4Current treatment options for abnormal uterine bleeding MEDICAL THERAPYLevonorgestrel intra-uterine system (LNGIUS),Non-steroidal anti-inflammatory drugs,Antifibrinolytic drugs,Progestogens,Oral contraceptivesDanazolThe 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.at best, oral medication reduces menstrual blood lossby only 50%
5Current treatment options for abnormal uterine bleeding SURGICAL THERAPYENDOMETRIAL RESECTION/ABLATIONHYSTERECTOMYOTHERMyomecyomyPolypectomyThe idea of destroying the endometrium and creating an iatrogenic ‘Asherman’s syndrome’as a treatment for dysfunctional bleeding.
6Inclusion and exclusion criteria for endometrial ablation
7Endometrial Ablation Techniques First-generation endometrial ablation: hysteroscopeLoop (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
8First-generation endometrial ablation: LoopRoller-ballLasereffective and safealternatives to hysterectomydysfunctional uterine bleedingreduction in menstrual blood lossdysmenorrhoea,correction of anaemiaimprovement 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.
9First-generation endometrial ablation: All these techniques are aimed atnormalising menorrhagia,making periods lighter,shorter andless painful;amenorrhoea can not be achieved reliably by any ablation technique, andhysterectomy remains the only realistic option even now if this endpoint is desired.
10Different strategies for endometrial preparations prior to first-generation ablation
11Equipment for hysteroscopic endometrial ablation
12Loop endometrial resection AdvantagesProvides endometrial tissue for histologySuitable if endometrium is thickSubmucous fibroids or polyps can be excised at the same timeDisadvantagesThe most skill dependent of the three techniquesGreatest risk of uterine perforationNeed to use electrolyte free distension media (with monopolar resectoscope)
14Rollerball endometrial ablation AdvantagesEasier to learn and perform than resectionLess risk of uterine perforation, fluid absorption and haemorrhage than endometrial resectionShorter operating time than laser ablationDisadvantagesNo 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
15Endometrial laser ablation AdvantagesTissue coagulation to 5–6 mmPerforation less likely than resectionSmall fibroids or polyps can be vaporisedDisadvantagesExpensive capital and running costsSlowest of all the techniquesGreater risk of fluid overload than with electrosurgeryNeed for special laser safety procedures and guidelines
16COMPARATIVE STUDIES OF HYSTEROSCOPIC ENDOMETRIAL ABLATION fluid overloaduterine perforationamenorrhoeafailure ratesubsequently undergoing hysterectomysatisfaction ratesrepeat ablationLaser ablation5.1%0.65%56%7%,5%93%11%Loop resection1.5%2.47%48%6-30%9%70 to 94%6%Roller-ball ablation1.2%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.
18Hot liquid balloonsThe 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.
19The 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.
20Microwave 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– MHz.
21NovasureThe 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
22Endometrial 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.
23THIRD-GENERATION ENDOMETRIAL ABLATION TECHNOLOGIES The 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.