(Note: This document is intended for medical professionals. A summary of this case for laypersons is available here)
Mrs. Martin, age 35, is a data analyst for a brokerage house in eastern Massachusetts. Married for 12 years, she is gravida III, para III. After the birth of her third child in 1992, she requested that she be sterilized. I performed the procedure using Hulka clips. I continued to serve as her gynecologist for 3 years afterwards, but she had not come in for any reason, including a regular exam, in over a year.
In late 1996 Mrs. Martin contacted our office and reported concern over the fact that her periods were occurring every 2 weeks. During the office visit, she stated that she was experiencing heavy bleeding with the passage of clots that lasted approximately 7 days, requiring the use of 10 or more pads per day. The problem was very upsetting to her and was interfering with daily life at home and at work.
The patient reported being somewhat more fatigued during the day than she usually was. She did not complain of other gastrointestinal or urogenital symptoms, nor did she experience pain during intercourse.
Mrs. Martin is only 5’1" in height, but at the time of the visit she weighed 289 pounds. According to her chart, she had gained approximately 40 pounds since her last visit the previous year.
The uterus was in mid position and bulky. No masses were detected in the adnexa. Rectal-vaginal exam confirmed the findings.
Office hysteroscopy confirmed the presence of a submucous fibroid approximately 3 cm in largest dimension, projecting into the uterine cavity. A biopsy was taken during the hysteroscopy. The pathology report indicated secretory endometrium. No hyperplasia or precancerous tissue was present.
Results of sensitive TSH test were within the normal range. Blood tests results included a hematocrit of 34 and a hemoglobin of 11, indicating slight anemia.
The patient and I discussed the treatment choices available to her. Long-term use of the birth control pill was not an option because of the submucous fibroid.
Long-term hormonal therapy with a GnRH agonist was not a satisfactory option to her. The high cost of monthly injections (approximately $400 each) coupled with "add-back" estrogen therapy and other treatments for osteoporosis.
She had already decided against having more children, since she had undergone tubal sterilization 4 years prior. Abdominal or even laparoscopically assisted hysterectomy were possibilities. But given the patient’s obesity, I was not eager to operate on her. I expressed my concern that abdominal surgery posed increased risks because of her obesity. The benign nature of the fibroid report made the potential risk outweigh the benefits. In addition, the patient was concerned that recovery from the operation would cause her to miss too many weeks of work, which could imperil her job and would have significant impact on her family’s income.
After careful counseling, Mrs. Martin agreed to undergo hysteroscopic myomectomy with endometrial resection and ablation.
Preparatory to the procedure, which was scheduled for 2 months later, the patient was started on a course of a GnRH agonist plus supplemental iron. When she returned for her second monthly injection, Mrs. Martin reported that the bleeding had largely been controlled since approximately the second week on hormonal therapy.
The procedure was performed on an outpatient basis at a local hospital under general anesthesia. After standard positioning, prepping, and draping, the patient underwent cervical dilation to a #9 Hegar. Hysteroscopy confirmed that hormonal treatment produced a reduction in fibroid volume of approximately 40%.
[Insert 2 hysteroscopic images]
Instrumentation for the procedure involved the OPERA Star system (FemRx) with an ACMI hysteroscope. The FemRx Flowstat system was used to monitor fluid balance. The conductive medium used was a mixture of 2% manitol and 1.5% Sorbitol.
The resection of the myoma and of the uterine lining was performed using a 200-watt pure cutting current. Ablation was done using a 75-watt coagulation current. Fluid balance was less than 50 cc, and an Istat showed normal electrolytes. The procedure was completed within 30 minutes. The patient recovered within 2 hours and was discharged to her home.
[Insert hysteroscopic image from end of procedure, showing removed fibroid]
Tissue collected during the procedure was sent to the lab for analysis. The report showed fibroid, myometrium, and endometrial tissue and confirmed that no abnormal tissue or pathology was present.
The resection took place on a Friday. By Monday Mrs. Martin felt well enough to return to work. The patient returned for follow-up exams at 1 week, 1 month, and 6 months after the procedure. At this time, approximately 1 year later, she is doing fine and has reported no further problems except for minor spotting on a regular cyclic basis.
Obesity increases the risk of complications during and after major abdominal surgery. In my opinion, based on my years of experience, Mrs. Martin’s excessive weight – nearly 300 pounds – made her an unsuitable candidate for traditional hysterectomy. Recent advances in technology have made myomectomy and endometrial resection and ablation a safe and effective alternative to hysterectomy for selected patients. In this instance, since the patient had undergone previous sterilization, there was no question about the need to preserve fertility. The choice of procedure was driven instead by concern about the potential risk of intraprocedural and postprocedural complications. Also, given her young age (35), the patient was not eager to undergo hormonal therapy, which would have had to continue for perhaps 15 years until menopause and which would not have completely eliminated periodic bleeding.
One key advantage of this procedure is the use of the Flowstat system, which permits easy and accurate monitoring of fluid balance and thus contributes to effective risk management. In my practice, I have implemented a protocol that calls for monitoring levels every 10 minutes, with electrolyte checks via Istat done at every 500-cc volume deficit. If we reach a volume deficit of 2000 cc, the operation is stopped. Recently, in another town in Massachusetts, a patient died due to hyponatremia during an otherwise routine endometrial ablation. Partly in response, we have been more aggressive in our efforts to monitor fluids. In Mrs. Martin’s case, it happened that there was almost no fluid deficit at all.
Recently FemRx has developed a system that permits the use of normal saline as the conductive medium. Saline reduces the chances of fluid imbalance even further. I plan to incorporate use of saline in the coming months.
The OPERA system incorporates an additional device called the morcellator. Tissue removed during the procedure is drawn into a tube within the shaft and carried to the morcellator, which grinds it into smaller pieces. This device offers several advantages. For one thing, it carries all resected tissue to a trap, so that it can be collected and sent to the pathology lab for analysis. Furthermore, removing the tissue keeps the operative field clear throughout the procedure, eliminating the need to continually retract and clean the resectoscope. As a result, the procedure is quicker and easier to perform.
As an alternative to other forms of hysterectomy, resection and ablation reduces the costs in several ways. It avoids inpatient hospitalization and minimizes the risk of adverse effects associated with major surgery. What’s more, it reduces the social costs, permitting rapid recovery and a faster return to normal activities.
Mrs. Martin was an excellent candidate for an alternative procedure to hysterectomy. Results were excellent and patient is doing well. Now, if only I could persuade her to lose some weight….
(To protect patient privacy, the patient’s name and certain identifying details have been changed.)