pain relief and shorter pain relief. It is the method of choice for suspected adnexal masses, suspected endometriosis and adhesiolysis. Mortality with vaginal hysterectomy is higher than with TAH as shown I the last CEPOD report.
Also women should be counseled regarding total and sub-total hysterectomy. The advantages of subtotal operation includes shorter anaesthetic and operation time, reduced risk of primary haemorrhage and damage to surrounding structures like bladder and ureters.There is also less morbidity from secondary hemorrhage, haematoma, bladder and bowel dysfunction, infection and vault granulations. There is a potential for early resumption of sexual activity, lesser incidence of dysperunia and sexual dysfunction with better vaginal lubrication. Potential disadvantages include menstruation from endometrial remnants; need to continue cervical smears, cervical pathology like cervicitis and cervical polyps. There is no substantial evidence available for or against the advantages of subtotal hysterectomy.
Another important point is to discuss conservation or removal of the ovaries. This depends on presence of any dysmenorrhea, premenstrual syndrome, chronic pelvic pain, benign ovarian disease and family history of ovarian cancer. It is also important for prevention of residual ovary syndrome and benign cyst formation.
It is important to offer hormone replacement therapy following Total abdominal hysterectomy and bilateral oophorectomy. Overall hysterectomy is the operation of choice in women who desire amenorrhoea.

Posted by Sreekala S.
Idiopathic menorrhagia is defined as blood loss of greater than 80ml per cycle in the absence of any pelvic pathology. It is a common gynaecological complaint.
Non surgical options with medications like NSAIDS, Tranexemic acid, Progestogens and LNG-IUS should always be tried before going ahead with surgery especially in a 35 year old lady.
Although the surgical methods give long lasting relief than the non surgical methods they are associated with a higher complication rate.
Surgical options include minimally invasive methods which act locally on the endometrium like the ablative techniques and hysterectomy.
Keeping the age of the woman into consideration, endometrial ablation should be considered first. Various minimally invasive techniques are available that act locally on the endometrium by ablating it by using microwave, lasers, Thermal balloon ablation, cryoablation, hydrothermal ablation etc..,They are highly effective with success rates of about 80-90%. The woman should be counselled that it is not a permanent method and that treatment failures can occur and may need hysterectomy if this fails. She should understand that she can become amenorrhoeic and should not plan pregnancies after treatment and that she needs to use a definitive method of contraception and should continue to follow up with her cervical smear testing. Although they are less invasive, they have potential to cause uterine perforation, visceral injury or fluid overload. GnRH analogues are often given about 6 weeks prior to the procedure to thin the endometrium.
The advantages with these ablative techiques is that they are minimally invasive, can be performed as a day case, easy to perform, take less time, cost effective, and the woman can retain the uterus. But, the disadvantage with these is they do not offer a permanent cure, may need follow up and may need a hyseterectomy if they fail.

On the other hand, hysterectomy gives a permanent cure from menorrhagia. But, it is associated with a mortality rate of 0.38 per 1000 and serious morbidity which is defined as return to the OT to stop bleeding , visceral injury or severe post operative complications in 3%. It is a major surgical procedure which needs skilled surgeons, is expensive, takes longer time to perform and needs prolonged hospital stay. The type of hysterectomy depends on the woman\'s wish, presence/absence of any other adnexal pathology, previous abdominal surgeries and uterine descent. it can be done by total abdominal hysetectomy, sub total hysterectomy, vaginal hysterectomy, Laparoscopically assisted vaginal hyseterectomy or by total laparoscopic hysterectomy. Surgical success depends on correct selection of the patient and on the skill of the operator.
Discussion regarding removal/retaining of ovaries and possible complications liek bleeding, visceral injury, infection and DVT should always be done pre-operatively with the woman. It is preferable to retain the ovaries in this 35 year woman if they don\'t look suspicious.

Posted by manjula C.
Menorologia is a common gynaecological complaint seen in a gynaec clinic and accounts for 40%of specialist referrals in u.k.
As the diagnosis is suggestive of dysfunctional uterine bleeding in a 35 yrs old lady,it is very important to know whether she has completed her family.as she is for a surgical management of her condition,the type of surgery offered ,either conservative ordefinitive has to be deciced.
Before resorting to the surgey certain things have to be evaluated.like her general condition,presence of anaemia which needs correction either by haematinics or blood transfusion depending on the severity or the urgency of the treatment.a thorough clinical examination is essential to lok for other major illnesses like subclinical hypothyroidism,cardiorespiratory disorders which can be a contraindication for minimal acsess surgeries like TCRE(where there could be a risk of fluid overlaod)
The minimal accesses surgeries offered are conservative in nature where the reproductive capacity is retained.however the operation could result in subfertility.and complications to the mother and the fetus.this has to be clearly explained to the patient both verbally and by information leaflets .the conservative surgeries offered are TCRE,laser ablationof endometium,microwave,thermal balloon,radio frequency induced thermal endometrial thermal ablation.
The satisfaction rate following thes conservative surgeries are about 80% and nearly40% becme amenorrhoic.however about 20% may need repeat procedure or a definitive surgery ,hysterectomy in near future. It should be made very clear to the patient that these surgeries do not benefit her if she has associated premenstrual symptoms.


The main advantages of these surgeries are they are

minimally invasive,could be done as a daycare case,less morbidity compared to hysterectomy,fast postoperative recovery,and early return to the routine.
However there is a risk of fluid overload and subsequent subfertility.
The definitive surgery offered will be hysterectomy,either total or subtotal.subtotal has an advantage of retaining the cervix so the injury to the bladder and ureter during surgery will be minimized.also it retains the satisfaction of deep orgasm.however the patient will require routine cervical smears like before.the ovaries should be retained during hysterectomy unless she has a risk of hereditary cancer syndromes.if removed she should be given HRT.patint should be suggested that even the definitive surgery may fail to relieve her premenstrual symptoms.
The route of surgery could be abdominal or vaginal,depending on the surgical expertise.if the patient is having a mild decent pf the pelvic organs a vaginal hysterectomy with pelvic floor repair will be the ideal.this route has many advantages like less visceral injury,less need for postoperative analgesia,early return to routine as there is faster recovery.
Hysterectomy by either route achieves about 100% satisfaction regarding mennorhagia.however the morbidity and mortality is little higher compared to conservative procedure.there is an increased risk of visceral injury,postop complications,return to the theatre as a result of bleeding etc.there are long term complications like residual and remnant ovary syndrome leading to deep dyspareunia.
The patient should be given the whole information regarding the surgeries ,risks and benefits and helped to make an infomed choice of hers which should be respected whichever she chooses.
Posted by Mangala sundari R.
Menorrhagia is one of the commonest gynaecological complaints. History is taken to know the amount of menstrual loss ( whether it is morethan 80 ml by pictorial assessment chart or semi objective methods), associated anemia,
investigations done. and the treatment taken sofar.
Her obstetric history and plan for future fertility is noted. Any associated medical conditions like thyroid disorder, diabetes, hypertension,or use of hormones noted .
Before advising her on surgical interventions she should be given advise on the alternative treatment.,medical management with cocp. Progestogens, danazol,,Gnrh analogues, and mirena LNG-IUS. These should be tried as a first line of management especially if she desires future preganancies.
The surgical treatment available for idiopathic menorrhagia are , endometrial ablation, and subtotal or total hysterctomy.
Pre operative evaluation investigations incluse CBC, U&E, sugar, Pap?s smear update, U/S of pelvis and adnexa,endometrial pathology (malignancy) ruled out by biopsy and histopathology. Improve her anemia and group and cross match.

Informed consent about the endometrial ablation obtained after expalaining the procedure, the anestheia, .and complications.She will be expalained that furthur preganancy is contraindicated after this treatment, but she will remain fertile and to use contraception. She cannot expect complete amenorrhea after this procedure. The endometrium is resected transcervically through an operative hysteroscope using an electrical wire loop.The medium used is glycine. The potential complications are perforation,bowel injury, hemorrhage, fluid overload which will cause pulmonary or cerebral edema, and convulsions.Strict fluid input and output to be maintained by the assistant to avoid fluid overload. She may require Laparoscopy or laparotomy for bowel injury. This procedure needs adequate training. 80% patients have long trem satisfaction and about 35% remain amennohic at the end of 3 years..Other methods of endometrial ablations are by microwave, laser ablasion.. Instuments and expertise are needed for all these procedures. Thermachoice ballon therapy is yet another method used for endometrial ablasion.All these procedures can be done under local in the outpatient clinic or .as inpatients under GA. The morbidities of major surgery like VTE, hemorrhage ,bowel injury , bladder injury and long hospital stay are avoided .Around 30 to 40% are amenorrhic at the end of 3 years.

20 t0 40%will come back for second ablation or opt for hysterectomy.

The definitive treatment for idiopathic menorrhagia is Hysterectomy with a good patient satisfaction of 100% amenorrhea.. It can be vaginal or abdominal / subtotal or total hysterectomy by laparotomy or laparoscopic assissted. If she has no ovarian pathology or any risk factors for future ovarian malignancy like ( family h/o ovarian, breast, colon cancer)they should be preserved at this age. Route of surgery depends on patients choice ,any descent ,and the expertise available.

Preoperative evaluation done , anemia improved, with anesthetic review, informed consent obtained for the hysterectomy. Her wishes for transfusion of blood products are noted and arrangements made accordingly.
In this young age she can be counselled for subtotal hysterectomy The advantages of having a good vault support, in sexual functions , ,, less operating time and morbidity, less alteration in the urethro vesical angle thus minimizing stress incontinence. The disadvantages are stump carcinoma 1% and irregular bleeding or spotting from the remaining endometrium.She should be compliant for screening for Cervical Ca. .Vagianl hysterectomy or abdominal hysterctomy are the definitive treatments for this patient.
TED stockings and early mobilization and adequate hydrations to prevent VTE. Prophylactic antibiotics during surgery .
Post operativeThromboprophylaxis should be done according to the risk facors .
She can be counselled for HRT during the follow up after verifying her histopathology report.
Posted by jyoti D.
The surgical options for idiopathic menorrhagia or dysfunctional uterine bleeding depends upon patients choice,desire for future fertility and fitness for surgery.
The options are hysteroscopic destruction of endometrium( endometrial ablation) and hysterectomy.reduced risk of thrombosis and is costeffective.
Endometrial ablation widely practised because of low morbidity ,less analgesia requirement,short hospital stay,quick recovery
The selection of patient is important for endometrial ablation like size of uterus less then 12 weeks ,experience heavy periods affecting quality of life ,no desire for future fertility and willing to continus contraception,there should be no endometrial atypia,normal cervical smears,no pelvic infections ,she should not expect amenorrhea as found only in 20-40% of cases,she should not expect relief of dysmenorrhea or premenstrual symptoms.
Preoperative counselling regarding the complications though a day case may require inpatient admission in case of complications like haemorrage,fluid overload and perforation in case of perforation may require laparoscopy or laparotomy and emergency hysterectomy in less then 1% of cases.The tecniques are transcervical resection of the endometrium /roller ball cautery/laser with satisfaction rate of 80% and repeat surgeries required in 38%in3 years and 10-25% requiring hysterectomy.
Others are radifrequency ablation,microwave ablation,thermal balloon endometrial ablation these avoids the risk of fluid overload because of the procedure.
The definative treatment is hysterectomy with satisfaction rate of 90% conservation of ovaries depends upon patients choice,family history of ovarian malignancies,should understand the implications of HRT if removed.Removal of ovaries will relieve premenstrual symptoms.Hysterectomy can be laparoscopically depending upon skill and facilities.
The option of subtotal hysterectomy should be given as associated with decreased operative time,less operative morbidity ,less recovery time., sexual function is resumed early because of cervix as lubrication not affected.Disadvantage requires smears regularly,risk of stump cancer and spotting because of endometrisl remnants.
Provide patient with information leaflets.
Posted by Shakira B.
A) The treatment of this patient will depend on several factors, the most important of which is her desire of have children, or more children, and also on the cause of her menorrhagia. Causes that will require specific surgical treatment include uterine fibroids, adenomyosis and endometriosis.
If the patient has dysfunctional uterine bleeding (that is, her menorrhagia is idiopathic) surgical options include destructive procedures of the endometrium and a hysterectomy. The destructive procedures (such as laser ablation, endometrial resection, balloon or thermal ablation. Other newer techniques of destruction of endometrium) are effective, easy to perform and associated with a lower morbidity. However most are only done in hospitals as day cases. Because of the short operative time and early post operative recovery, they have a significant advantage in a patient who is at a risk of VTE from prolonged surgery. In good hands, 70-80% of patients are very satisfied with the results. When it fails it must be considered as an expensive option as it has to be superseded by a hysterectomy or a repeat procedure. A local destructive procedure will only be considered in this patient if she has completed her family.
The second surgical option, hysterectomy, is appropriate for idiopathic menorrhagia and that secondary to uterine fibroids, pelvic inflammatory disease, adenomyosis and endometriosis. The advantage of this is that it is the definitive treatment of menorrhagia. It is cost effective and completely eliminates the problem. However, it is expensive and may be associated with complications, including mortality. Although very effective it can only be performed in hospital and is associated with a prolonged recovery when compared to that of an ablative/destructive procedure. Its main advantage is the effectiveness of the treatment.
If the cause of menorrhagia in this patient is uterine fibroid, another option for her treatment would be myomectomy. This surgical procedure is associated with complications, such as bleeding, adhesion formation and, in some cases, progression to a hysterectomy. It is the best option if the patient has not completed her family. Myomectomy is expensive and has to be performed by an experienced surgeon. The possible drawback is the fact that not all the fibroids may be removed. The patient may therefore represent with menorrhagia and require a repeat procedure.
Lastly, if endometriosis is the cause of the patient\'s menorrhagia, laser destruction of the endometriosis and uterosacral nerve division (LUNA) may reduce the menorrhagia. The success of these procedures is poor, although when combined with medical treatment there is significant benefit. These procedures may also be associated with complications, such as damage to the bladder, bowel and ureters.
Posted by Vandana D.
In a 35 yr old woman ,surgical options for the treatment of idiopathic menorrhagia are advisable only if medical Tt. fails to control the bleeding,the woman opts for it & understands the implications of surgical Tt. methods. One of them-She would not be able to conceive thereafter,therefore preferably she should have completed her family.
Available surgical methods are: minimal invasive techniques of endometrial ablation/resection ;hysterectomy.
Endometrial ablation/resection can be performed preferably after Tt. with GnRH ANALOGUES,to minimise the thickness of endometrium.Various techniques have been used:1st generation-TCRE,ELA,RFEA-2nd gen.microwave EA,Thermal EA,.TCRE & ELA are performed under hysteroscopic vision-risks of fluid overload-oedema,hyponatraemia with glycine.The advantage of tnese minimal invasive techniques are-short operation time,shorter hospital stay,quicker return to normal activities,lesser morbidity, positive psychological impact of intact uterus,no effect on ovarian function,satisfactory in ~60-70% of patients.amenorrhoea in ~40%.The results depend upon the unit\'s performance.RCOG recommends them Grade A for the Tt. of idiopathic menor. based upon evidence.
Disadvantages are:fails to provide relief from symptoms in ~20 % OF PATIENTS.These require further Tt. usaully hysterectomy.Though repeat EA/resection can provide effective relief in some.,if the patient wishes.Risks of uterine perforation,may need emergency laparotomy,fluid overload,eletrol;yte imbalance,visceral injury.Mortality rate ~2/10,000.Morbidity rate 2-6%. Can cause vaginal discharge for upto~ 3 weeks,cramps abdomen.
Need to use contraception,regular cervical smears.,later when she wishes to start HRT need to take combined preparations-their risks.
Hysterectomy provides definitive cure .100% amenorrhoea.Suitable to those who want amenorrhoea.With total hys no future risk of cervical/uterine cancer.It can be performed by vaginal/laparoscopic/abdominal route.it can be total/subtotal with or without BSO,DEPENDING UPON Expertise available associated conditions & patients wishes.Adequate counselling & informed consent prior to surgery is must.Vaginal hyst.(especially non descent with BSO REQUIRES optimum surgical expertise)Benefits are-lesser post op morbidity,lesser post op pain,early mobilisation,shorter hospital stay.Drawbacks:surgical expertise,adverse sequelae of major surgery.
Risks of hysterectomy:Mortality rate6/10,000,serious morbidity-3%(haemorrhage-return to theatre,visceral injury,infection ,VTE.Bladder dysfunction,vault haematoma/granuloma with total hys.)long term risks-vault prolapse`1.8%.Also it leads to menopause earlier.Subtotal hys carries the risk of stump carcinoma of cervix-needs regular cervical screening.
Laparoscopic surgery causes lesser post op adhesions,lesser pain,quicker recovery.Requires surgical expertise,risks of lap surgery-visceral/vascular injury,emergency laparotomy.
Regarding BSO bilateral salpingooophorectomy-can be considered if: she has severe premenstrual syndrome refractory to medical /conservative Tt.OREndometriosis or has strong family history of ovarian/breast/GIT malignancy,the woman is willing for it after considering the effects of BSO-Premature menopause,acute menapausal symptoms of surgical menopause,need to take HRT for longer time-its risks & anxiety due to risks,regular check-ups.Also counsel her reg.benefits of HRT.
The choice of surgical Tt would depend upon patient\'s wishes.Provide information leaflets.
I
Posted by Yusuf K.
The surgical options are hysterectomy and endometrial ablation.for this 35 year old lady.
For hysterectomy-
Counselling is very important.This may be acceptable if she has completed her family,to improve her quality of life.
Hysterectomy is associated with 100% amenorrhoea-this may be acceptable to patient depending on the severity of her symptoms especially if associated with social embarrassment with attendant poot quality of life.with satisfaction rate very high on medium and long term basis.
With hysterectomy,there may be a delay in return to full activities to between 4-12 weeks, this may not be acceptable to self employed.
Re-operation is virtually nil except late vault prolapse which is not very common.
However, it is associated with complication.there is the risk of bowel, bladder ureteral injuries and attendant problem and maternal mortality.With proper counselling and carefully planned operation this may be minimised.With vaginal hysterectomy, these complications are not common.

With Endometrial ablation
this can be performed either by laser,thermal, balloon or by transcervical endometrial resection.
Using this there is 75% of reduction in menstrual flow, this may be acceptable if she has not completed her family.A
And since it is idiopathic there is no associated co=morbid factor on the uterus, this may be a good surgical option.However, it may induce amenorrhoea in about 25% of cases, which may constitute another clinical problem if she still desires family.
Postoperative complication and mortality is lesser compare to hysterectomy,this may be acceptable if she fears major operation.However, re-operation rate is about 15% and 25% in the first and second year respectively.
Satisfaction rate after 4 months is comparable to hysterectomy and there is quick return to work within 1-4 weeks, this is more likely to be acceptable if she is self employed.
On a balance, with careful counselling and addressing her concern either option may be benefitial to her.