Endometrial Destruction Research Articles

Hysterectomy, endometrial destruction, and levonorgestrel releasing intrauterine system (Mirena) for heavy menstrual bleeding: systematic review and meta-analysis of data from individual patients

Objective To evaluate the relative effectiveness of hysterectomy, endometrial destruction (both “first generation” hysteroscopic and “second generation” non-hysteroscopic techniques), and the levonorgestrel releasing intrauterine system (Mirena) in the treatment of...

Thérapeutique chirurgicale des pathologies fonctionnelles

In patients with dysfunctionnal uterine bleeding, endometrial hypertrophy or endometrial hyperplasia without atypie, the curettage is the only surgical conservative treatment which allows preservation of fertility. Its efficacy is limited to about 50%. In women without wish for further childbearing, endometrial destruction techniques are effective with high satisfaction levels. Second generation devices should be preferred because they are as effective as first generation techniques, but are easier and faster to perform with less complications. There is no indication for systematic use of pre operative thinning agents. Endometrial destruction techniques are an alternative to hysterectomy that should be offered to women with heavy menstrual bleeding, because there are shorter operation time and hospital stay, earlier recovery and reduced post operative complications. The possibility of further surgery should however be discussed pre-operatively. In case of hysterectomy, abdominal route is not recommended, and vaginal or laparoscopic routes are preferred.

Les hémorragies utérines fonctionnelles

Dysfunctionnal uterine bleeding (DUB) is a significant health problem in premenopausal women. First line therapy is traditionally medical therapy but often ineffective. Hysterectomy is obviously effective in stopping bleeding but is associated with morbidity and is most costly. Endometrial ablation technique is becoming the first conservative line in the management of DUB. In 2007, the Cochrane Data Base, and the NICE published the new guidelines for DUB treatment. Pharmaceutical treatments should be considered in the following order: levonorgestrel-releasing intra uterine system and if hormonal treatment is not acceptable, tranexamic acid can be used. This is the exclusive line of treatment for women who desire to be pregnant, and the first step for the others one. The rapid development of second generation technique of endometrial destruction suggests that these techniques are becoming "the gold standart" for the patients without desire of future pregnancy. These techniques are easier that endometrial resection/ablation by hysteroscopy without major complications. In France, the National Health Insurance must find a codification CCAM for giving an exact price to the procedure. This new tarification could include the device cost and could avoid either inefficient procedure like datation and curetage or morbide procedure like hysterectomy.

What’s new in the other journals?

What’s new in the other journals?

Endometrial bleeding

Abnormal bleeding is a significant health problem, especially during adolescence and before menopause when anovulatory cycles are common. Curettage is rarely necessary to investigate or treat menstrual problems in adolescents, and its use should also be minimized in women younger than 40 years. In every age group, medical treatment is the initial choice, but surgical treatment by endometrial destruction or hysterectomy is sometimes required. Benign causes of bleeding include fibroids and possibly adenomyosis, but the indications for treatment in each case depend upon the extent of bleeding, not the extent of the lesion. Breakthrough bleeding (BTB) with combined oral contraceptives commonly leads to discontinuation of the method. As BTB tends to improve with time, in the first 3 months of pill use, unless there are obvious underlying causes, women should be reassured that it will likely settle. BTB is often the reason for discontinuing progestogen-only contraception, and there is a need for effective means of treating unscheduled bleeding. Bleeding occurs in approximately 3% of post-menopausal women, and the use of hormones increases the likelihood of bleeding by >5-fold. Knowledge of the underlying mechanisms of bleeding is essential to the development of effective treatment.

Concomitant Essure® tubal sterilization and Thermachoice® endometrial ablation: feasibility and safety

To evaluate the feasibility and safety of combining endometrial ablation (EA) with a thermal balloon endometrial ablation system (Gynecare Thermachoice IIIC Uterine Balloon Therapy System; Ethicon Inc., Somerville, NJ) and transcervical sterilization by intratubal insert (Essure Permanent Birth Control System; Conceptus, San Carlos, CA). Feasibility and safety studies. University hospital in Chihuahua, Mexico. There were 40 volunteers in the feasibility study and 9 in the safety study, all requiring hysterectomies for benign uterine bleeding. In the feasibility study, both procedures were performed just before hysterectomy; in the safety study, thermocouples were inserted under the tubal serosa to assess heat transmission from the intratubal insert devices to the tubes and surrounding organs during EA. Completeness of EA and possible device dislodgement in the feasibility study; temperature readings in the safety study. No disturbance of the intratubal insert devices was noted, and EA by the thermal balloon endometrial ablation system was complete visually and histologically, although small areas near the tubal ostia exhibited less endometrial destruction. Mean tubal temperatures ranged from 37.1 degrees C to 37.5 degrees C and did not reach the critical temperature of 45 degrees C. No damage to the tubes was noted. Performance of EA and sterilization with these two systems in a one-step approach is safe for women who require EA and permanent contraception.

BOOK REVIEW

RP Pasic, RL Levine (eds). A Practical Manual of Hysteroscopy and Endometrial Ablation Techniques. A Clinical Cookbook. 259 pages, illustrated. London, UK: Taylor & Francis, 2004. ISBN 1-84214-224-0 hardback. Price: GBP 99.00. This is a nice work, which truly accomplishes what it set out to do, to provide a state of the art atlas for endoscopic surgeons with interest in hysteroscopy. The book is well organized into 20 chapters, all of them organized identically, with outline of major aspects and conclusions in each section. Beautiful illustrations with the same design are a lead throughout the book, with major references at the end of each chapter. A good index at the end helps the reader to topics of interest. The authors have devoted 100 pages out of 259 to the different ways of destroying, removing, heating, and freezing the endometrium. In my opinion, this could have been presented more compact, as the principle behind the different techniques is one way or another identical. Although the book deals with hysteroscopy, a chapter on other diagnostic modalities like CT and MRI investigations apart from saline-infusion sonogram might have been useful. With a high number of experts gathered to write a book about hysteroscopy, there is bound to be some overlap and different opinions of treatment modalities. Problems common to books written by multiple authors are evident, some subjects are repeated in several chapters, and different authors present contradictory opinions. I miss a summary representing the authority's opinion of the present golden standard of diagnosis and surgical treatment, in particular for endometrial destruction due to dysfunctional bleeding. These minor drawbacks, however, do not detract from the excellent overall quality of this book, which should be included in all medical libraries and departments doing hysteroscopy.

Hysterectomy and incontinence: a study from the Swedish national register for gynecological surgery

Hysterectomy is one factor that has been suggested to be a risk factor for developing stress incontinence. In Sweden, with a population of 8.86 million, a national register was set up in 1997 in order to have data for assessing the quality of gynecological surgery for benign disorders. Data in the Swedish national register for gynecological surgery during the period 1997-2002 were investigated. Surgical methods compared during this time period were: total hysterectomy (abdominal/laparoscopic, n=198/116), subtotal hysterectomy (abdominal/laparoscopic, n=163/86), and total hysterectomy (vaginal/laparoscopic assisted vaginal, n=265/7). Patients who underwent endometrial destruction (endometrial ablation, endometrial balloon treatment, n=187) were used as a control group. Only patients with no preoperative complaints were included. Outcome measures were answers to subjective questions asked pre- and postoperatively regarding urinary problems and incontinence. De novo symptoms of stress incontinence, urgency and urgency incontinence, and/or mixed incontinence were noted in all groups. No differences were found among the groups. Factors other than hysterectomy should be discussed causing stress incontinence in women.

Pregnancy after endometrial ablation: English literature review and case report

Endometrial ablation is an effective treatment for dysfunctional uterine bleeding. The incidence of pregnancy after endometrial destruction is low and is reported to be 0.7%. We report what is to the best of our knowledge the first case of pregnancy after microwave endometrial ablation and review the outcomes of 74 pregnancies after various methods of endometrial destruction.

Endometrial Carcinoma After Endometrial Resection for Dysfunctional Uterine Bleeding

Endometrial destruction is an accepted conservative surgical approach for women with dysfunctional uterine bleeding. However, this procedure cannot guarantee complete removal of the entire endometrium. The possibility exists that endometrial carcinoma may develop even years after such procedure. We report on a case of endometrial carcinoma, which was diagnosed 3 years after hysteroscopic resection of the endometrium for dysfunctional uterine bleeding in a patient with no risk factors. Endometrial carcinoma after hysteroscopic endometrial ablation is still a possibility even when strict selection criteria are applied.

Identification of Chemokines Important for Leukocyte Recruitment to the Human Endometrium at the Times of Embryo Implantation and Menstruation

Human endometrium possesses a unique immunological environment enabling implantation of the semiallogeneic embryo. Large populations of macrophages and uterine-specific natural killer cells infiltrate the implantation site, believed to be important modulators of trophoblast invasion and decidualization. In the absence of pregnancy, there is a dramatic influx of neutrophils, eosinophils, and macrophages, likely to be critical for focal inflammatory endometrial destruction. However, little is known regarding selective recruitment of leukocyte subtypes. We employed a gene array approach to analyze the expression of 21 chemokines in endometrium. Real-time RT-PCR and immunohistochemistry was conducted to verify expression patterns and determine cellular source. Nine chemokines were highly abundant in human endometrium: monocyte chemotactic protein-3, eotaxin, fractalkine, macrophage inflammatory protein-1beta, 6Ckine, IL-8, hemofiltrate CC chemokine-1 and -4, and macrophage-derived chemokine. Chemokine mRNA was generally up-regulated during endometrial receptivity and early pregnancy, particularly of macrophage and natural killer chemoattractants. Chemokine protein was predominantly localized to epithelial glands, whereas differentiated stromal cells were a major source of chemokines after decidualization. This is the first study to use an unbiased approach to screen for endometrial chemokines, and we report the selective regulation of chemokines, corresponding to the recruitment of distinct leukocyte subpopulations required for pregnancy and menstruation.

Endometrial ablation.

Although endometrial ablation has now been accepted practice for more than 20 years, it continues to be a source of research, controversy and speculation. This is illustrated by the 175 articles found in PubMed between the years 2000 and 2003 under the search term 'endometrial ablation' commissioned as part of the preparation for this article. The so-called first-generation methods (laser, resection, rollerball) have now got long-term follow-up data of up to 20 years. A few of the second-generation devices have published long-term follow-up data of 5 years. All of the second-generation devices assessed in randomized trials with the first-generation methods compare favourably; however, there are few data on cost effectiveness. Similarly, there are few data comparing endometrial ablation with the Mirena intrauterine device. Conventional endometrial ablation has been extensively validated; however, many of the newer techniques have inadequate patient numbers or lengths of follow-up on which to evaluate their long-term efficacy, safety or cost effectiveness fully. The anticipated decline in hysterectomy rates with the advent of endometrial destruction methods has not occurred, and this may indicate a lower threshold for surgical management.

Thermal effects of microwaves can treat menorrhagia: microwave endometrial ablation

Menorrhagia is a disabling condition for which many women seek medical help. It is preferable to use medical instead of surgical treatment, especially if the woman desires to retain her childbearing potential or will be undergoing natural menopause within a short time. The management options after failed medical therapy have tended to be surgical. Hysterectomy is the definitive treatment, however, it is a major operation with all the attendant morbidity and mortality. Endometrial ablation means destruction of the endometrium performed by various techniques, which is a less invasive alternative to hysterectomy. Microwave endometrial ablation is one of the most promising ablative techniques developed in the past 10 years. With microwave endometrial ablation using a curved applicator to treat excessive menstrual blood loss in an enlarged uterus with a distorted uterine cavity, the incidence of hysterectomy should decrease.

Pre-operative endometrial thinning agents before hysteroscopic surgery for heavy menstrual bleeding.

Menorrhagia is one of the most common reasons for pre-menopausal women to be referred to a gynaecologist. Although medical therapy is generally the first approach, many will eventually require or request a hysterectomy. Hysterectomy is associated with a significant in-patient hospital stay and a period of convalescence that makes it an unattractive and unnecessarily invasive option for many women. Hysteroscopic endometrial ablation or resection offers a day-case surgical alternative to hysterectomy for these women. It is also a cheaper procedure than hysterectomy. Complete endometrial removal or destruction is one of the most important determinants of treatment success. Therefore surgery will be most effective if undertaken when endometrial thickness is less than 4mm, in the immediate post-menstrual phase, however there are often difficulties in reliably arranging surgery for this time. The other option is the use of hormonal agents which induce endometrial thinning or atrophy prior to surgery. The most commonly evaluated agents have been goserelin (a GnRH analogue) and danazol. Progestogens and other GnRH analogues have also been studied although less data are available. It has been suggested that the use of these agents, particularly GnRH analogues, will reduce operating time, improve the intra-uterine operating environment, and reduce distension medium absorption (this is the fluid used to distend the uterine cavity during surgery). To investigate the effectiveness of gonadotrophin-releasing hormone (GnRH) analogues, danazol, and progestogens, when used for endometrial thinning prior to hysteroscopic surgery for menorrhagia, in improving the intra-uterine operating environment and treatment outcome after surgery. The Menstrual Disorders and Subfertility Group search strategy (see Review Group details) was used to identify randomised trials that had compared the use of these drugs with either each other, or placebo, or no pre-operative treatment. Trials were included if they compared the effects of these agents with each other, or with placebo or no treatment on relevant intra-operative and post-operative treatment outcomes. Only randomised studies were included in this review. Eight studies met the inclusion criteria for this review. Four studies compared goserelin (a GnRH analogue) with no treatment or placebo. Three studies compared goserelin with danazol. One study compared progestogens, danazol and triptorelin (a GnRH analogue) with no treatment. Data was extracted independently by two reviewers. A third reviewer checked data extraction for accuracy and wrote to authors where relevant data was missing or unclear. Intra-operative parameters included endometrial thickness, duration of surgery, ease of surgery, distension medium absorption and complication rate. Post-operative outcomes compared were the proportion of women with amenorrhoea, post-operative menstrual loss and dysmenorrhoea, and the need for further surgery. Data on side-effects were also recorded. When compared with no treatment GnRH analogues are associated with a shorter duration of surgery, greater ease of surgery and a higher rate of post-operative amenorrhoea. Post-operative dysmenorrhoea also appears to be reduced. The use of GnRH analogues has no effect on intra-operative complication rates and patient satisfaction with this surgery is high irrespective of the use of any pre-operative endometrial thinning agent. GnRH analogues produce more consistent endometrial atrophy than danazol. For other intra-operative and post-operative outcomes any differences are minimal. Both GnRH analogues and danazol produce side-effects in a significant proportion of women, though few studies have reported these in detail. Little randomised data is available to assess the effectiveness of progestogens as endometrial thinning agents and the effect of any thinning agent

The VALUE national hysterectomy study: description of the patients and their surgery.

To describe hysterectomies practised in 1994 and 1995: the patients, their surgery and short term outcomes. One of two large cohorts, with prospective follow up, recruited to compare the outcomes of endometrial destruction with those of hysterectomy. England, Wales and Northern Ireland. All women who had hysterectomies for non-malignant indications carried out during a 12-month period. Gynaecologists in NHS and independent hospitals were asked to report cases. Follow up data were obtained at outpatient follow up approximately six weeks post-surgery. Indication for surgery, method of hysterectomy, ovarian status post-surgery, surgical complications. 37,298 cases were reported which is estimated to reflect about 45% of hysterectomies performed during the period studied. The median age was 45 years, and the most common indication for surgery was dysfunctional uterine bleeding (46%). Most hysterectomies were carried out by consultants (55%). The proportions of women having abdominal, vaginal or laparoscopically-assisted hysterectomy were 67%, 30% and 3%, respectively. Forty-three percent of women had no ovaries conserved after surgery. The median length of stay was five days. The overall operative complication rate was 3.5%, and highest for the laparoscopic techniques. The overall post-operative complication rate was 9%. One percent of these was regarded as severe, with the highest rate for severe in the laparoscopic group (2%). There were no operative deaths; 14 deaths were reported within the six-week post-operative period: a crude mortality rate soon after surgery of 0.38 per thousand (95% CI 0.25-0.64). This large study describes women who undergo hysterectomy in the UK, and presents results on early complications associated with the surgery. Operative complications occurred in one in 30 women, and post-operative complications in at least one in 10. Laparoscopic techniques tend to be associated with higher complication rates than other methods.

The VALUE national hysterectomy study: description of the patients and their surgery

Objectives To describe hysterectomies practised in 1994 and 1995: the patients, their surgery and short term outcomes. Design One of two large cohorts, with prospective follow up, recruited to compare the outcomes of endometrial destruction with those of hysterectomy. Setting England, Wales and Northern Ireland. Population All women who had hysterectomies for non-malignant indications carried out during a 12-month period. Methods Gynaecologists in NHS and independent hospitals were asked to report cases. Follow up data were obtained at outpatient follow up approximately six weeks post-surgery. Main outcome measures Indication for surgery, method of hysterectomy, ovarian status post-surgery, surgical complications. Results 37,298 cases were reported which is estimated to reflect about 45% of hysterectomies performed during the period studied. The median age was 45 years, and the most common indication for surgery was dysfunctional uterine bleeding (46%). Most hysterectomies were carried out by consultants (55%). The proportions of women having abdominal, vaginal or laparoscopically-assisted hysterectomy were 67%, 30% and 3%, respectively. Forty-three percent of women had no ovaries conserved after surgery. The median length of stay was five days. The overall operative complication rate was 3.5%, and highest for the laparoscopic techniques. The overall post-operative complication rate was 9%. One percent of these was regarded as severe, with the highest rate for severe in the laparoscopic group (2%). There were no operative deaths; 14 deaths were reported within the six-week post-operative period: a crude mortality rate soon after surgery of 0.38 per thousand (95% CI 0.25–0.64). Conclusions This large study describes women who undergo hysterectomy in the UK, and presents results on early complications associated with the surgery. Operative complications occurred in one in 30 women, and post-operative complications in at least one in 10. Laparoscopic techniques tend to be associated with higher complication rates than other methods.

Thermal balloon endometrial destruction: the outcome of treatment of 117 women followed up for a maximum period of 4 years

Objective To study the long-term results of treatment for menorrhagia involving the thermal destruction of the endometrium by means of a balloon catheter. Design Between August 1993 and December 1996, 117 women were treated and, in a prospective study, 116 (99%) of them were followed up with consultations and questionnaires. No pretreatment with gonadotrophin-releasing hormone (GnRH) analogues was given. Setting Gynaecology department at a university hospital. Results There were no immediate peroperative complications. The success rate after 25 months (range 10–49) was 94%, excluding women with preoperative intracavitary changes and pretreatment ultrasonographically identified submucosal leiomyomas. Life-table analysis showed that the probability of assessing the treatment as ‘excellent’ or ‘good’ and avoiding hysterectomy over a 49-month period was 81%, and the probability of avoiding hysterectomy over the same time period was 85% when no exclusions were made. Conclusions For women with menorrhagia, who have no further wish for pregnancy, this study shows that thermal endometrial destruction by means of the balloon catheter technique is a safe type of day case procedure with a high success rate. Pretreatment examination is important in order to select women well suited for the treatment. A successful result 1 year after treatment implies a successful result in the long term.

Photodynamic endometrial ablation in the nonhuman primate.

To test the effectiveness of 5-aminolevulinic acid (ALA)-induced photodynamic endometrial ablation in the rhesus monkey under varying conditions of light delivery (fractionated versus continuous) and steroid priming. Photodynamic endometrial ablation was carried out in 17 rhesus monkeys that were either postmenopausal or in the early proliferative phase. Four hours after intralumenal injection of ALA (250 mg in 1 mL hyskon), a quartz fiber with a diffusing tip was inserted. A KTP tunable dye laser delivered 300 mW of light (635 nm) for 60 minutes in either continuous or fractionated fashion (20 minutes on, 5 minutes off, and 40 minutes on). In some experiments, thermistors were used to monitor temperature in the lumen and myometrium during light treatment. Hysterectomy was performed 3 or 4 days after treatment, and endometrial damage was assessed histologically. Two additional monkeys (one rhesus and one cynomolgus monkey) were exposed to the same protocol, except hyskon was substituted for ALA to control for potential ablative effects due to light treatment alone. Endometrial ablation was evident in all ALA-photosensitized specimens. The degree of ablation around the light fiber ranged from moderate to complete. The depth of ablation ranged from 1.14 +/- 0.54 to 2.15 +/- 1.62 mm (mean +/- standard deviation). Ablation was most complete in uteri of menopausal monkeys. Light treatment after ALA increased lumenal temperature from 36 C to 50 C, whereas temperature was not significantly increased by light treatment in the controls. This is the first report of endometrial destruction in the primate using a photodynamic approach. Whereas clinical application of photodynamic therapy (PDT) requires complete endometrial ablation to produce long-lasting amenorrhea, our results suggest that PDT may offer a simple office-based approach to endometrial ablation.

Endometrial cryoablation with ultrasound visualization in women undergoing hysterectomy

Study Objectives To evaluate tissue effects of cryosurgical endometrial ablation in women just before hysterectomy, characterize ultrasound monitoring of freezing, determine the feasibility of a new probe-angling procedure, and assess the safety profile by monitoring serosal surface temperatures. Design. Single arm safety study enrolling ten women at two centers (Canadian Task Force classification II-2). Setting. Two clinical sites. Patients Ten women scheduled for hysterectomy. Intervention. Hysterectomy with a new cryosurgical device (First Option, CryoGen Inc., San Diego, CA) that achieves surface temperatures below −90°C to freeze endometrium. Measurements and Main Results. The freeze protocol involved angling the probe toward each cornu. Maximum ice front diameter at the end of the first angled freeze ranged from 24 to 34 mm, and maximum ice ball diameter at the end of the second freeze ranged from 28 to 37 mm. The margin between the advancing ice front and serosal surface was monitored by ultrasound. In all cases the margin was safe and no reduction in serosal surface temperatures occurred. Depth of necrosis ranged from 9 to 12 mm as determined by tetrazolium staining and electron microscopy, and there was no full-thickness myometrial destruction. Total endometrial destruction was achieved. Conclusion. Cryosurgical ablation of the endometrium with the First Option system with angled freezes and ultrasound monitoring appears to be feasible and safe given our preliminary data.

Evaluation of hydro thermablator for endometrial destruction in patients with menorrhagia

To describe endometrial destruction with the Hydro ThermAblator. (Canadian Task Force classification II-1). University-affiliated hospital. Twenty-six women with uncontrolled menorrhagia. Endometrial ablation with saline heated to 90 degrees C and circulated in the uterine cavity for 10 minutes under hysteroscopic control. All patients tolerated the procedure well, all but one was satisfied with the results, and there were no significant side effects or complications. Seventy-seven percent of women were either amenorrheic or hypomenorrheic after 6 months, and 88% were amenorrheic or hypomenorrheic after 1 year, including one patient who was treated a second time; 87.5% were amenorrheic or hypomenorrheic at 18 months. One woman had persistent menorrhagia and was treated by hysterectomy. In this study, endometrial ablation was performed successfully with the Hydro ThermAblator in 25 of 26 women. (J Am Assoc Gynecol Laparosc 6(3):275-278, 1999)