Hysteroscopic Appearance of Endometrial Cavity after Microwave Endometrial Ablation

Study ObjectiveTo assess the appearance of the endometrial cavity after microwave endometrial ablation.DesignProspective observational study.SettingGuangDong Women's and Children's Hospital, GuangDong, China.PatientsA total of 349 patients who underwent microwave endometrial ablation from January 2000 through August 2008 were followed up for 1 month to 8 years. At follow-up in 2007 and 2008, patients were advised of this clinical study and were randomly selected for participation if they agreed to undergo outpatient hysteroscopy to assess the uterine cavity during follow-up visits. Fifty three patients (median [range] age, 43.1 [33–53] years) were recruited into the study at the time of endometrial ablation.InterventionOutpatient hysteroscopy.Main ResultsWithin the first 3 months after ablation, outpatient hysteroscopy revealed varying amounts of necrotic tissue from the endometrium and superficial myometrium of the uterus. Six months postablation, a granulomatous reaction and fibrosis were present. A fibrotic cavity was also evident, and menstrual flow was reduced or had ceased. One year after ablation, hysteroscopy demonstrated a fibrotic cavity with myofibrous scars. Most patients developed amenorrhea at this time. Two years or more postablation, a second hysteroscopy demonstrated various types of intrauterine adhesions in 28 of the 53 women (52.8%). A cervical adhesion was observed in 1 patient (1.9%), focal adhesions in the fundal area in 12 (22.6%), a narrowed and scarred uterine cavity with bilateral stenotic tubal ostia in 11 (20.7%), and complete obliteration of the cavity in 4 (7.5%). Of these 28 women, 22 had amenorrhea, 3 had vaginal spotting during menstruation, and 2 had hypomenorrhea. Of those without intrauterine adhesions, only 5 had amenorrhea, 10 had vaginal spotting, and 8 had hypomenorrhea.ConclusionThe hysteroscopic appearance of the uterine cavity after microwave endometrial ablation varies considerably. In this study, the menstrual outcome was correlated with postablation uterine cavity appearance.     

NovaSure impedance-controlled system for endometrial ablation

STUDY OBJECTIVE: To assess the efficacy and safety of the NovaSure endometrial ablation system in women with severe dysfunctional uterine bleeding (DUB). STUDY DESIGN: Prospective, single-arm, controlled, observational pilot study (Canadian Task Force classification II-1). SETTING: Free-standing center for gynecologic endoscopy. PATIENTS: One hundred seven premenopausal women whose menorrhagia was unresponsive to medical therapy, who had completed childbearing, and who had undistorted uterine cavities. INTERVENTION: Endometrial ablation with the NovaSure system. MEASUREMENTS AND MAIN RESULTS: Diaries were used to qualify patients for the study, as well as for posttreatment evaluation of menstrual blood loss and bleeding pattern (amenorrhea, spotting, hypomenorrhea, eumenorrhea, menorrhagia). No drug or mechanical endometrial pretreatment was administered. Position of the uterus was not a factor in patient selection. No intraoperative or postoperative complications occurred. Treatment time averaged 94 seconds. Of 107 women, 106 completed 6 months of follow-up and 105 had 12 months. Amenorrhea was 46% and 58%, respectively. CONCLUSION: The NovaSure System is safe and is effective in treating women with DUB. Endometrial pretreatment is not necessary, and presence of blood in the uterine cavity during treatment is not a limiting factor.     

Hysteroscopic endometrial ablation as a treatment for abnormal uterine bleeding in patients with renal transplants

STUDY OBJECTIVE: To assess the effectiveness and safety of hysteroscopic endometrial ablation as a surgical management of abnormal uterine bleeding that develops in patients with renal transplants. DESIGN: Retrospective study (Canadian Task Force classification II-2). SETTING: Yonsei University Medical College, Severance Hospital. PATIENTS: Sixty-two women with abnormal uterine bleeding who had undergone renal transplantation. INTERVENTION: Hysteroscopic endometrial ablation. MEASUREMENTS AND MAIN RESULTS: Fifty-four out of 62 patients (87.0%) who had undergone hysteroscopic endometrial ablation reported decreased bleeding (95% CI: 0.76 to 0.94): amenorrhea in 25 (40.3%), spotting in 19 (30.6%), and eumenorrhea in 10 (16.1%). Mean follow-up duration was 6 months. No complications related to the procedure were reported. Levonorgestrel-releasing intrauterine systems (LNG-IUSs) were inserted into eight patients who experienced continuous bleeding, five of whom showed symptomatic improvement: spotting in three (4.9%) and eumenorrhea in two (3.2%). The three patients (4.9%) in whom the LNG-IUS had no effect had hysterectomies, and the resultant pathologic findings were two cases of adenomyosis and one case of simple endometrial hyperplasia without atypia. CONCLUSION: Hysteroscopic endometrial ablation as a surgical management of abnormal uterine bleeding that develops in patients with renal transplants is an effective and safe procedure.     

Intrauterine instillation of trichloroacetic acid is effective for the treatment of dysfunctional uterine bleeding

OBJECTIVE: To evaluate the effectiveness of trichloroacetic acid (TCA) instillation into uterine cavity for the treatment of dysfunctional uterine bleeding (DUB). DESIGN: Prospective clinical study. SETTING: A university research hospital. PATIENT(S): Ninety women participated who had dysfunctional uterine bleeding. INTERVENTION(S): Ninety-five percent of TCA was instilled into uterine cavity for endometrial ablation in women with dysfunctional uterine bleeding who want conservative treatment. Participants in group 1 received only TCA; participants in group 2 received a single dose of gonadotropin-releasing hormone analogue 1 month before the procedure. MAIN OUTCOME MEASURE(S): All participants underwent an evaluation that included cycle history, body mass index measurement, and transvaginal ultrasonography of pelvis, diagnostic hysteroscopy and endometrial biopsy. RESULT(S): At the end of 12 months of the treatment, amenorrhea rates in group 1 and group 2 were 26.7% vs. 31.1%, with pooled amenorrhea, hypomenorrhea, and eumenorrhea rates of 95.6% vs. 97.8%, respectively. There was no significant difference between the groups vis-a-vis postprocedure results. More than 90% of women who have this procedure are satisfied with the results. There were no observed negative effects or related complications with this treatment. CONCLUSION(S): An instillation of TCA into uterine cavity produces acceptable results and provides conservative management of DUB.     

Thermal balloon endometrial ablation to treat menorrhagia in high-risk surgical candidates.

OBJECTIVE: To evaluate the safety and efficacy of thermal balloon therapy in a subset of women with menorrhagia considered to be high-risk surgical candidates for hysteroscopic endometrial ablation or hysterectomy. DESIGN: Prospective, observational study (Canadian Task Force classification II-2). SETTING: University-affiliated teaching hospital. PATIENTS: Women with menorrhagia, at high risk because of bleeding disorders (12), morbid obesity (6), heart-lung transplantation (2), cardiac pacemaker (2), postmenopausal bleeding (8), bowel disease with extensive adhesions and ileostomies (3), cervical stenosis (3), and other medical disorders (9). INTERVENTION: Treatment consisted of controlled heating to 87 degrees C of 5% dextrose in water within an intrauterine latex balloon pressurized to 170 mm Hg for 8 minutes. General anesthesia was used in 28 patients (60%) and local anesthesia with or without intravenous sedation in 18 (40%). MEASUREMENTS and MAIN RESULTS: No intraoperative complication occurred and postoperative morbidity was minimal. Follow-up of 43 women ranged between 6 and 30 months. Overall success of the procedure was 79% (34 patients), with 33% reporting amenorrhea, 19% hypomenorrhea, 28% eumenorrhea, and 21% menorrhagia. CONCLUSION: Thermal balloon endometrial ablation is safe and effective in treating menorrhagia when other therapies are contraindicated or difficult to perform.     

Hysteroscopic endometrial ablation is an effective alternative to hysterectomy in women with menorrhagia and large uteri

STUDY OBJECTIVES: To examine the feasibility, safety, and outcome of hysteroscopic endometrial ablation, and to determine the volume of fluid absorbed during resection versus rollerball coagulation in women with menorrhagia and large uteri. DESIGN: Retrospective review (Canadian Task Force classification II-2). SETTING: University-affiliated teaching hospital. PATIENTS: Forty-two consecutive patients (mean +/- SD age 45.6 +/- 6 yrs) with uterine size greater than 12 weeks (cavity >12 cm). Intervention. Endometrial ablation; 26 (62%) women were pretreated to thin the endometrium. MEASUREMENTS AND MAIN RESULTS: Resection was performed in 27 patients (65%) and rollerball coagulation in 15 (35%). Ablation was successfully performed in all patients in a day surgery setting. Multiple regression analysis examined the relationship of uterine size, pretreatment, procedure, and duration of surgery to amount of glycine absorbed. Glycine absorption was higher with resection than with coagulation (p = 0.04). Fluid absorption correlated with type of procedure (r = 0.32, p = 0.04) but not with duration of the procedure, uterine size, or pretreatment. One patient with uterine fibroids and one with endometrial adenocarcinoma had hysterectomy. With follow-up of 39 (95%) of 41 women (excluding the one with adenocarcinoma) for 14 +/- 2 months, 38 (93%) were very satisfied. Thirty (73%) had amenorrhea, six (15%) had hypomenorrhea (<3 pads/day), and three (7%) had eumenorrhea (<10 pads/day). CONCLUSION: Hysteroscopic endometrial ablation may be a feasible, safe, and effective alternative to hysterectomy in women with menorrhagia and large uteri.     

Thermablate EAS: a new endometrial ablation system

Objective To report on Thermablate EAS, the newest endometrial thermal balloon ablation system now available.Design Thermablate EAS consists of a light-weight reusable hand-held treatment control unit (TCU) with a single use disposable catheter–balloon–cartridge system. Treatment time is <2.5 min. A 6.0-mm diameter catheter allows it to be used in an office or outpatient setting utilizing minimal anesthesia/analgesia.Results Six-month follow-up data obtained under a Special Access Program for Health Canada in a series of 54 patients showed amenorrhea 20%, spotting 20%, hypomenorrhea 37%, eumenorrhea 16%, and persisting menorrhagia 6%.Conclusion Thermablate EAS is the smallest, most portable, and simplest endometrial ablation presently available. High rates of clinical success and patient satisfaction combined with enthusiastic acceptance by clinicians of this compact device makes it a very attractive endometrial ablation system.D.B. Yackel is coinventor of Thermablate EAS and is a shareholder of MDMI Technologies, Inc.     

Prediction of successful menorrhagia treatment after thermal balloon endometrial ablation

BACKGROUND: Thermal balloon endometrial ablation (TBEA) is a non-hysteroscopic technique, which relies on a combination of heat and pressure within the uterine cavity to destroy endometrium and superficial myometrium. It is a simple, easy and minimally invasive procedure with an equivalent effectiveness to hysteroscopic endometrial ablation. OBJECTIVES: To evaluate the effectiveness of TBEA in the treatment of menorrhagia and to identify the possible predictive factors for a successful outcome after 2-year follow-up. METHODS: A prospective study was conducted, including 45 patients suffering from serious menorrhagia. Under local anesthesia with i.v. sedation, the Therma-Choice trade mark (Gynecare, Somerville, NJ, USA) balloon was inserted transcervically and after inflation in the endometrial cavity with 5% dextrose, it was heated to 87 degrees C for an 8-minute treatment cycle. RESULTS: There were no intraoperative complications and postoperative morbidity was minimal. At 2-year follow-up the overall improvement of menstrual pattern was 85%; with reported 29% amenorrhea, 23.5% hypomenorrhea and 32.5% euomenorrhea. Menorrhagia persisted in 15% of patients. Multiple logistic regression analysis of the factors that could affect the outcome showed that the chance for a successful treatment increased significantly with increased age (P = 0.044), shorter uterine depth (P = 0.049) and adequate balloon pressure (P = 0.027). These were the predictive factors for successful outcome. However, parity, uterine volume and endometrial thickness were not predictive factors. CONCLUSION: At 2-year follow-up, thermal balloon endometrial ablation is effective in menorrhagia treatment. Increased age, shorter uterine depth and adequate balloon pressure can be predictive factors for successful treatment.     

A double-blind randomized trial comparing the Cavaterm and the NovaSure endometrial ablation systems for the treatment of dysfunctional uterine bleeding

OBJECTIVE: To compare two second-generation endometrial ablation systems in women with dysfunctional uterine bleeding (DUB) who want conservative surgical treatment. DESIGN: A double-blind, randomized trial. SETTING: A minimal access gynecological surgery unit in northeast England. PATIENT(S): Fifty-seven women diagnosed with DUB were recruited, with 55 undergoing surgery and completing 12-month follow-up. INTERVENTION(S): Thirty-seven women underwent a NovaSure endometrial ablation, and 18 had a Cavaterm endometrial ablation. Clinical and quality of life data were collected 6 and 12 months after treatment. MAIN OUTCOME MEASURE(S): Amenorrhea, menstrual change, quality of life, sexual activity, patient satisfaction, and procedure acceptability. RESULT(S): Amenorrhea, hypomenorrhea, eumenorrhea, and menorrhagia rates for the Cavaterm and Novasure groups at 12 months were 2/18 (11%) vs. 16/37 (43%); 11/18 (61%) vs. 10/37 (27%); 5/18 (27%) vs. 6/37 (16%); and 0/18 vs. 5/37 (13%), respectively. At 12 months, 83% and 92% of women were either satisfied or very satisfied in the Cavaterm or Novasure groups, respectively. There were no major complications in either group. CONCLUSION(S): Both the Cavaterm and the Novasure endometrial ablation systems are effective in reducing menstrual loss in women with DUB and achieve high rates of patient satisfaction. The Novasure system achieved a statistically significantly higher rate of amenorrhea in this study.     

Feasibility of endometrial assessment after thermal ablation

Objective

To evaluate the feasibility of endometrial assessment after endometrial thermal ablation.

Study design

Prospective observational study. A total of 57 women (age 47–52 years), who had undergone endometrial thermal ablation as a treatment for heavy menstrual bleeding (HMB) 3–10 years (mean 6 years) earlier, were examined with transvaginal ultrasound and saline sonohysterography. Endometrial samples were collected with a Pipelle device. Visualisation of endometrium, access to uterine cavity, change in cavity length, success in outpatient endometrial sampling and success in sonohysterography were evaluated.

Results

Endometrial thickness was 4.5 mm in amenorrhoeic women (n = 17), 5.6 mm in eumenorrhoeic women (n = 37) and 6.6 mm in hypermenorrhoeic women (n = 3). An endometrial sample was successfully taken in 44 (77%) women, and in 13 (23%) women endometrial sample taking failed. The length of the uterine cavity compared to the length measured before endometrial thermal ablation was 0.5–5 cm (mean 2 cm) shorter in 34 women, unchanged in four women and longer in five women. The uterine cavity distended regularly in only nine (16%) women. In 14 (25%) women the cavity distended irregularly or only partly, and in 24 (42%) women the uterine cavity did not distend at all, but appeared as a narrow tube. In 10 (18%) women the sonohysterography catheter did not enter the uterine cavity at all.

Conclusion

Endometrial assessment is compromised after previous endometrial thermal ablation. Both endometrial sampling and sonohysterography fail quite often, causing problems in diagnosis of abnormal bleeding. Intrauterine adhesions may also decrease the reliability of the endometrial sampling.     

Hysteroscopic evaluation of the uterine cavity in postmenopausal women with uterine bleeding

Postmenopausal uterine bleeding is the most characteristic and frequent endometrial adenocarcinoma symptom. Patient with uterine bleeding appeared at least 12 months after the last menstruation needs diagnostic management before initiation of any treatment. OBJECTIVES: Evaluation of hysteroscopy for the recognition of pathologies causing postmenopausal uterine bleeding. MATERIALS AND METHODS: Seventy-nine women aged 48-80 without hormonal replacement therapy hospitalized in the 1st Department of Gynecology and Gynecological Oncology of the Medical University of ?ód? between 1998-2002 because of postmenopausal uterine bleeding were included in the study. In each case diagnostic hysteroscopy with visualisation of the uterine cavity was performed and then histopathologic biopsy by a curretage was taken. Hysteroscopic images were analyzed and compared with the histopathological results. RESULTS: 2 women had the oncologically suspected hysteroscopic images. In both cases endometrial adenocarcinoma was histopathologically confirmed. Among 5 patients with hysteroscopic images suggesting non-malignant endometrial proliferation 4 cases of endometrial hyperplasia were found. 11 times hysteroscopic visualisation of endometrial polyps enabled their complete deletion. In 8 cases intrauterine adhesions were found and dissected: 11 patients presented submucous myomas during hysteroscopy. In 3 cases visualisation of the uterine cavity was not possible because of technical failure. Any patient with absence of hysteroscopically found uterine abnormalities had a poor histopathological result. CONCLUSIONS: Hysteroscopic investigation in postmenopausal women with uterine bleeding reduce the risk of false negative histopathological result. Hysteroscopy is useful method of the uterine cavity visualisation. Thanks to localization and elimination of the pathologies like endometrial polyps and intrauterine adhesions the repeated bleeding and the second time admission of the patient for the same reason can be avoided.     

Outpatient thermal balloon ablation of the endometrium

OBJECTIVE: To determine the feasibility and potential efficacy of thermal balloon ablation of the endometrium in the outpatient setting without the need for general anesthesia or conscious sedation. DESIGN: Prospective observational study. SETTING: Outpatient hysteroscopy clinic in a university-affiliated teaching hospital. PATIENT(S): Fifty-three consecutively recruited women with menorrhagia that was unresponsive to medical treatment. INTERVENTION(S): Thermal balloon endometrial ablation using local anesthetic without conscious sedation. MAIN OUTCOME MEASURE(S): Procedure feasibility, change in menstrual symptoms, and patient satisfaction and quality of life (Menorrhagia Utility Scale and EuroQol) at 6-month follow-up. RESULT(S): Thermal balloon ablation was successfully completed in 50 (94%) of 53 women. The three failed procedures consisted of one case in which the woman could not tolerate the procedure because of severe discomfort, one case of equipment failure, and one case in which the balloon catheter could not be inserted into the uterine cavity. Completed outcome questionnaires were returned by 49 (98%) of 50 treated women. Improvement in menstrual loss was experienced by 39 (80%) of 49 women, and satisfaction with the outcome of treatment on menstrual symptoms was reported by 33 (67%) of 49 women. Significantly higher condition-specific quality-of-life scores were associated with treatment satisfaction. CONCLUSION(S): Thermal balloon ablation of the endometrium is feasible in the outpatient setting. Improvement in menstrual symptoms and satisfaction with the outcome of treatment appear to be comparable to published inpatient data. Further studies are required to determine the cost-effectiveness of outpatient compared with inpatient thermal balloon therapy.     

Long-term histopathologic and morphologic changes after thermal endometrial ablation

STUDY OBJECTIVE: To outline long-term histologic features of endometrial ablation. DESIGN: Prospective longitudinal study (Canadian Task Force classification II-3). SETTING: Tertiary-care teaching hospital. PATIENTS: Twenty-six patients. INTERVENTION: Thermal ablation followed by second-look office hysteroscopy with endometrial biopsy. MEASUREMENTS AND MAIN RESULTS: Mean follow-up time to second-look hysteroscopy after ablation was 33.4 +/- 2,1 months. Complete atrophy, partial adhesions or obliteration of the cavity, and fibrosis were observed at second-look hysteroscopy. Whereas all random biopsies were normal before ablation, biopsies after ablation revealed diminished endometrial glands with necrosis and scarring. The number of endometrial glands was not correlated with amount of bleeding or menstrual pattern. No premalignant or malignant lesions were found after ablation. CONCLUSION: Although efficacy of endometrial ablation is related to initial thermal destruction and correlated with postablation hysteroscopic and histologic findings, endometrial regrowth is an expected development, not a failure of ablation.     

Hysteroscopic appearance of the uterine cavity before and after microwave endometrial ablation

STUDY OBJECTIVE: To evaluate the appearance of the uterine cavity before and after microwave endometrial ablation (MEA). DESIGN: Prospective observational study (Canadian Task Force classification II-2). SETTING: University teaching hospital. PATIENTS: Sixty-two women with menorrhagia. INTERVENTION: Hysteroscopic examination the uterine cavity before and after MEA. MEASUREMENTS AND MAIN RESULTS: Ablation was complete in 55 patients (group A). Seven women had a small island of intact endometrium (group B); the uterine cavity was severely distorted in six of these patients due to submucous myomas in five and adenomyosis in one. Another patient in this group had an acutely retroverted uterus, a 15-mm intramural myoma, and a normal uterine cavity. Women in group B had deeper uterine cavity than those in group A (101.4 +/- 15.5 and 84.7. +/- 12.8 mm, respectively, p = 0.008). The duration of ablation was also longer in group B (329.1 +/- 158.4 sec) than in group A (206.1 +/- 67.4 sec, p = 0.01). CONCLUSION: Microwave endometrial ablation tends to be incomplete in women with a large and severely distorted uterine cavity. Whether, this results in a lower success rate remains to be seen. (J Am Assoc Gynecol Laparosc 8(1):83-86, 2001)     

A randomized prospective study of the use of endometrial ablation for prevention of recurrent endometrial polyps in breast cancer patients receiving tamoxifen

Objective: To assess the roles of endometrial ablation in prevention of recurrence of tamoxifen-associated endometrial polyps in breast cancer patients.Design: A randomized prospective study of tamoxifen-treated patients who underwent hysteroscopic removal of endometrial polyps with or without simultaneous resection of the endometrium.Materials and Methods: Twenty consecutive women (aged 43–61 years) undergoing hysteroscopic removal of tamoxifen-associated endometrial polyps were randomized via a computer-generated random table to undergo or not to undergo concomitant endometrial ablation. All patients had undergone endometrial sampling prior to the procedure. The patients were followed for at least 18 months (range 18–24 months). The follow-up included transvaginal ultrasonography every 6 months and hysteroscopy when endometrial irregularity was noted. The main outcome variable was recurrence of endometrial polyps while the occurrence of uterine bleeding was noted.Results: In the 10 study group women, who underwent endometrial ablation, only 1 patient had a 1 × 1 cm endometrial polyp diagnosed and removed during the follow-up period. Seven of the study women remained amenorrheic, and 3 experienced spotting a few days every month. In the control group, a recurrent endometrial polyp, necessitating hysteroscopic removal, was diagnosed postoperatively in 6 women (two-tailed Fisher’s Exact test; P < .06).Conclusion: Recurrence of endometrial polyps, one of the most common problems in breast cancer patients receiving long-term treatment with tamoxifen, can be significantly reduced by performing endometrial ablation at the time of hysteroscopic removal of the polyp. The possible risk of occult endometrial cancer is yet to be determined.     

Ultrasonographic features following thermal balloon endometrial ablation therapy

The aim of this study was to evaluate the ultrasonographic changes taking place in the uterus after thermal balloon endometrial ablation therapy. The ultrasonographic findings in the uterus after thermal balloon endometrial ablation in 13 patients were compared to those found in 13 patients treated with gestagen therapy. Examinations took place before initiation of the treatment, on the 1st postoperative day (thermal balloon ablation group only), and 1 and 6 months later. One month after thermal balloon endometrial ablation therapy, the ultrasonographic examination revealed a clear-limited hyperechogenic zone surrounding the uterine cavity which was filled with fluid in 6 out of 10 patients. The ultrasonographic findings may represent a burn-injury-induced obstruction in the cervical canal with subsequent collection of fluid in the uterine cavity and a zone of coagulation in the submucosal layers. At the final examination in the thermal balloon group, the mean endometrial thickness was lower than the pretreatment level. No changes were observed in the gestagen therapy group.     

Efficacy and satisfaction rate comparing endometrial ablation by rollerball electrocoagulation to uterine balloon thermal ablation in a randomised controlled trial

OBJECTIVE: To compare two methods of endometrial ablation, hysteroscopic rollerball electrocoagulation (RBE) and non-hysteroscopic uterine balloon thermal ablation (Thermachoice trade mark ), regarding efficacy for reducing dysfunctional uterine bleeding and patients satisfaction rate. METHODS: A randomised controlled study was performed in a teaching hospital at the department of gynaecology. One hundred and thirty-seven premenopausal women with dysfunctional uterine bleeding proved by validated menstrual score list were included. Endometrial ablation by a hysteroscopic or non-hysteroscopic method was performed by one gynaecologist. RESULTS: Reduction of menstrual blood loss was significantly more successful at 24 months for thermal ablation with uterine balloon. Success rate measured by menstrual score < 185 for rollerball and thermal balloon ablation are equivalent at 12 and 24 months post-operatively. Satisfaction of the patients for both methods at 24 months post-operatively is not significantly different (respective 75% for rollerball and 80% for uterine balloon). CONCLUSIONS: Endometrial ablation by uterine balloon thermal ablation (Thermachoice trade mark ) is equally effective as hysteroscopic RBE of the endometrium.     

Role of hysteroscopy and endometrial biopsy in women with unexplained infertility

Objectives

This study was designed to evaluate the role of hysteroscopy and endometrial biopsy in women with unexplained infertility.

Patients and methods

Women with unexplained infertility were included in this prospective study, evaluated with transvaginal sonography and diagnostic hysteroscopy. Diagnostic hysteroscopy was performed between the 7th and 11th day of the cycle. The criteria for hysteroscopic findings were based on the cervical canal, uterine cavity, endometrium, visualization of the ostium tubae and lesions of the utero-tubal junction. After the hysteroscopic examination, endometrial biopsy was performed using a Pipelle^® endometrial suction curette. Patients were classified according to the hysteroscopy results into four groups: patients with no abnormality detected (14), patients with cervical abnormalities (six), patients with endometrial abnormalities (73) and patients with uterine abnormalities (seven).

Results

One hundred women with unexplained infertility were included. All patients underwent diagnostic hysteroscopy, except for seven patients: six patients had stenotic external or internal cervical ostium and one had inadequate visualization as the uterine cavity was filled with blood. Based on hysteroscopic findings, 31 patients were finally diagnosed with endometrial polyps; 14 endometritis; 15 endometrial hyperplasia; six submucous myomas; seven intrauterine synechiae (73 cases = endometrial abnormalities group); seven congenital uterine anomalies (uterine abnormalities group), six cervical stenosis (cervical abnormalities group) and 14 women without any uterine abnormalities (no abnormalities group). Analysis of samples obtained using the Pipelle^® endometrial suction curette was non-diagnostic in 16 cases; the most common endometrial pathological feature detected by this analysis was endometritis (15 %).

Conclusions

Routine hysteroscopy and endometrial biopsy should be used as a basic part of the work-up for women with unexplained infertility.     

Uterine balloon therapy for the treatment of menorrhagia

Objective(s)

To evaluate the effectiveness of uterine balloon therapy for the treatment of menorrhagia and to determine its prognostic factors.

Method(s)

Seventy five patients were treated with uterine balloon therapy with thermachoice II for intractable menorrhagia without detectable pathology and the results were statistically analyzed regarding procedure efficacy, safety, side effects and prognostic factors at follow-up periods of one month, three months, six months and 12 months.

Results(s)

After undergoing uterine balloon therapy, 41.30% patients attained eumenorrhea, 30.43% hypomenorrhea and 15.21% amenorrhea at the end of 12 months follow-up. Retroverted uterus, prolonged duration of menstruation, endometrial thickness of at least 9mm and uterine depth >10 cm were associated with an increased risk of treatment failure.

Conclusion(s)

Uterine balloon therapy is an efficient and reliable modality to treat women with intractable menorrhagia especially those who have completed their families but do not want to part with their uterus which of course is without any organic pathology.     

Randomized Comparison of Goserelin Versus Suction Curettage Prior to Thermachoice II Balloon Endometrial Ablation: One-year Results

ObjectivesTo evaluate the clinical outcomes following the use of goserelin and suction curettage prior to ThermaChoice II balloon endometrial ablation to treat menorrhagia.MethodsQualified patients (n = 105) were randomized to receive either goserelin 3.6 mg one month before or suction curettage immediately before undergoing thermal balloon endometrial ablation. All patients had negative Papanicolaou smears, normal endometrial histology, and normal findings on transvaginal sonography. Uterine bleeding was documented by menstrual diary scores at baseline (Higham score > 150), and at three, six, and 12 months after the procedure. Five patients withdrew prior to surgery and 50 patients were anaesthetized in each group. Two patients in the suction curettage group had their management converted to hysteroscopic ablation, one because of a large uterine cavity (> 12 mL) and one because of a submucous myoma. The ThermaChoice II system circulated the liquid within the silicone balloon for eight minutes at approximately 180 mmHg pressure and 87°C.ResultsParticipants’ mean age, weight, and duration of menorrhagia were not significantly different between the groups. No safety issues related to the device were noted. At one year after ablation, the median reduction in Higham score was from 286 to 10 (96.5%) in the goserelin group (n = 47), and from 272 to 14 (94.9%) in the curettage group (n = 45). The combined amenorrhea/hypomenorrhea rates (higham score 0 to 35), eumenorrhea rate (higham score 36 to 75) and menorrhagia rate (higham score > 75) were 85%, 9%, and 6% (goserelin), and 76%, 16%, 9% (curettage), respectively. Patients’ reported self-assessment of dysmenorrhea was none (51%), mild (30%), moderate (10%), and severe (9%) in both groups. Patient satisfaction was 89% in the goserelin group and 95% in the curettage group. In the goserelin group, one patient had a hysterectomy for bleeding and two had repeat resectoscopic endometrial ablations, one for pain (hematometra) and one for pain and bleeding. In the curettage group, one patient had repeat resectoscopic ablation, one patient withdrew, and one requested hormone therapy. The overall success rates were 88% in the goserelin group and 89% in the curettage group.ConclusionAt one year after ThermaChoice II treatment, 88.5% of women had normal menstrual bleeding or less. There was a non-significant trend (a lower Higham score) towards superiority of goserelin therapy before ablation compared with curettage.