Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea
© Blue Cross and Blue Shield of Montana
Current Effective Date:
September 24, 2013
Original Effective Date:
September 24, 2013
June 24, 2013
Two laparoscopic surgical approaches are proposed as adjuncts to conservative surgical therapy for the treatment of primary and secondary dysmenorrhea. These approaches are laparoscopic uterine nerve ablation (LUNA) and presacral neurectomy (PSN).
Dysmenorrhea is defined as the occurrence of painful menstrual cramps. Primary dysmenorrhea occurs in the absence of an identifiable cause, while secondary dysmenorrhea is related to an identifiable pathologic condition, such as endometriosis, adenomyosis, or pelvic adhesions. The etiology of primary dysmenorrhea is incompletely understood but is thought to be related to the overproduction of uterine prostaglandins. Therefore, first-line pharmacologic therapy typically includes nonsteroidal anti-inflammatory drugs (NSAIDs), which reduce prostaglandin production. Oral contraceptives are another approach. Patients with secondary dysmenorrhea may be offered both NSAIDs and oral contraceptives, as well as a variety of other hormonal therapies. Patients with endometriosis frequently undergo surgery to ablate, excise, or enucleate endometrial deposits or lyse pelvic adhesions. Collectively, these surgical procedures may be referred to as “conservative surgical therapy.”
Uterine nerve ablation (UNA) and presacral neurectomy are two laparoscopic surgical approaches that have been investigated as techniques to interrupt the majority of the cervical sensory nerve fibers in patients with dysmenorrhea. UNA involves the transection of the uterosacral ligaments at their insertion into the cervix, while PSN involves the removal of the presacral nerves lying within the interiliac triangle. PSN interrupts a greater number of nerve pathways compared to laparoscopic uterine nerve ablation (LUNA), and is technically more demanding. Either LUNA or PSN can be performed as adjuncts to conservative surgical therapy in patients with secondary dysmenorrhea.
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||New 2013 BCBSMT medical policy. Laparoscopic uterine nerve ablation (LUNA) or presacral neurectomy as a technique to treat primary or secondary dysmenorrhea is considered experimental, investigational and unproven. |