Dysfunctional uterine bleeding (DUB) is the major cause of heavy menstrual bleeding and impacts on women’s health both medically and socially. First-line therapy has traditionally been medical therapy but this is frequently ineffective. On the other hand, hysterectomy is obviously 100% effective in stopping bleeding but is more costly and can cause severe complications and affect the quality of life. Endometrial ablation is less invasive and preserves the uterus and has shown to improve the quality of life indices.

1. Transcervical Resection of Endometrium

2. Review Article
TRANSCERVICAL RESECTION OF ENDOMETRIUM
Geeta Chadha* and Surpreet**
*Senior Consultant, **Registrar, Department of Obstetrics & Gynaecology, Indraprastha Apollo Hospitals,
Sarita Vihar, New Delhi 110 076, India.
Correspondence to: Dr Geeta Chadha, Senior Consultant, Department of Obstetrics & Gynaecology,
Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India.
e-mail: geeta_chadha@hotmail.com
Dysfunctional uterine bleeding (DUB) is the major cause of heavy menstrual bleeding and impacts on
women’s health both medically and socially. First-line therapy has traditionally been medical therapy but this is
frequently ineffective. On the other hand, hysterectomy is obviously 100% effective in stopping bleeding but is
more costly and can cause severe complications and affect the quality of life. Endometrial ablation is less
invasive and preserves the uterus and has shown to improve the quality of life indices.
Key words: Dysfunctional uterine bleeding.
INTRODUCTION
Dysfunctional uterine bleeding is defined as heavy
menstrual uterine bleeding not due to any recognizable
cause and is therefore a diagnosis of exclusion. Other
conditions such as uterine fibroids, endometrial polyps and
systemic diseases should be excluded by appropriate
investigations. In the adolescent, investigations for a
coagulopathy should be performed. The pathophysiology
of DUB is largely unknown but occurs in both ovulatory
and anovulatory menstrual cycles [1]. Heavy menstrual
bleeding is clinically defined as greater than or equal to 80
mL of blood loss per menstrual cycle [2]. Heavy menstrual
bleeding (HMB) is a significant health problem in
premenopausal women; it can reduce their quality of life
and cause anemia [3]. Various treatment modalities are
available for the management of DUB.
MEDICAL MANAGEMENT
This has been traditionally been the first-line therapy.
Medical
treatments
include
nonsteroidal
antiinflammatory drugs or antiprostaglandins, tranexamic
acid, the progesto-gen releasing intrauterine device,
combined oral contra-ceptive pills, and other hormonal
therapies. As no medical treatment is superior to another,
each woman should be individually assessed as to
appropriate management [1].
The LNG IUS (MIRENA, PROGESTASERT) results
in a smaller mean reduction in menstrual blood loss than
121
endometrial ablation [2]. Women with an LNG IUS
experience more progestogenic side effects compared to
women having TCRE for treatment of their heavy
menstrual bleeding [2,4].
Studies show that surgery reduces menstrual bleeding
at one year more than medical treatment alone [4].
Studies have shown that medical management alone is
usually insufficient for treating DUB [5]. Cooper KG, et
al in there study found that only 10% of those randomized
to the medical arm still used medical treatment, at 5 year
follow up. While 77% had undergone surgical treatment
like endometrial ablation and 18% a hysterectomy [5]. In
the surgical group, only 27% women allocated to
transcervical resection of the endometrium had
undergone further surgery, and 19% required a
hysterectomy [5].
At five years women initially randomized to medical
treatment were significantly less likely to be totally
satisfied or to recommend their allocated treatment to a
friend. Bleeding and pain scores were similar in both
groups and highly significantly reduced. Significantly
more women in the transcervical resection of the
endometrium arm had no bleeding or very light bleeding
and they had significantly less days of heavy bleeding [5].
HYSTERECTOMY
Hysterectomy is obviously 100% effective in stopping
Apollo Medicine, Vol. 7, No. 2, June 2010

3. Review Article
bleeding but it cause severe complications like urinary
incontinence, psychosexual ailments and it affects the
quality of life.
It is associated with prolonged hospital stay, more
chances of anesthetic complications and pain [3,6].
Allahdin S, et al in there 10 year follow up of patients
undergoing TAH for DUB as compared with TCRE,
showed that TAH is associated with a significantly
increased incidence of hospital referrals for Urinary
Incontinence(UI) , urological investigations and treatment
for UI as compared to TCRE [7].
Women’s fears about sexual function after
hysterectomy might not be unfounded. The psychosexual
problems like (i) libido loss, (ii) difficulty with sexual
arousal, and (iii) vaginal dryness may return and/or
develop with time. The removal of ovaries at the time of
hysterectomy is associated with greater deterioration of
self-reported sexual function. Surgical menopause
significantly impairs sexual wellbeing despite hormone
replacement therapy (HRT) [8]. McPherson K, et al
reported that five years after surgery for DUB, the crude
and adjusted prevalence of psychosexual problems was
higher after hysterectomy than after TCRE [8]. So the role
of hysterectomy for DUB should be reserved for the
recalcitrant cases of endometrial ablation who do not get
relief from symptoms with the less radical procedures
[3,8].
ENDOMETRIAL ABLATION
Endometrial ablation is less invasive and preserves the
uterus, although long-term studies have found that the
costs of ablative surgery approach the cost of
hysterectomy due to the requirement for repeat
procedures. A large number of techniques have been
developed to ‘ablate’ (remove) the lining of the
endometrium. The gold standard techniques (laser,
transcervical resection of the endometrium and rollerball)
require visualization of the uterus with a hysteroscope
and, although safe, require skilled surgeons. A number of
newer techniques of ablation include microwave
endometrial ablation (MEA) and thermal balloon
endometrial ablation (TBEA) have been developed for
heavy menstrual bleeding (HMB) [1,3,6,9,10].
TCRE, has been the gold standard of the endometrial
ablation techniques for DUB and has been shown to be
effective and achieves high rate of patient satisfaction
(88.8%) [9]. The procedure is also known as
Hysteroscopic Endometrial Ablation or Hysteroscopic
Endometrial Resection. The surgical procedure is
performed under general anesthesia using a
Apollo Medicine, Vol. 7, No. 2, June 2010
hystereroscope after gently dilating the cervix to 10 mm. A
roller ball coagulation at the fundus and cornual region is
done while resection of the cavity walls is done using an
angled cutting loop, with 1.5% glycine solution as
distending medium [9]. TCRE affords reasonable longterm effectiveness in the treatment of dysfunctional
uterine bleeding, even without any preoperative hormonal
endometrial preparation [11].
TCRE is also an effective and safe method for the
management of benign intracavitary pathology like
submucous myomas or polyps [12]. TCRE for treatment
of heavy menstrual loss achieves higher levels of
satisfaction, better menstrual status, and greater
improvements in health related quality of life than medical
treatment [5]. In addition, transcervical resection of the
endometrium is safe and does not lead to an increase in the
number of hysterectomies [5].
TCRE did not lead to any alteration of uterine and
ovarian haemodynamics per se [13], but patients who had
relapse of menorrhagia at 1 year after TCRE had a lower
Resistant Index (RI) at all levels of uterine arteries
compared with those who had persistent improvement
[13]. Pregnancies after TCRE although rare, are
associated with increased risk of ectopic pregnancy.
Surgical termination of pregnancy after TCRE is
potentially a difficult procedure and should be carried out
under ultrasound guidance [14].
Fluid overload, uterine perforation, hematometra even
though rare, is the main complications associated with
TCRE. Post operative infections are rare [3].Studies show
that in 70% of the patients post TCRE, even with a
postoperative amenorrhoea, a residual endometrium can
be found. For the prevention of a hematometra due to
TCRE , the cervix should be spared during endometrium
ablation and a hormone replacement therapy can be used
alongside [15].
Fluid overload and equipment failure were higher for
those women having laser treatment as compared with
TCRE [3]. Comparison between newer techniques like
MEA and TBEA and TCRE do not show significant
difference. All the techniques achieve significant and
comparable improvements in menstrual symptoms, and
health-related quality of life [9].
In conclusion TCRE should be considered as the
mainstay of treatment for DUB, it can be supported with
hormonal replacement. Hysterectomy should be reserved
for recalcitrant cases of DUB.
REFERENCES
122
1. Farrell E. Dysfunctional uterine bleeding. Aust Fam

4. Review Article
Physician. 2004; 33(11): 906-908.
9. Sambrook AM, Bain C, Parkin DE, Cooper KG. A
randomized comparison of microwave endometrial
ablation with transcervical resection of the endometrium:
follow up at a minimum of 10 years. BJOG.
2009;116(8):1033-1037.
2. Lethaby AE, Cooke I, Rees M. Progesterone or
progestogen-releasing intrauterine systems for heavy
menstrual bleeding. Cochrane Database Syst Rev.
2000;(2): CD002126.
3. Lethaby A, Hickey M, Garry R. Endometrial destruction
techniques for heavy menstrual bleeding. Cochrane
Database Syst Rev 2009;(4): CD001501.
4. Marjoribanks J, Lethaby A, Farquhar C. Surgery versus
medical therapy for heavy menstrual bleeding. Cochrane
Database Syst Rev. 2006;(2): CD003855.
5. Cooper KG, Jack SA, Parkin DE, Grant AM. Five-year
follow up of women randomized to medical management
or transcervical resection of the endometrium for heavy
menstrual loss: clinical and quality of life outcomes.
BJOG. 2001;108 (12):1222-1228; Comment in BJOG.
2003; 110 (1): 87.
6. Duggal BS, Wadhwa RD, Sunder Narayan, Tarneja P,
AB Chattopadhya. Transcervical Resection of
Endometrium Will it edge out Hysterectomy MJAFI,
2003; 59 (3).
7. Allahdin S, Harrild K, Warraich QA, Bain C.Comparison
of the long-term effects of simple total abdominal
hysterectomy with transcervical endometrial resection on
urinary incontinence. BJOG. 2008; 115(2): 199-204.
8. McPherson K, Herbert A, Judge A, Clarke A, Bridgman S,
Maresh M, Overton C. Psychosexual health 5 years after
hysterectomy: population-based comparison with
endometrial ablation for dysfunctional uterine bleeding.
Health Expect. 2005; 8(3): 234-243.
10. Garside R, Stein K, Wyatt K, Round A, Price A. The
effectiveness and cost-effectiveness of microwave and
thermal balloon endometrial ablation for heavy menstrual
bleeding: a systematic review and economic modeling.
Health Technol Assess 2004; 8(3).
11.
Molnár BG, Kormányos Z, Kovács L, Pál A. Long-term
efficacy of transcervical endometrial resection with no
preoperative hormonal preparation. Eur J Obstet
Gynecol Reprod Biol. 2006;127(1):115-122.
12. Stamatellos I, Koutsougeras G, Karamanidis D,
Stamatopoulos P, Timpanidis I, Bontis J; Results after
hysteroscopic management of premenopausal patients
with dysfunctional uterine bleeding or intrauterine
lesions. Clin Exp Obstet Gynecol. 2007;34(1): 35-38.
13. Liu Y, Cheong Y, Li TC, Xia E, Zhang D, Ma Y. Impact of
transcervical resection of endometrium on uterine and
ovarian haemodynamics. Reprod Biomed Online. 2007;
15(1): 57-62.
14. Xia E, Li TC, Yu D, Huang X, Zheng J, Liu Y, Zhang M.The
occurrence and outcome of 39 pregnancies after 1621
cases of transcervical resection of endometrium. Hum
Reprod. 2006;21(12): 3282-3286.
15. Römer T. Hormone substitution following transcervical
endometrial ablation. Zentralbl Gynakol. 1997;119(5):
229-231.
123
Apollo Medicine, Vol. 7, No. 2, June 2010

5. A o oh s i l ht:w wa o o o p a . m/
p l o p a : t / w .p l h s i lc
l
ts p /
l
ts o
T ie: t s / ie. m/o p a A o o
wt rht :t t r o H s i l p l
t
p /w t c
ts
l
Y uu e ht:w wy uu ec m/p l h s i ln i
o tb : t / w . tb . a o o o p a i a
p/
o
o
l
ts d
F c b o : t :w wfc b o . m/h A o o o p a
a e o k ht / w . e o k o T e p l H s i l
p/
a
c
l
ts
Si s ae ht:w wsd s aen t p l _ o p a
l e h r: t / w .i h r.e/ o o H s i l
d
p/
le
A l
ts
L k d : t :w wl k d . m/ mp n /p l -o p a
i e i ht / w . e i c c a y o oh s i l
n n p/
i
n no o
a l
ts
Bo : t :w wl s l e l . /
l ht / w . t a h a hi
g p/
e tk t n