Endometrial ablation as an alternative to hysterectomy - Home Study Program

AORN Journal, Feb, 2003 by Diane D. League

The article "Endometrial ablation as an alternative to hysterectomy" is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, education program professional, Center for Perioperative Education.

A minimum score of 70% on the multiple-choice examination is necessary to earn 3.5 contact hours for this independent study. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is Feb 28, 2006.

Send the completed application form, multiple-choice examination, learner evaluation, and appropriate fee to

AORN Customer Service
c/o Home Study Program
2170 S Parker Rd, Suite 300
Denver, CO 80231-5711

or fax the information with a credit card number to (303) 750-3212.

BEHAVIORAL OBJECTIVES

After reading and studying the article on endometrial ablation, the nurse will be able to

(1) define menorrhagia,

(2) discuss the types of hormone therapy available to treat menorrhagia,

(3) identify the fluid medium of choice used during each of the endometrial ablation approaches, and

(4) describe the phases of care for a patient undergoing endometrial ablation.

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

Endometrial Ablation as an Alternative to Hysterectomy

In the United States, two million women consult their physicians regarding abnormal or excessive menstrual bleeding each year. (1) Of these, approximately 700,000 undergo hysterectomies for symptomatic menorrhagia. The term menorrhagia is defined as menstrual bleeding lasting longer than seven days or bleeding that occurs in an amount exceeding 80 mL during a menstrual cycle. It is a condition that can be life-altering for women experiencing symptoms (eg, fatigue, anemia). (2) Women with menorrhagia experience embarrassing accidents and limitations to their normal daily activities. Some must change protection nearly every hour during their menstrual cycle.

Although hysterectomy is the definitive treatment for menorrhagia, studies show that 35% to 50% of uterine specimens taken from women who underwent a hysterectomy demonstrate no histological abnormality. (3) Procedural costs, risks, and complications, in addition to the significant percentage of specimens showing no abnormality, suggest that the majority of hysterectomies performed for menorrhagia are unnecessary. (4) Data suggest that a less invasive procedure in which the endometrial lining is destroyed but the uterus is preserved would be beneficial to patients with menorrhagia. Endometrial ablation is an alternative to hysterectomy for women with menorrhagia.

A definitive diagnosis of menorrhagia may be difficult to attain, however, because of the subjectivity of a patient's symptoms. Perception of excessive menstrual bleeding can be affected by patient's cultural background, level of activity, sense of cleanliness, degree of menstrual symptoms, and mental status. (5) It has been suggested that menorrhagia may be a consequence of a modern woman's lifestyle. It is thought to have increased in frequency with shortened breast-feeding intervals, fewer pregnancies, higher frequency of permanent sterilization, and later age of conception. Organic diseases also may contribute to a diagnosis of menorrhagia, including

* carcinoma,

* endometrial polyps,

* infection,

* myoma, or

* systemic illness. (6)

TREATMENT OPTIONS

Treatment for menorrhagia may include hormone therapy, endometrial curettage, endometrial ablation, or hysterectomy. Hormone therapy generally is the first treatment option. Oral contraception or hormone replacement therapies to correct imbalances initially are selected in an effort to alleviate the condition.

Hormone therapy. Sixty-five percent of women treated with hormone therapy experience good results. High-dose estrogen can be used initially to treat women who are hemodynamically stable but experiencing significant uterine bleeding. The result is a rapid regrowth of the endometrium. The estrogen acts to increase fibrinogen and factors V and IX. It also promotes clotting and the aggregation of platelets at the capillary level; however, the risk of deep vein thrombosis with high-dose estrogen use exists. Low-dose estrogen or oral contraceptives are prescribed after uterine bleeding has been controlled, but patients often experience nausea and vomiting. The quantity of menstrual flow can decrease by 50% to 60% when oral contraceptives are used long term (Table 1). (7)

Progestin usually is initiated concurrently with estrogen and continued for five to 10 days to help regulate and prevent episodes of heavy bleeding. It sometimes is considered an antiestrogen because it helps stop endometrial growth by promoting support and reorganization of the endometrial lining. A natural sloughing of the tissue occurs when progestin is discontinued, although menstruation may be heavy. Long-term side effects of progestin use may include