Your endometrium changes with your monthly menstrual cycle. Chemicals from your ovaries, called hormones, control your menstrual cycle. Every month, provided you are not pregnant or past the menopause, your endometrium is shed as a period.
Near the middle of your cycle you release an egg from one of your ovaries. Hormones from your ovaries will have already thickened your endometrium, ready to receive the egg. If your egg is fertilised by a sperm, it will stick firmly to your endometrium and develop into a baby in your uterus. If it is not fertilised, your hormones change. This change makes your endometrium come away with some bleeding; this is a period. After a few days a new thin layer of endometrium forms. This starts to thicken, ready to receive a fertilised egg during your next cycle. After the menopause, your ovaries stop producing the hormones that control your menstrual cycle. Your endometrium remains thin and your periods stop.
What has gone wrong?
We have been unable to find a definite cause for your period problem. You will already have had tests to rule out serious conditions, such as fibroids or cancer. In some way, the shedding mechanism of your endometrium is not working properly. This condition is called dysfunctional uterine bleeding. Tablet medication will not have helped with the problem.
What is a transcervical resection of endometrium?
This is an operation to cut away your endometrium, which lines the inside of your uterus. It may be called a TCRE for short. We pass a thin telescope, called a hysteroscope, through your vagina and cervix and into your uterus. This lets us see inside your uterus. We pass another instrument, called a resectoscope, through the hysteroscope to remove your endometrium. The resectoscope has a loop of wire at the end, which cuts using an electric current called diathermy. Diathermy not only cuts but is also used to seal off any bleeding. You will usually be unconscious with a general anaesthetic while this is done.
Weeks before your operation you will need drug treatment to make your endometrium thinner and reduce its blood supply. These drugs are usually danazol tablets or hormone injections, called GnRH analogues.
We aim to stop your bleeding problems by removing the endometrium lining your uterus. We call this process resection. We send the removed tissue for laboratory examination.
If your endometrium is completely removed you will have no further periods. If only a small amount of your endometrium remains, your periods should be light.
Your endometrium has great powers of regeneration. It can grow back if only a very small amount is not destroyed. We cannot guarantee that this operation will permanently stop your periods. Most women, about 85%, are pleased with the result after four years. Some of the remaining women will need a repeat TCRE or even an operation to remove the uterus, called a hysterectomy.
After a TCRE you will have much less chance of becoming pregnant, but it can still occur. You must still use contraception. Only some forms of contraception are suitable. Sterilisation is ideal. The contraceptive pill and the coil (IUCD) are not.
All of your endometrium and some of the muscle layer below it must be removed for an effective long-lasting result. There is a danger of making a hole, called a perforation, through the muscle layer. If this happens you may need a hysterectomy.
Are there any alternatives?
If your bleeding is not severe, treatment with hormones and other drugs may help. A special device like a coil, called a Mirena IUS, can be put into your uterus. It contains hormones that stop your endometrium working.
Instead of removing your endometrium we can destroy it with an endometrial ablation. A disadvantage of ablation is that it leaves no tissue for examination, so we do a hysteroscopy and endometrial biopsy a few weeks before to get the samples. There are several ways of doing an ablation. These are detailed in the leaflet Hysteroscopic Endometrial Ablation that is within this series.
A hysterectomy, where your uterus is removed, is the only operation guaranteed to permanently stop your periods and bleeding problems. If you have other problems with your uterus, such as a prolapse or a disease of the cervix, a hysterectomy is often the most effective treatment. Discuss the various options with your gynaecologist.
What if you do nothing?
If you do nothing and you have not reached the menopause, your period problems are likely to continue until you do. If you have heavy bleeding, you may become anaemic over time. Anaemia is when your blood does not contain enough oxygen-carrying, red blood cells.
Author: Dr David Hutchon F.R.C.O.G. Consultant Gynaecologist.
© Dumas Ltd 2006