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.
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