Menstruation: Severe Cramps (Dysmenorrhea)

Description

Alternative Names

Surgery

A number of procedures are available for women with pain related to heavy menstrual bleeding or endometriosis. When the cause of menstrual pain is unknown, the options are limited.

Nerve Destruction Techniques

There is some evidence that when the pain-conducting nerve fibers leading from the uterus are surgically severed, the amount of pain from dysmenorrhea diminishes. Two procedures, uterine nerve ablation and laparoscopic presacral neurectomy, are used to block such nerves. Small studies have shown benefits from these procedures, but stronger evidence is needed before they can be recommended for women with severe primary dysmenorrhea.

Laparoscopic Uterosacral Nerve Ablation (LUNA). LUNA is a recent approach that uses either laser or cauterization to destroy nerves in a small segment of the ligaments that connect the cervix with the lower back. The ligaments do not appear to provide any structural support. About 30% of patients do not respond to this treatment. There are few side effects from the procedure. The patient does not lose any sensations associated with sexual activity.

Laparoscopic Presacral Neurectomy. Laparoscopic presacral neurectomy uses laser techniques to sever a web of nerves between the lower spine and tail bone that transmit pain from the uterus. The procedure does not affect fertility. Some studies report pain relief in about 90% of women. It has more complications than LUNA, however. They include constipation, diarrhea, and urinary problems. (It should be noted, however, that these symptoms improve after the procedure in as many women.) Although injury can occur during the procedure, it is uncommon.

Surgical Procedures for Endometriosis

There are two basic surgical approaches for endometriosis:

• Conservative Surgery (Laparoscopy or Laparotomy). Conservative surgery uses laparotomy or laparoscopy to remove the endometriosis implants without removing any other reproductive organs. It is a good option for women who wish to become pregnant or who cannot tolerate hormone therapy. In fact, some experts believe that laparoscopic surgery should be the treatment of choice for women with endometriosis. Endometriosis often recurs after conservative surgery, however. Recurrence rates at two years range from 2% to 47%. The risk for recurrence or residual pain after any procedure increases with the severity of the condition, particularly if endometriosis has affected areas outside the uterus.
• Radical Surgical Therapy (Hysterectomy). Hysterectomy with removal of ovaries (oophorectomy) along with all endometrial implants is the only potential cure for endometriosis. If endometriosis has developed outside the uterus than even this procedure is not curative. Removing only the uterus with hysterectomy, in any case, has the same risk for recurrence as conservative surgery.

In choosing between hysterectomy (with or without oophorectomy) and conservative surgeries, age and the desire for children are important factors. One study reported a greater sense of loss, more residual symptoms, and more pain in younger women (under 30) who have undergone hysterectomy than in older women. In one study, 37% of such younger women regretted their decision to have a hysterectomy.

Once careful instruction is given for all the risks and benefits of the different surgical options, the physician must then respect any decision a patient makes to retain as much of her reproductive system as she wants, even if she is past menopause. Both the patient and the physician should also be clear about the possibility of changing procedures once the operation has begun, depending on what the surgeon may observe. For example, the surgeon may find abnormalities that require more extensive surgery.

Procedures for Pain Associated with Menstrual Bleeding

Women with heavy menstrual bleeding, dysmenorrhea, or both now have surgical and medical options available to them. Surgical procedures include endometrial ablation, resection, or hysterectomy. Women with fibroids have additional options. Most procedures eliminate the possibility for childbearing, however. Hysterectomy removes the entire uterus while ablation and resection destroy most or all of uterine lining. Women should be sure to ask their physicians about all medical options before undergoing surgical procedures.