Endometrial Ablation Techniques

Endometrial Ablation Techniques

Bilgin GURATES, M.D.

A

bnormal Uterine Bleeding

Causes of abnormal uterine bleeding

Current treatment options for abnormaluterine bleeding

MEDICAL THERAPYLevonorgestrel 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 those

women 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 bleeding

SURGICAL THERAPYENDOMETRIAL RESECTION/ABLATIONHYSTERECTOMYOTHERMyomecyomyPolypectomy.......................

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 Techniques

First-generation endometrial ablation:

hysteroscope

L

oop

(

Hallez

in 1985

)

R

oller

-ball

(

DeCherney

and

Polan

in 1983

)

L

aser

(

Goldrath

in 1981

)

Second-generation endometrial

ablation

:

non-

hysteroscopic

H

ot

liquid

balloons

(

Cavaterm

,

ThermaChoice

,

Menotreat

)

M

icrowave

Hydro

Therm

Ablator

(

BEI

,

Enabl

)

C

ryotherapy

(

Her

Option,

Soprano

)

Electrode: mesh –

NovaSure

Laser interstitial

hyperthermy

Photodynamic therapy

First-generation endometrial ablation:

L

oop

R

oller

-ball

L

aser

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 1

st

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

Advantages

Provides endometrial tissue for histology

Suitable if

endometrium

is thick

Submucous

fibroids or polyps can be excised at the same time

Disadvantages

The most skill dependent of the three techniques

Greatest risk of uterine perforation

Need 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 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

Endometrial 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

COMPARATIVE STUDIES OF HYSTEROSCOPICENDOMETRIAL ABLATION

fluid overloaduterine perforationamenorrhoea failure rate subsequently undergoing hysterectomysatisfaction ratesrepeat ablationLaser ablation5.1%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

hysteroscopic

methods of endometrial ablation is not the technique per se but the experience

of the operator.

Second-generation endometrial ablation:

H

ot

liquid balloons

(

Cavaterm

,

ThermaChoice

,

Menotreat

)

M

icrowave

Hydro

Therm

Ablator

(

BEI

,

Enabl

)

C

ryotherapy

(

Her Option, Soprano

)

Electrode: mesh –

NovaSure

Laser 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 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

.

THANK YOU