Endometrial Ablation Techniques

Bilgin GURATES, M.D.

Abnormal Uterine Bleeding

Causes of abnormal uterine bleeding

Current treatment options for abnormaluterine bleedingMEDICAL THERAPY

Levonorgestrel intra-uterine system (LNGIUS),Non-steroidal anti-inflammatory drugs, Antifibrinolytic drugs, Progestogens, Oral contraceptives Danazol

at best, oral medication reduces menstrual blood lossby only 50%

The levonorgestrel-releasing intrauterine system is more effective, and has been shown to be as effective as endometrial ablation.

It could be argued that endometrial surgery is only appropriate for thosewomen who are not suitable (i.e.polyps, fibroids) or for women who do not wish to have treatment with the intrauterine system.

Current treatment options for abnormaluterine bleedingSURGICAL THERAPY

ENDOMETRIAL RESECTION/ABLATIONHYSTERECTOMYOTHER

Myomecyomy Polypectomy .......................

The idea of destroying the endometrium and creating an iatrogenic ‘Asherman’s syndrome’as a treatment for dysfunctional bleeding.

Inclusion and exclusion criteria for endometrial ablation

Endometrial Ablation TechniquesFirst-generation endometrial ablation: hysteroscope

Loop (Hallez in 1985)Roller-ball (DeCherney and Polan in 1983)Laser(Goldrath in 1981)

Second-generation endometrial ablation: non-hysteroscopicHot liquid balloons(Cavaterm, ThermaChoice, Menotreat)MicrowaveHydro Therm Ablator(BEI, Enabl)Cryotherapy (Her Option, Soprano)Electrode: mesh – NovaSureLaser interstitial hyperthermyPhotodynamic therapy

First-generation endometrial ablation: Loop Roller-ball Laser

effective and safe alternatives to hysterectomy

dysfunctional uterine bleeding reduction in menstrual blood loss dysmenorrhoea, correction of anaemia improvement in quality of life.

lower morbidity,shorter hospitalisation and faster recovery, reduced treatment costs. As a result, the 1st generation ablation techniques are

recognized as the ‘‘gold standard’’ ablation methods.

First-generation endometrial ablation:

All these techniques are aimed at normalising menorrhagia, making periods lighter,shorter and less painful; amenorrhoea can not be achieved reliably by

any ablation technique, and hysterectomy remains the only realistic option

even now if this endpoint is desired.

Different strategies for endometrial preparations prior to first-generation ablation

Equipment for hysteroscopic endometrial ablation

Loop endometrial resection

AdvantagesProvides endometrial tissue for histologySuitable if endometrium is thickSubmucous fibroids or polyps can be excised at

the same timeDisadvantages

The most skill dependent of the three techniquesGreatest risk of uterine perforationNeed to use electrolyte free distension media

(with monopolar resectoscope)

Rollerball endometrial ablation

AdvantagesEasier to learn and perform than resectionLess risk of uterine perforation, fluid absorption and

haemorrhage than endometrial resectionShorter operating time than laser ablation

DisadvantagesNo endometrial specimen for histologyCannot treat submucous fibroids (unless using

rollerbar or barrel)Use of monopolar energy which is less safe than

bipolarNeed to use non-physiologic distension media

Endometrial laser ablation

AdvantagesTissue coagulation to 5–6 mmPerforation less likely than resectionSmall fibroids or polyps can be vaporised

DisadvantagesExpensive capital and running costsSlowest of all the techniquesGreater risk of fluid overload than with

electrosurgeryNeed for special laser safety procedures and

guidelines

COMPARATIVE STUDIES OF HYSTEROSCOPICENDOMETRIAL ABLATION

fluid overload

uterine perforation

amenorrhoea

failure rate

subsequently undergoing

hysterectomy

satisfaction rates

repeat ablation

Laser ablation 5.1% 0.65% 56% 7%, 5% 93% 11%

Loop resection 1.5% 2.47% 48% 6-

30% 9% 70 to 94% 6%

Roller-ball ablation 1.2% 2.1% 46% 10% 5.5% 90% 16.4

%

The most important determinant of the success and safety of hysteroscopicmethods of endometrial ablation is not the technique per se but the experienceof the operator.

Second-generation endometrial ablation:

Hot liquid balloons(Cavaterm, ThermaChoice, Menotreat)

MicrowaveHydro Therm Ablator(BEI, Enabl)Cryotherapy (Her Option, Soprano)Electrode: mesh – NovaSureLaser interstitial hyperthermy (ELITT

Gynelase)Photodynamic therapy

Hot liquid balloons

The advantages of the ThermaChoice balloon device include portability, ease of use, and short learning curve.

The small-diameter catheter requires minimal cervical dilatation (5 mm) and allows treatment under minimal analgesia/anesthesia requirements, including no local anesthesia or IV sedation.

The HydroThermAblator

Disadvantages of the HTA system include cervical dilatation to 8mm, the requirement for pretreatment, reduced portability, the need for hysteroscopic equipment and potential thermal burns.

Microwave endometrial ablation

The system consists of an 8-mm diameter reusable probe which is inserted into the uterus.

Microwaves are short high-frequency radio waves. They are part of the electromagnetic spectrum with a wavelength of 0.3–30 cm and a frequency of 300– 300 000 MHz.

Novasure

The Novasure endometrial ablation system consists of a single-use device and a radiofrequency controller.

It is a three-dimensional, triangular-shaped bipolar ablation device.

cerival dilatation to 7.5 mm

Endometrial cryoablation

The Her Option In-Office Cryoablation Therapy system is ideal for in-office procedures. The unique analgesic properties of cryotherapy, small-diameter probe size, and the ease of use make it appropriate for use in an office setting.

This cryosurgical system is compressor driven and uses a new mixed gas coolant to generate temperatures of –90° to –100°C.

THIRD-GENERATION ENDOMETRIALABLATION TECHNOLOGIESThe idea of injecting a gel or solution via a

small-diameter catheter, to destroy the endometrium globally in an office setting, using no analgesia, is so attractive that several such agents are currently undergoing feasibility and safety evaluation.

THANK YOU