Hysteroscopic Endometrial Ablation Research Articles

Hysteroscopic Endometrial Ablation: From Indications to Instrumentation and Techniques-A Call to Action.

The development of minimally invasive techniques has led to the creation of innovative alternatives in cases where traditional methods are not applicable. In modern gynecology, hysteroscopy has become the gold standard for the evaluation and treatment of intrauterine pathology. Endometrial ablation (EA) is a procedure that uses different types of energy to destroy the endometrium and is currently used as an alternative technique in cases of heavy menstrual bleeding when medical treatment has failed and uterine preservation is desired. The aim of this review was to evaluate the feasibility, safety, and clinical outcomes of hysteroscopic EA as an alternative in patients with abnormal uterine bleeding. A detailed computerized search of the literature was performed in the main electronic databases (MEDLINE, EMBASE, Web of Science, PubMed, and Cochrane Library), from 1994 to June 2022, to evaluate the outcomes in patients with abnormal uterine bleeding (AUB) undergoing EA using hysteroscopic and non-hysteroscopic techniques. Only scientific publications in English were included. Twelve articles on the current use of endometrial ablation were included. Data on patient symptoms, tools used for EA, primary outcomes, and adverse events were recorded. EA should be considered an effective and safe approach in the management of patients with abnormal uterine bleeding caused by benign pathology, in whom medical treatment has failed or is contraindicated. Due to the lack of evidence, it would be interesting to determine whether EA would also have a role in the treatment of women with premalignant lesions, avoiding invasive surgical procedures or medical treatment in those patients for whom hysterectomy or the use of hormonal treatment is contraindicated.

Clinical Predictive Factors of Failure of Hysteroscopic Endometrial Ablation: Retrospective Cohort Study at a Tertiary University Hospital

Background: Endometrial ablation is a safe and effective minimally invasive surgical procedure. Despite the high success rate of endometrial ablation for heavy uterine bleeding management, some patients experience persistent symptoms after the procedure, necessitating a hysterectomy. The aim of this study is to determine the pre-operative clinical predictive factors of failure of endometrial ablation in the management of uterine bleeding. Methods: Retrospective cohort study of endometrial ablation procedures performed for treating heavy uterine bleeding. Results: Ninety five patients were included in the study. The failure rate was 24.2%. There was a statistically significant association between ablation failure and fluid deficit (p = 0.002) and intra-operative blood loss (p = 0.047). There was a statistically significant moderate association between adenomyosis (p = 0.003, φ = 0.37) and failed endometrial ablation. However, the age, body mass index (BMI), parity, number of miscarriages, number of cesarean sections, uterine length, endometrial thickness and procedure duration had no significant association with endometrial ablation. There was no significant relationship between the uterine abnormalities in general and the outcome of the endometrial ablation (p = 0.637). However, patients with combined adenomyosis and dysmenorrhea had a statistically significant association with outcome of the endometrial ablation (p = 0.016, φ = 0.28) and were more likely to have a failed endometrial ablation (crude odds ratio (COR) = 4.67, 95% confidence interval (CI), 1.35–16.09). Logistic regression to adjust for related factors revealed that the adenomyosis (adjusted odds ratio (AOR) = 50.83, 95% CI, 3.64–706.75, p = 0.003) and fluid deficit (AOR = 1.003, 95% CI, 1.000–1.006, p = 0.044) had a higher likelihood of an unsuccessful outcome. Hysterectomy was performed in 47.8% of patients who had failure of the ablation. Conclusions: Among pre-operative factors, adenomyosis, fluid deficit and combined adenomyosis and dysmenorrhea were found to predict failure of hysteroscopic endometrial ablation. Clinical Trial Registration: It was registered in https://www.clinicaltrials.gov database with Identifier: NCT05483348.

Quality of Life, Anxiety and Depression in Women Treated with Hysteroscopic Endometrial Resection or Ablation for Heavy Menstrual Bleeding: Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Background and Objectives: Hysteroscopic endometrial resection (ER) or global endometrial ablation (GEA) are feasible methods to treat heavy menstrual bleeding (HMB). The aim of this systematic review and meta-analysis of randomized controlled trials (RCTs) was to assess patient's quality of life (QoL) in women treated with ER/GEA compared to hysterectomy. Materials and Methods: Electronic searches in MEDLINE Scopus, ClinicalTrials.gov, EMBASE, PROSPERO and Cochrane CENTRAL were conducted from their inception to July 2022. Inclusion criteria were RCTs of premenopausal women with HMB randomized to conservative surgical treatment (ER/GEA) or hysterectomy. The primary outcome was the evaluation of QoL using the SF-36 score. Results: Twelve RCTs (2773 women) were included in the analysis. Women treated with hysteroscopic ER/GEA showed significantly lower scores for the SF-36 general health perception (mean difference (MD) -8.56 [95% CI -11.75 to -5.36]; I2 = 0%), social function (MD -12.90 [95% CI -23.90 to -1.68]; I2 = 91%), emotional role limitation (MD -4.64 [95% CI -8.43 to -0.85]; I2 = 0%) and vitality (MD -8.01 [95% CI -14.73 to -1.30]; I2 = 74%) domains relative to hysterectomy. Anxiety, depression scores and complication rates were similar between treatments. Relative to uterine balloon therapy, amenorrhea was more common with EA/GER (relative risk 1.51 [95% CI 1.03 to 1.20] I2 = 28%), but posttreatment satisfaction was similar. Conclusions: Women's perception of QoL might be seen to be less improved after hysteroscopic ER/GEA rather than hysterectomy. However, such findings need to be confirmed by additional trials due to the high number of outdated studies and recent improvements in hysteroscopic instrumentation and techniques.

Resectoscopic Surgery Part I: Overcoming Obstacles and Mastering the Basics

The introduction of the continuous flow gynecologic resectoscope (CFGR) in 1989 revolutionized minimally invasive gynecologic surgery (MIGS) by introducing such intrauterine procedures as hysteroscopic myomectomy, polypectomy, and endometrial ablation. However, with the subsequent introduction of global endometrial ablation (GEA) devices and hysteroscopic morcellators (HMs), the CFGR has fallen into relative disuse—a regrettable situation since it remains ideally suited for accomplishing many procedures that are otherwise not achievable with these newer technologies. Procedures which involve greater precision and control—endomyometrial resection (EMR), hysteroscopic metroplasty, the correction of isthmoceles, the resection of intramural myomas, and the management of late-onset endometrial ablation failure—are only possible with the CFGR. In addition, the CFGR permits a variety of functions that would otherwise require several different disposable platforms. Despite the benefits of the gynecologic resectoscope, there are clear impediments to its use including a scarcity of educational resources and trained experts, medico-legal concerns, institutional obstacles to organizing an operative team, and the need to develop and maintain an adequate caseload. In Part I of this three-part series, the author will review why the CFGR remains a relevant and indispensable tool for the minimally invasive gynecologic surgeon, the composition of an operating room team, and the instrumentation and skills necessary to accomplish basic resectoscopic surgery. In Part II, we will describe how ultrasound guidance can be used to assist the execution of more challenging intermediate-level cases. Finally, in Part III, we will discuss the most demanding cases for the resectoscopic surgeon—the treatment of post-ablation failures and the removal of intramural leiomyomas—which are clinical scenarios that require ultrasound guidance and well-honed resectoscopic surgical skills.

Venous Gas Embolism during Hysteroscopic Endometrial Ablation: Report of 5 Cases and Review of the Literature

To highlight the circumstances, presentation, and treatment of venous gas embolism (VGE) and provide guidance and propose potential changes in surgical practice and perioperative monitoring to minimize the adverse consequences and sequalae of this potentially serious complication. A case series. A university-affiliated teaching hospital. Five women developed VGE during hysteroscopic endometrial ablation. From 1990 through 2014, the principle author (G.A.V.) performed 5249 primary and 458 repeat hysteroscopic endometrial ablations under general anesthesia using a monopolar 26F (9-mm) resectoscope connected to a peristaltic pump-driven active inflow and outflow irrigation and distension system (1.5% glycine) and an 8-mm monopolar loop electrode at a 120-W continuous (cut) and/or a 3- to 5-mm rollerball interrupted (coagulation) waveform or a combination of them. Among 5707 procedures, we encountered 5 (0.09%, 1/1140) incidents of VGE during primary ablations. All patients exhibited the same symptoms of ventilatory and hemodynamic decompensation, beginning with a reduction in end-tidal carbon dioxide and arterial oxygen desaturation. All patients recovered after immediate cessation of the surgery and resuscitation including ventilatory support with 100% O2 and intravenous fluids. Although entrainment of some air/gas bubbles is common during hysteroscopy, life-threatening/fatal VGE is rare (1/1140 cases). Situational awareness and strict adherence to certain principles including understanding the conditions, prerequisites, and pathophysiology of VGE; attention to surgical principles and operative technique; close communication with the anesthesiologist; and early therapeutic intervention are of paramount importance to avoid this rare but potentially serious complication.

Usefulness of hysteroscopic endometrial ablation for adenomyosis

Usefulness of hysteroscopic endometrial ablation for adenomyosis

Resolution of Uterine Arteriovenous Malformation and Maintenance of Reproduction in 20 Women Treated with a GnRH Agonist Concomitantly with an Aromatase Inhibitor and Tranexamic Acid.

This study investigated the efficacy of GnRH agonists concomitantly with transient aromatase inhibitor and tranexamic acid to treat women with uterine arteriovenous malformations (AVMs) associated with abnormal uterine bleeding (AUB) to preserve fertility and determine reproductive outcome. This was a prospective cohort study in a tertiary centre. Doppler ultrasound demonstrated AVM in 19 women with AUB 1-28 weeks following spontaneous or therapeutic abortion and in one woman 4 years after normal pregnancy while taking an oral contraceptive. On the basis of experience from the first three cases, 17 women were treated with tranexamic acid (1 g three times daily orally for 5 days), a GnRH agonist (3.75-11.25 mg, for 1-3 months), plus an aromatase inhibitor (letrozole 2.5 mg once daily for 5days) with the initial injection of GnRH agonist. Two women required blood transfusion, and one required uterine tamponade with Foley catheter balloon in the first 48 hours to control heavy bleeding (Canadian Task Force Classification II-2). All 20 AVMs resolved within 1-3 months of treatment. Of 16 women who attempted pregnancy, all (100%), including two who had uterine artery embolization (one after hysteroscopic septoplasty), conceived spontaneously with 18 live births. Two women are using contraception (one taking an oral contraceptive, one using a levonorgestrel intrauterine system), and one 40-year-old is not using contraception. One woman had hysteroscopic endometrial ablation followed by vaginal hysterectomy for AUB at 1 and 2 years later. A GnRH agonist in combination with transient aromatase inhibitor and tranexamic acid is an effective management strategy to treat and maintain reproduction in women with AVMs associated with AUB.

Uterine Tumors Resembling Ovarian Sex Cord Tumors Identified at Resectoscopic Endometrial Ablation: Report of 2 Cases

Study ObjectivesTo report 2 cases of uterine tumors resembling ovarian sex cord tumors (UTROSCTs) and examine the clinical significance of these tumors found during hysteroscopic endometrial ablation despite benign preoperative endometrial biopsy analysis and imaging suggestive of leiomyoma. DesignCase report (Canadian Task Force classification III). SettingTertiary care hospital. PatientsTwo patients with abnormal uterine bleeding. InterventionsHysteroscopic endometrial ablation/resection. Measurements and Main ResultsPathological analysis of intrauterine tissue/lesions obtained by curettage or resection identified 2 unexpected UTROSCTs masquerading as leiomyomas. Following hysterectomy, no residual UTROSCT was identified in the specimens, and both women are well, one at 1 year postsurgery and the other at 3 years postsurgery. ConclusionObtaining additional tissue by routine curettage before endometrial ablation and/or endomyometrial resection, in conjunction with removal of any intrauterine lesions, can identify rare unexpected endometrial lesions not sampled by endometrial biopsy, not detected with ultrasound, and masquerading as leiomyomas during endometrial ablation.

Complete amenorrhea following NovaSure endometrial ablation for resistant menorrhagia: a case report

Heavy menstrual bleeding (HMB) or menorrhagia is the most common form of dysfunctional uterine bleeding (DUB). In spite of medical treatment for DUB, many women will eventually require a hysterectomy, which is an invasive treatment option. NovaSure ablation offers a same day non-invasive alternative to hysterectomy and hysteroscopic ablation. A 38-year-old woman presented with HMB in 2015. The attacks of HMB interrupted her lifestyle, and she refused to continue with medical treatment, which failed to resolve her symptoms. This patient was admitted to the hospital four times over 2015 due to the anemia caused by the DUB. Medroxyprogesterone acetate and oral contraceptive pills failed to control the patient’s bleeding episodes. Hysteroscopic examination of the uterine cavity showed a normal cavity, and the endometrial biopsy showed proliferative endometrium. She was counseled about NovaSure ablation as the last treatment option before hysterectomy. The NovaSure ablation procedure took 90 s, and the patient was discharged from the hospital 6 h after the procedure. At follow-up, the patient is completely amenorrheic, and she is satisfied with her results. This study demonstrated that NovaSure endometrial ablation is a safe, effective, non-invasive alternative to hysteroscopic endometrial ablation for treatment of DUB.

A Novel Treatment of Women with Endometriosis Pain Using a Combination of Laparoscopic Surgery, Hysteroscopic Endometrial Ablation and Insertion of a LNG-IUS

A Novel Treatment of Women with Endometriosis Pain Using a Combination of Laparoscopic Surgery, Hysteroscopic Endometrial Ablation and Insertion of a LNG-IUS

Інноваційні підходи до оперативного лікування жінок репродуктивного та пременопаузального віку з гіперпластичними процесами ендометрія

The aim of the study: was improvement of results of surgical treatment of patients of reproductive age eligibility with hyperplastic processes of endometrium (HPE) through the introduction of individualized treatment algorithm with the use of monopolar radio wave and hysteroscopic endometrial ablation. Materials and methods. The study included 62 women with non-atypical form of hyperplasia of the endometrium who were treated at the Center of General gynecology of the clinical hospital «Feofania», gynecological Department at the city maternity hospital № 3 of Kyiv. Depending on the age group, nature of the pathological process and method of treatment is randomized, the distribution of women according to groups: group 1 – 41 women's reproductive eligibility age netipichnaya forms of endometrial hyperplasia (PHEBA and KGEB), who were subjected to hysteroscopic monopolar endometrial ablation; group 2 – 21 female reproductive eligibility age netipichnaya forms of endometrial hyperplasia (PHEBA and KGEB), which was held radiowave ablation of the endometrium (RHAE). In the 1st group the age of patients ranged from 42 to 54 years, mean age was 49.9±4.7 years. In the 2nd group the age of patients ranged from 41 to 53 years, mean age of 51.6±4.3 years. Results. A comparative analysis of the techniques for hysteroscopic monopolar ablation and RHEE showed the fact that for RHEE used local anesthesia, while carrying out hysteroscopic monopolar ablation was necessary intravenous anesthesia. The duration of the hysteroscopic monopolar endometrial ablation was 28.6±5.5 min, RAE – according to the standard method – 44.3±0.3 min. When performing hysteroscopic monopolar endometrial ablation in 2 patients (3.7%) patients observed the signs of intravasation of fluid, increased blood pressure and tachycardia. This syndrome was successfully docked, but in the future, women have conducted a thorough examination. When you run RHAE intraoperative complications have been identified. Conclusion. 1. Women with netipichnaya forms of endometrial hyperplasia eligibility and late reproductive age who do not have reproductive plans as an alternative to hysterectomy, in the presence of contraindications or ineffectiveness of hormone treatment may be recommended or radiowave monopolar hysteroscopic ablation of the endometrium. 2. Monopolar hysteroscopic endometrial ablation is indicated for women with netipichnaya forms of endometrial hyperplasia, can be used in the presence of submucous form of uterine fibroids, postoperative scars on the uterus, but in the absence of adenomyosis II–III degree. The effectiveness of monopolar hysteroscopic endometrial ablation in women with non-atypical form of hyperplasia of the endometrium is 87.8%. 3. Women after endometrial ablation should be under observation for two years. The method of choice for dynamic monitoring of the condition of the uterus in women who underwent endometrial ablation is transvaginal ultrasound which should be performed after 1, 3, 6, 12 and 24 months of follow up. 4. In case of recurrence of hyperplastic process of the endometrium (bleeding, thickening of the M-mode echo according to the ultrasound) shows a hysteroscopy with a mandatory histopathological examination and verification of the diagnosis. Key words: endometrial hyperplasia, women eligibility age, women of reproductive age, ablation of the endometrium.

Long-term clinical outcomes of repeat hysteroscopic endometrial ablation after failed hysteroscopic endometrial ablation

The study aims to describe patient characteristics, uterine cavity shape and histopathology, complications, and long-term clinical outcomes of women who failed hysteroscopic rollerball or loop endometrial ablation (HEA) and subsequently consented to repeat hysteroscopic endometrial ablation (RHEA), and is a retrospective cohort study (Canadian Task Force classification II-2). The study was conducted in the university-affiliated teaching hospital. Patients included women who failed primary hysteroscopic endometrial ablation (PHEA, n = 183) and subsequently underwent RHEA by the senior author (GAV) from 1993 through 2007 with a minimum follow-up of 5 years. RHEA was performed under general anesthesia using 26 F (~9 mm) resectoscope, monopolar loop electrode in 136 (74.3 %), 3–5 mm rollerball in 41 (22.4 %) or combination in 6 (3.3 %) women. Patient characteristics, uterine cavity, and clinical outcomes of women who failed PHEA and subsequently consented to RHEA were evaluated by retrospective chart review and patient follow-up including office visits and/or telephone interview. The corresponding median age (range) for PHEA and RHEA was 40 (26–70) and 43 (29–76) years. Indications for PHEA included abnormal uterine bleeding (AUB, 52.7 %), AUB and dysmenorrhea (25.8 %), dysmenorrhea (18.8 %), and others (2.7 %). Indications for RHEA included persistent AUB (53 %), AUB and uterine/pelvic pain (26.2 %), uterine/pelvic pain only (19.1 %), postmenopausal bleeding (1.1 %), and thickened endometrium (0.5 %). Complications of RHEA (n = 7, 3.8 %) included false passage (3), uterine perforation (2), and bleeding (2). One patient with excessive bleeding required immediate hysterectomy. At a median follow-up of 9 years (5–19), 69 % of women avoided hysterectomy. Repeat hysteroscopic endometrial ablation is a feasible, safe, and long-term effective alternative to hysterectomy for abnormal uterine bleeding from benign causes when performed by experienced surgeons.

Outcome and Hemodynamic Alternation in Uterine Artery Following Hysteroscopic Roller-Ball Endometrial Ablation

Objectives: To detect the outcome and changes in uterine arteries blood flow after hysteroscopic roller-ball endometrial ablation. Methods: 84 women with menorrhagia refused to continue or had failed medical treatment with uterine size <12 weeks were included in this study. Diagnostic hysteroscopy was done for women included in this study prior to endometrial ablation. A rigid operative hysteroscopy, with normal saline distention media and roller-ball electrode were used for endometrial ablation procedure. Preoperative findings of studied women including Doppler findings were compared to 3, 6 and 12 months post-operative findings to detect outcome and changes in uterine arteries blood flow after hysteroscopic roller-ball endometrial ablation. Results: 77/84 (91.7%) women were satisfied and their HMB was improved after rollerball endometrial ablation (33/84 (39.30%) amenorrhea, 27/84 (32.14%) hypo-menorrhea and 17/84 (20.24%) euomenorrhea = normal menstrual flow). ED (End Diastolic velocity), (9.2±7.4 cm/s before ablation) was significantly decreased 6 and 12 months after roller-ball endometrial ablation (5.0±6.0 and 4.6±6.1; respectively), also, TAMX (Time-averaged maximum velocity), (21.8±8.2 cm/s before ablation) was significantly decreased 6 and 12 months after roller-ball ablation (14.8±6.4 and 13.9±6.3; respectively). PI (Pulsatiliy Index), (1.32±0.5 cm/s before ablation) was significantly increased 6 and 12 months after roller-ball ablation (1.64±0.45 and 1.69±0.4; respectively), also, RI (Resistance Index), (0.80±0.2 cm/s before ablation) was significantly increased 3, 6 and 12 months after roller-ball ablation (0.84±0.4, 0.89±0.2 and 0.90±0.3; respectively). Conclusion: Hysteroscopic roller-ball endometrial ablation is a safe and effective therapeutic option for selected cases of menorrhagia. It increases stiffness and decreases mobility of uterine arteries during cardiac cycle, also, it induces rise in impedance with subsequent decrease in uterine blood flow and menstrual flow which completed 6-12 months following ablation procedure.

Long-Term Clinical Outcomes Following Resectoscopic Endometrial Ablation of Non-Atypical Endometrial Hyperplasia in Women With Abnormal Uterine Bleeding

Study ObjectiveTo determine the feasibility, efficacy, and long-term clinical outcomes of resectoscopic endometrial ablation as primary treatment of simple endometrial hyperplasia (SH) and complex endometrial hyperplasia (CH) without atypia in women with abnormal uterine bleeding (AUB). DesignProspective follow-up study (Canadian Task Force classification II-2). SettingTeaching hospital. PatientsOne hundred sixty-one women with hyperplasia, either SH (n = 107) or CH (n = 54). InterventionsFrom January 1990 through December 2012, one of us performed 4729 primary resectoscopic endometrial ablation procedures in women with AUB. This group included 161 women with endometrial hyperplasia, identified either at office biopsy (n = 62) or incidentally during routine hysteroscopic endometrial ablation (n = 99). Endometrial tissue obtained at dilation and curettage and/or resected during resectoscopic surgery enabled identification of atypical hyperplasia in 6 patients (4 CH, 2 SH) and 1 patient with adenosarcoma. One patient with atypical CH and the patient with adenosarcoma underwent hysterectomy. The remaining 159 women, including 5 with atypical hyperplasia (3 CH, 2 SH), underwent resectoscopic endometrial ablation (102 SH, 52 CH) as primary treatment. Patient median age was 50 years (range, 30–87 years), and body mass index was 32 (range, 17–59). Comorbidities included hypertension in 25 patients, diabetes in 14, cerebrovascular disease in 3, cardiovascular disease in 7, and hypothyroidism in 8. Office biopsy demonstrated proliferative endometrium in 68 patients, SH in 43, CH in 19, and inadequate findings in 13. In 18 women, we were unable to perform biopsy because of cervical stenosis, morbid obesity, or patient intolerance. Endometrium was resected in 120 patients, electrocoagulated in 34, and a combination of procedures in 5, using a 9-mm (26F) resectoscope, 1.5% glycine, and 120W power. Patients were followed up annually. Three patients were lost to follow-up, and 1 died of an unrelated cause 5 years after surgery. Measurements and Main ResultsOne uterine perforation occurred, which required no additional treatment. After endometrial ablation, SH was identified in 70 patients, and CH in 35 patients. At a median follow-up of 7 years (range, 1.5–18), 12 patients underwent hysterectomy to treat persistent bleeding (n = 6), benign ovarian cyst (n = 2), pelvic organ prolapse (n = 1), chronic pelvic pain (n = 2), or myomas (n = 1). Uterine histopathology in 11 patients demonstrated no residual endometrial hyperplasia. We were unable to obtain a pathology report for 1 patient. The remaining 138 women were satisfied with the treatment, with no further bleeding or pain in 132 (95.7%). Six patients (4.3%) had monthly spotting. ConclusionWhen performed by surgeons experienced in hysteroscopy, resectoscopic endometrial ablation is feasible, safe, and effective for treatment of SH and CH without atypia in women with AUB.

Outcomes and problems of hysteroscopic endometrial ablation in a University Hospital

To evaluate outcomes and hysteroscopic endometrial ablation challenge in Assuit University Hospital. Descriptive study. Woman’s Health Hospital a tertiary health center in upper Egypt. Fifty premenopausal women complaining of dysfunction uterine bleeding. Number of occasions where hysteroscopic endometrial ablation was achieved without intra-operative or technical complications. (1) Number of occasions where hysteroscopic endometrial ablation was not possible. (2) Causes of inability to achieve hysteroscopic endometrial ablation and methods used to overcome these causes. (3) Postoperative outcomes at 1 year follow up. Among 50 premenopausal women included in the study, hysteroscopic endometrial ablation was achieved in 41 cases (82%), 31 (62%) cases of them by the primary prepared hysteroscopic instruments and 10 cases (20%) by backup instruments. Tactile endometrial ablation was used as a backup method for hysteroscopic failures in 8 (16%) cases; and one (2%) woman had undergone a hysterectomy. Although hysteroscopic endometrial ablation is simple and feasible procedure, yet due to financial constrains in many occasions inability to complete the procedure as was intended can occur.

Concomitant hysteroscopic endometrial ablation and Essure procedure: feasibility, efficacy and satisfaction

ObjectiveHysteroscopic endometrial destruction procedures for abnormal uterine bleeding are an alternative to hysterectomy. Such procedures are not contraceptive and are performed on fertile patients, requiring long-term contraception.This is the first study evaluating long-term results of a combined procedure associating endometrial destruction and concomitant hysteroscopic tubal sterilization by Essure® micro-inserts.Our goal is to evaluate efficacy of endometrial destruction as well as hysteroscopic sterilization and satisfaction after a combined procedure in the case of abnormal uterine bleeding in non-menopausal patients. Study designThis is a retrospective study (Canadian task force II-2) that includes 131 patients operated with combined endometrial destruction and hysteroscopic tubal sterilization between 2002 and 2011 at our university hospital.The patients were contacted to answer a questionnaire. Statistical analysis was performed with SAS© version 9.2. (SAS Institute Inc., Cary, NC). ResultsNinety-three patients out of 131 could be reached. The mean follow-up was of 37.8 months (min=8, max=87, SD=6.2). Thirty-eight patients (29%) were lost to follow-up.Essure® micro-inserts introduction success rate (evaluated on 131 patients) was 95.8%, and their position was appropriate in 81.1% of the 106 patients with position control. Efficacy of the procedure on the haemorrhagic symptoms (evaluated on 93 patients) was 80.6%. Twelve patients (12.9%) underwent a hysterectomy, 7 of which (58.3%) were a direct consequence of treatment failure. No pregnancies were reported. Satisfaction rate was of 90.3%. ConclusionInadequate position rates of the micro-inserts after 3 months seem somewhat above literature findings, though no pregnancy has been reported.However, recurrent bleeding symptoms and hysterectomy rates are consistent with those observed after an endometrial destruction procedure alone.Limitations are the limited number of patients, the bias inherent to retrospective studies (lost of follow-up, selection bias).The concomitant endometrial destruction and tubal sterilization by micro-inserts is a safe and efficient procedure.

Microwave endometrial ablation for hypermenorrhea treatment: a new era in Japan

An estimated six million women in Japan suffer from excessive menstruation and the treatment of this disorder has been undergoing dramatic changes recently. In April 2012, microwave endometrial ablation (MEA) was approved for insurance coverage as a K863-3: a hysteroscopic endometrial ablation (17,810 points). Since the introduction of MEA to Shimane University Hospital in August 2007, authors (KN, KM) have performed the procedure in 96 patients with excessive menstruation. They have also evaluated its safety and its efficacy, not only by comparing it to the existing surgical treatment but by quantifying patients’ satisfaction levels and symptom improvement. The authors conclude that MEA is a safe, effective, a low-cost treatment, and they recommend that it be considered as a standard treatment for conservative therapy-resistant excessive menstruation.

Achados histeroscópicos na cavidade endometrial após ablação endometrial

To examine the aspect of the uterine cavity after hysteroscopic endometrial ablation, to determine the prevalence of synechiae after the procedure, and to analyze the importance of hysteroscopy during the postoperative period. The results of the hysteroscopic exams of 153 patients who underwent outpatient hysteroscopy after endometrial ablation due to abnormal uterine bleeding of benign etiology during the period from January 2006 to July 2011 were retrospectively reviewed. The patients were divided into two groups: HIST≤60 (n=90) consisting of patients undergoing the exam 40-60 days after the ablation procedure, and the group HIST>60 (n=63) consisting of patients undergoing the exam between 61 days and 12 months after the procedure. In the HIST≤60 group, 30% of the patients presented some degree of synechiae: synechiae grade I in 4.4% of patients, grade II in 6.7% , grade IIa in 4.4%, grade III in 7.8%, and grade IV in 2.2%. In the HIST>60 group, 53.9% of all cases had synechiae, 3.2% were grade I, 11.1% grade II, 7.9% grade IIa, 15.9% grade III, and 4.8% grade IV. Hematometra was detected in 2.2 % of all cases in group HIST≤60 and in 6.3% of all cases in group HIST>60. The uterine cavity of the patients submitted to diagnostic hysteroscopy up to 60 days after endometrial ablation showed significantly fewer synechiae compared to the uterine cavity of patients who underwent the exam after 60 days. Long-term follow-up is necessary to fully evaluate the importance of outpatient hysteroscopy after endometrial ablation regarding menstrual patterns, risk of cancer and prevalence of treatment failure.

Hysteroscopic Endometrial Resection in the Management of Abnormal Uterine Bleeding Among Libyan Women

Background: Abnormal uterine bleeding (AUB) is a major health problem and it is a substantial cause of ill health in women. Medical treatment has a high failure rate and adverse effects. There are few published data on hysteroscopic endometrial resection (HER) in the management of patients with AUB. Objective: To investigate the efficacy and outcomes of hysteroscopic endometrial resection (HER) in patients with AUB. Materials and Methods: A descriptive hospital - based study was carried out at the departments of Obstetrics and Gynecology, Misurata and Sirt, Libya, during the period from January 2009 to December 2013. Women with AUB were recruited in the study. All women had a detailed medical and obstetrical history, physical examination and the hysteroscopic endometrial ablation and were followed-up for success or failure of the procedure which was assessed via symptoms (bleeding). Results: A total of 120 women with mean (SD) of age and parity of 42.3 (6.8) years and 3.8 (2.4), respectively were recruited in the study initially. Thirty (25%) of these women were lost of followup Therefore, only 70 women (50 with DUB, and 20 women with fibroids) were available for the final analysis. All women underwent hysteroscopic endometrial resection and 28 of them had hysteroscopic myomectomy. The success rate was 92.8% (65/70) after 2 years follow up. All the five women with failure of the procedure were younger ( 7 mm) and they had fibroids. Conclusions: Endometrial resection is an effective procedure in the majority of women with AUB, especially in those over age of 40 and without an increase in uterine size and has no fibroids.

Analysis of uterine and ovarian arterial blood flow and ovarian hormone levels prior to and after hysteroscopic endometrial resection

The objective of this study was to evaluate the effect of hysteroscopic endometrial ablation on the ovarian and uterine artery blood flow and on follicle stimulating hormone (FSH) and oestradiol (E2) levels. A total of 26 consecutive women with abnormal uterine bleeding refractory to medical treatment had undergone hysteroscopic electrosurgical transcervical resection of the endometrium (TCRE). Ultrasonographic measurement of ovarian volumes and colour Doppler flow assessment of the uterine and ovarian arteries were performed on all patients before surgery (group 1) and 1 week (group 2) and 6 months (group 3) after surgery. Blood samples were also collected for determination of FSH and E2 levels, 4 weeks before and 1 month after surgery. No statistically significant change was observed between preoperative and postoperative (1st week and 3rd month) volumes of the ovaries. The mean pulsatility index (PI) of the uterine and ovarian artery did not show statistically significant differences between postoperative 1st week and 3rd month measurements of uterine and ovarian artery PI. The increase in serum levels of FSH and E2 after endometrial resection did not reach statistical significance. Although women may present with climacteric complaints of hot flushes and nocturnal sweating after endometrial resection, this is probably a psychological response to hypomenorrhoea and amenorrhoea, as no statistically significant changes in FSH and E2 levels and uterine/ovarian blood flow were demonstrated in the early postoperative period.