Long-term outcome of hysteroscopic endometrial ablation without endometrial preparation

OBJECTIVE: To describe the three-step hysteroscopic endometrial ablation (EA) technique without endometrial preparation, and its long-term outcomes. STUDY DESIGN: Four hundred and thirty-eight premenopausal women with menorrhagia or menometrorrhagia underwent three-step hysteroscopic EA, which consists of rollerball ablation of the fundus and cornual regions, a cutting loop endomyometrial resection of the rest of the cavity, and rollerball redessication of the whole pre-ablated uterine cavity. The main outcome measures were menstrual status, level of satisfaction with the procedure, and the need for repeat ablation or hysterectomy. Questionnaires were completed for 385 women (87.9%) with a mean follow-up of 48.2 months. RESULTS: One hundred and eighty-four responders (47.8%) reported amenorrhea; 177 (46%) had light to normal flow. One patient (0.3%) underwent repeat ablation and 20 (5.2%) underwent hysterectomy: 15 (3.9%) because of endometrial ablation failure and 5 (1.3%) because of indications unrelated to the ablation (three cases of atypical endometrial hyperplasia and two cases of fibroids). Two hundred and ninety-two patients (75.8%) were very satisfied, and 78 (20.3%) satisfied with the results. No major complications occurred and three women (0.8%) became pregnant during the follow-up period. CONCLUSIONS: EA is safe and effective means of treating of menorrhagia and menometrorrhagia in premenopausal women, and helps avoid hysterectomy in 95% of patients suffering from heavy bleeding, with or without uterine fibroids. Women should be informed that the procedure is not contraceptive and that pregnancy is possible after treatment.     

Perioperative predictors of successful hysteroscopic endometrial ablation

OBJECTIVE: To determine which perioperative factors influence the success of hysteroscopic endometrial ablation in patients with menorrhagia. STUDY DESIGN: A longitudinal study of 128 women who underwent hysteroscopic endometrial ablation or resection. Clinical data included age, uterine size, the presence of intramural or submucosal myomas and polyps, and length of follow-up from initial hysteroscopic ablation to re-ablation or hysterectomy ('failure'). Kaplan-Meier survival analysis, log-rank tests and Cox proportional hazard regression were used to evaluate the equality of survival distributions and to model the overall effects of the various predictor variables on surgical outcomes. RESULTS: Patients were followed for a median time of 44 months. Thirteen women (10.2%) underwent a second operative procedure. Multivariate analysis identified submucosal myoma as a statistically significant positive predictor of the risk of failure [hazard ratio (HR) 5.22, 95% confidence interval (CI) = 1.63, 16.73)]. Older age was associated with a marginally lower risk of subsequent surgery (HR 0.90 per additional year of age, 95% CI = 0.81, 1.00). CONCLUSIONS: The presence of submucosal myoma increases the risk of subsequent surgery in patients undergoing endometrial ablation.     

Perioperative factors for predicting successful hysteroscopic endometrial ablation

OBJECTIVE: To investigate factors affecting the success of hysteroscopic endometrial ablation in order to improve patient counseling. STUDY DESIGN: Preoperative patient characteristics (age, parity, uterine length, and presence and location of myomas) and intraoperative factors (intracavitary findings, ablation or resection, and operator) were analyzed. Forty-three women with a uterine size of < or = 10 weeks underwent hysteroscopic endometrial ablation or resection and had a median follow-up of 20 months. All were treated with depot triptorelin, 3.75 mg, 1 month prior to the procedure. Alleviation of menorrhagia and amenorrhea was classified as treatment success. Comparative analyses were made between patients with failed vs. successful procedures and with reduced bleeding vs. those with amenorrhea following surgery. RESULTS: Thirty-seven women (86%) reported a decrease in menstrual flow or amenorrhea. In 6 patients (14%), bleeding persisted or became more severe. There were no statistically significant differences between women who had successful vs. failed procedures with regard to all preoperative and intraoperative parameters analyzed. Patients with amenorrhea were significantly older as compared to women with reduced bleeding (47.5 +/- SD 5.0) vs. 44.0 +/- SD 4.1 years, P = .03. CONCLUSION: Most women with uterine size of < or = 10 weeks may expect alleviation of menorrhagia or amenorrhea after surgery. Apart from age, all other preoparative and intraoperative factors examined had no predictive value for a successful procedure. These data are valuable for proper patient counseling before hysteroscopic endometrial ablation.     

Essure sterilization associated with endometrial ablation.

OBJECTIVE: To evaluate the feasibility and the outcome of Essure sterilization associated with different techniques of endometrial ablation. METHOD: Retrospective study conducted among 23 women with confirmed menometrorrhagia and with the desire for or the medical need for permanent tubal sterilization. Patients underwent combined hysteroscopic placement of Essure and hysteroscopic endometrial resection procedures: ThermaChoice (n=14), NovaSure (n=4), Hydrothermablator (n=2) and endometrial resection using monopolar energy (n=1), or bipolar energy (n=2). RESULTS: Fallopian tubes were successfully cannulated bilaterally in 87% of the cases (20/23). No adverse event was reported. Adequate bilateral occlusion was confirmed for all patients (20/20) by 3D ultrasound and pelvic X-ray at a 3-month follow-up. Furthermore, 85% of these patients were satisfied with the results of the procedure, all experiencing a significant reduction in menstrual blood loss (Higham blood loss score). CONCLUSION: Combining EA and hysteroscopic sterilization seems to be feasible and efficient in patients with menometrorrhagia.     

Radiofrequency induced endometrial ablation: an update

Objective To test the safety and efficiency of radiofrequency endometrial ablation as a nonhysteroscopic treatment of dysfunctional uterine bleeding.
Design A multicentre trial. Setting Nineteen clinics in six countries.
Methods From February 1990 to December 1994, 1280 women were treated with radiofrequency endometrial ablation. Inclusion criteria were: menorrhagia, age 30–55 years, a completed family, a wish to retain the uterus, no hypergonadotropic state indicating an approaching menopause, a normal sized uterus, normal cervical cytology, normal adnexa, no prolapse, no intrauterine abnormalities, and no history of a bleeding disorder. Treatment was performed according to a standard operating protocol.
Results Either amenorrhoea or a satisfactory improvement of menstruation was obtained in 78.5% of 944 women followed for six months or more. The design of the equipment has been thoroughly revised and improved during the last four years. The complications encountered were mostly related to the handling of radiofrequency and sometimes due to failures in following the safety protocol.
Conclusions Although the technology is complicated, the treatment is simple, fast and effective. The complications have often been unpredictable. Despite the improvements made during this period, safety must be further enhanced to develop the original concept into an established technique.     

Improving results of hysteroscopic submucosal myomectomy for menorrhagia by concomitant endometrial ablation

STUDY OBJECTIVE: To evaluate the effect of endometrial ablation on the outcome of premenopausal patients undergoing hysteroscopic myomectomy for menorrhagia or menometrorrhagia DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Private practice. PATIENTS: One hundred seventy-seven women with one or more submucosal myomas experiencing menorrhagia or menometrorrhagia. INTERVENTION: Hysteroscopic myomectomy without endometrial ablation in 104 patients and with concomitant endometrial ablation in 73 patients. MEASUREMENTS AND MAIN RESULTS: Bleeding was controlled in 95.9% of patients with endometrial ablation and in 80.8% of patients without endometrial ablation (p = .003). Complete removal of the myoma led to better results (p = .039), which were further improved by endometrial ablation (p = .022). Endometrial ablation improved bleeding in patients whose myomas could not be completely removed, but the difference was not statistically significant (p = .23). Subsequent hysterectomies were not decreased by endometrial ablation (p = .48) or by complete removal of the myoma (p = .83). Hysterectomies for bleeding problems were decreased by endometrial ablation. Pain and dysmenorrhea were a frequent cause of hysterectomy. CONCLUSION: Endometrial ablation at the time of hysteroscopic myomectomy improves results in the control of bleeding.     

Post-ablation tubal sterilization syndrome following microwave endometrial ablation

A 45-year-old lady with previous history of laporoscopic sterilization developed bilateral haematosalpinges 3 months post-microwave endometrial ablation (MEA). She subsequently underwent bilateral salpingectomy. This presentation, described as post-ablative tubal sterilization syndrome, has been reported in the literature with different endometrial ablation methods. However, according to our literature search, no case has been reported to date with MEA.     

Permanent sterilization by hysteroscopic cauterization.

A small series of 22 patients who underwent hysteroscopy cauterization is reported. The uterus was distended with CO2 and dextran. Cauterization was done with a 6 mm. long, active-tip, No. 4 electrode: There was a 27 per cent failure rate for the controlled cases, this dropping to 11 per cent after recauterization. A significant complication, small bowel perforation, was treated by resection and anastomosis with complete recovery. The uterine distention with CO2 is safe but ostium visualization is not very good; Dextran distention is more cumbersone but gives excellent visualization and exposure of the ostium because higher intrauterine pressures are developed.     

Endometrial adenocarcinoma encountered at the time of hysteroscopic endometrial ablation

STUDY OBJECTIVE: To determine the diagnostic accuracy and possible role of treatment of hysteroscopic endometrial resection in women with abnormal uterine bleeding (AUB) diagnosed with endometrial adenocarcinoma. DESIGN: Retrospective analysis (Canadian Task Force classification II-2). SETTING: University-affiliated center. PATIENTS: Thirteen women with AUB and eight with postmenopausal bleeding. INTERVENTION: Preablation endometrial office biopsy and hysteroscopic evaluation. MEASUREMENTS AND MAIN RESULTS: Preablation endometrial biopsy was inadequate, inconclusive, or difficult to obtain in these women, and endometrial cancer was found at the time of resectoscopic surgery. Total endomyometrial resection including the tubal ostia was completed in eight women (group 1) and partial resection in five (group 2). Endometrial adenocarcinoma was confirmed histologically in all patients. A small focus of cancer was found in only two women in group 1 after total resection; in one the procedure was performed 9 years earlier and in the other it was completed hastily after absorption of 800 ml of 1.5% glycine irrigation solution. In women in group 2 malignancy was highly suspected and total resection was considered unwise. CONCLUSION: All patients were alive and well 0.5 to 9 years after hysterectomy, with no evidence of recurrent cancer.     

Minimal-deviation adenocarcinoma of the cervix encountered during hysteroscopic endometrial ablation

A 43-year-old, para 2, gravida 2 woman experienced menorrhagia. She had no risk factors for endometrial neoplasia, and five annual Papanicolaou smears, the last one 3 months earlier, were satisfactory for evaluation and within normal limits. During hysteroscopic endometrial ablation the endometrium appeared normal. The uterine-cervical cavity was normal other than a 1-cm, prominent, vascular, erythematous lesion in the posterior cervical canal, which was resected together with the entire endometrium. Pathology was reported as highly suggestive of a minimal-deviation adenocarcinoma of the cervix, and the patient underwent radical hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy. No residual cancer was found in the surgical specimen and the patient was alive and well 1 year later. Preablation evaluation is not adequate to detect all gynecologic malignancies. Routine resection of all unrecognizable lesions may identify rare tumors such as the one discovered in this woman.     

Bilateral cornual abscess after endometrial ablation following Essure sterilization

Endometrial ablation is used extensively to treat dysfunctional bleeding. Since the introduction of Essure tubal sterilization, this permanent contraception method has been widely used. Both endometrial ablation and Essure sterilization are procedures reported to have only a few complications. We describe a serious infectious complication shortly after an endometrial ablation in a patient with Essure microinserts in situ. To our knowledge, this complication has not been reported before in patients with Essure microinserts in situ. We suggest administering prophylactic antibiotics before endometrial ablation in women with Essure microinserts in situ.     

Essure: hysteroscopic sterilization

Essure, a new female sterilization method approved by the US Food and Drug Administration, offers women a new option for controlling fertility. The technique is done without an incision, is hormone-free, and can be performed on an outpatient basis under local anesthesia. There are few or no side effects. It is important for providers to understand how the device works, appropriate candidates for use, and requirements for preplacement and postplacement management.     

Permanent tubal hysteroscopic sterilization

Tubal sterilization, of common practice all over the world, has had a quick spread in France since its legalization in 2001 and the income of a new hysteroscopic method. As a matter of fact, France is the second greater country for women having Essure^® and the first country where Essure^® method forestall surgical tubal ligation. Thus we focus on good practice and update knowledge about Essure^® method.     

Microinsert nonincisional hysteroscopic sterilization

OBJECTIVE: To assess the safety, effectiveness, and reliability of a tubal occlusion microinsert for permanent contraception, as well as to document patient recovery from the placement procedure and overall patient satisfaction. METHODS: A cohort of 518 previously fertile women seeking sterilization participated in this prospective, phase III, international, multicenter trial. Microinsert placement was attempted in 507 women. Microinserts were placed bilaterally into the proximal fallopian tube lumens under hysteroscopic visualization in outpatient procedures. RESULTS: Bilateral placement of the microinsert was achieved in 464 (92%) of 507 women. The most common reasons for failure to achieve satisfactory placement were tubal obstruction and stenosis or difficult access to the proximal tubal lumen. More than half of the women rated the average pain during the procedure as either mild or none, and 88% rated tolerance of device placement procedure as good to excellent. Average time to discharge was 80 minutes. Sixty percent of women returned to normal function within 1 day or less, and 92% missed 1 day or less of work. Three months after placement, correct microinsert placement and tubal occlusion were confirmed in 96% and 92% of cases, respectively. Comfort was rated as good to excellent by 99% of women at all follow-up visits. Ultimately, 449 of 518 women (87%) could rely on the microinsert for permanent contraception. After 9620 woman-months of exposure to intercourse, no pregnancies have been recorded. CONCLUSION: This study demonstrates that hysteroscopic interval tubal sterilization with microinserts is well tolerated and results in rapid recovery, high patient satisfaction, and effective permanent contraception.     

Balloon endometrial ablation under hysteroscopic control of septate uterus complicated by postcesarean scar defect

Use of second-generation endometrial ablation devices has largely supplanted hysteroscopic resection and rollerball ablation for treatment of menorrhagia. Pathology of the uterus may be diagnosed immediately before endometrial ablation procedure using these newer instruments, making the chosen device inappropriate and requiring a change in planned procedure. Preprocedural assessment with 1 or a combination of transvaginal ultrasound (TVS), saline-infusion sonography, and hysteroscopy is necessary to identify suitability for preferred technique. TVS is frequently used as the only investigation to assess uterine cavity, and undiagnosed or missed pathology on TVS may render chosen endometrial ablation procedure inappropriate. Previously undiagnosed septate uterus and postcesarean scar defect were diagnosed at hysteroscopy immediately before endometrial ablation, but missed by routine TVS. Balloon endometrial ablation in the septate uterus was used.     

The role of Essure sterilization performed simultaneously with endometrial ablation

PURPOSE OF REVIEW: To review operative procedures, specific risks, complications and evaluation of efficacy of Essure tubal sterilization performed simultaneously with endometrial ablation. RECENT FINDINGS: Dysfunctional uterine bleeding is a significant health problem in premenopausal women. Endometrial ablation is an effective therapeutic option for the management of menorrhagia and an alternative to hysterectomy. Most women undergoing endometrial ablation are of reproductive age, and, because pregnancy after endometrial ablation could be complicated, many of these women require permanent birth control. Since the introduction of Essure tubal sterilization, this permanent contraception method has been widely used and offers an hysteroscopic approach similar to endometrial ablation techniques. Combining these two procedures offers the advantage of performing the two procedures simultaneously, but inherent rules and technical procedures must be followed to avoid any kind of injury such as heat conduction, material injuries, specific complications and specific follow-up. SUMMARY: The combination of safety and efficacy of endometrial ablation and hysteroscopic sterilization makes a compelling argument for their concomitant use.     

Pelvic pain following microwave endometrial ablation—is hysteroscopic adhesiolysis worthwhile?

A proportion of patients present with chronic pelvic pain following microwave endometrial ablation, presumed to be due to the development of a haematometra. This retrospective observational study of 20 patients was performed to determine if hysteroscopy and adhesiolysis is beneficial in this group of patients. Seventeen patients were found to have intrauterine adhesions at hysteroscopy that were divided. At follow-up, nine patients were cured of pain and discharged. Of the remaining 11 patients, one patient with endometriosis underwent laparoscopic bilateral salpingo-oophorectomy. Nine patients underwent hysterectomy and one patient was put on mefenamic acid. In conclusion, some patients were still symptomatic following hysteroscopy and needed further intervention in the form of major gynaecological surgery. However, 45% of patients improved following only the minor day case procedure, without needing to resort to a hysterectomy with its inherent risks and costs.