Trends in first-generation endometrial ablation procedures performed in a district general hospital, 1995–2005

Heavy menstrual bleeding is a common presenting complaint and can significantly affect the quality of life of affected women. The 2007 National Institute for Clinical Excellence guideline on heavy menstrual bleeding states that in women with heavy menstrual bleeding alone, endometrial ablation should be considered preferable to hysterectomy. The choice of the type of endometrial ablation procedure would depend on several factors including the availability of first-, second- or even third-generation endometrial ablation equipment, clinician experience and preference as well as patient choice and if procedure is intended to be performed as an office procedure without the use of general anaesthetic where second- or third-generation endometrial ablation equipment would be used. The number of first-generation endometrial ablation procedures being performed is expected to decrease over time. This is as a result of clinicians’ preference, due to reported higher operative complication rates in some studies, even though a meta-analysis of individual patient data has found it to be as effective as the second-generation techniques for heavy menstrual bleeding. We performed a retrospective clinical audit to investigate the trend from January 1995 to December 2005 in the use of first-generation endometrial ablation techniques performed at a district general hospital in the UK. We found that the general trend is of a rapidly decreasing number of first-generation endometrial ablation procedures being performed. We also found that the operative complication rates are low and similar to rates in the published literature. The long-term hysterectomy rate after first-generation endometrial ablation procedure in our audit population is also low and similar to the rates in the published literature. We conclude from our audit data that first-generation endometrial ablation techniques such as trans-cervical resection of the endometrium for heavy menstrual bleeding are effective and in experienced hands have fairly low operative complication rates and long-term hysterectomy rates. These are similar to rates in the published literature for second-generation endometrial ablation techniques. We recommend that until further larger scale randomised controlled trials comparing first generation and the newer second-generation endometrial ablation techniques are performed which would provide clinicians with better evidence, first-generation endometrial ablation equipment should not yet be condemned to gather dust in hospital storage facilities and become ‘museum pieces’. Rather, a concerted effort must be made to increase training opportunities in the use of first-generation endometrial ablation techniques especially in institutions that have already made the financial investment and are in possession of perfectly functioning equipment. This would ensure that the valuable clinical skill in the use of available first-generation endometrial ablation technique is not lost over time.     

Endometrial ablation for heavy menstrual bleeding

PURPOSE OF REVIEW: This review evaluates the currently available evidence regarding resectoscopic endometrial ablation (REA) and the various nonresectoscopic endometrial ablation (NREA) techniques used for heavy menstrual bleeding. RECENT FINDINGS: Laser endometrial ablation is now used infrequently, largely because of procedure time, but also because of the cost and training associated with the technique. REA can be performed in a wider spectrum of endometrial cavity configurations than NREA and, at least in expert hands, remains the gold standard. Each of the five available types of NREA device possesses advantages and disadvantages over the others with respect to variables such as treatment time, required cervical dilation, and size and configuration of the endometrial cavity. All provide acceptable results that are comparable to that of REA in expert hands. Serious complications seem to be less common with NREA, but uterine perforation and bowel or other visceral injury can still occur. When endometrial-ablation patients were followed for up to 5 years, repeat surgery rates ranged from 20 to 40%, thereby eroding both the direct and indirect treatment-related resource utilization. Levonorgestrel-releasing intrauterine devices demonstrate similar clinical and patient-satisfaction outcomes to endometrial ablation but can be inserted in the office and allow maintenance of fertility. SUMMARY: Both REA and NREA provide at least short- to intermediate-term options to hysterectomy for patients with heavy menstrual bleeding and normal or near-normal endometrial cavities. Consequently, the ideal candidates are likely those who are within 5 years of menopause.     

Heavy menstrual bleeding

Heavy menstrual bleeding is defined as excessive menstrual blood loss which interferes with the woman's physical, emotional, social and material quality of life, and which can occur alone or in combination with other symptoms. All interventions should aim to improve quality of life rather than focussing on menstrual blood loss alone. An accurate history may indicate the cause of the bleeding. Indications for endometrial biopsy include persistent intermenstrual bleeding as well as heavy menstrual bleeding, in women aged 45 and over and those where there is evidence of treatment failure. First line treatment includes tranexamic acid or non-steroidal anti-inflammatory drugs or combined oral contraceptives.Second line treatment options include, levonorgestrel-releasing intrauterine system (provided long-term use is anticipated), oral norethisterone or injectable long-acting progestogens.In women with HMB alone who have failed to respond to the above treatment options: with uterus no bigger than a 10-week pregnancy, endometrial ablation should be considered in preference to hysterectomy. Where hysterectomy is indicated, the route of hysterectomy should be considered in the following order: first-line vaginal; second-line abdominal/laparoscopic.     

Molecular and cellular causes of abnormal uterine bleeding of endometrial origin

Women today may reasonably anticipate in the order of some 400 menstrual cycles over their reproductive lifespan. The endometrium is thus subject to repeat cycles of shedding and repair and notably healing of the endometrium post menses is "scarless". The local molecular and cellular mechanisms involved in post menstrual resolution of the inflammatory events associated with menstruation and endometrial repair remain to be fully determined. Menstrual complaints are common. It is highly likely that unrestrained local inflammatory events and/ or deficient repair processes within the endometrium contribute to the women's experience of heavy menstrual bleeding (HMB). The management of women with HMB may need to utilize therapeutic approaches that optimize endometrial repair processes, post menses. These approaches may be necessary in addition to current therapies that hitherto have focused on limiting the local inflammation associated with menstruation. Research endeavors thus need to focus upon the molecular and cellular causes of problematic uterine bleeding. Herein the events associated with pre-menstrual progesterone withdrawal, limitation of blood loss, the expression of vasoactive mediators and factors that may modulate vascular morphology are described. Such lines of enquiry and knowledge will be essential if novel targets for treatment of menstrual bleeding complaints, such as HMB, are to be identified.     

The relationship of bleeding patterns to daily reproductive hormones in women approaching menopause

OBJECTIVE: To discover early hormonal predictors of menopause and the stages of the menopausal transition and to understand the hormonal basis behind the bleeding abnormalities common in the menopausal transition. METHODS: A cohort of 804 women aged 42-52 collected first void urine samples daily for one complete menstrual cycle or 50 days (whichever came first) once a year for 3 years. Urine was assayed for excreted levels of follicle-stimulating hormone, luteinizing hormone, estrogen metabolites, and progesterone metabolites, which were normalized for creatinine concentration. Anovulation was defined by an algorithm based on progesterone secretion. Menstrual bleeding parameters were derived from daily calendars. Correlations among bleeding characteristics, hormone concentrations, and other potential clinical predictors were analyzed using multivariable logistic regression models. RESULTS: An ethnically diverse population of women (mean age of 47) with a majority in the early perimenopause was studied. Approximately 20% of all cycles were anovulatory. Short cycle intervals (fewer than 21 days) were common early in the menopause transition and were associated with anovulation (44%). Long cycle intervals (more than 36 days) also were associated with anovulatory cycles (65%). Both short (1-3 days) and long (more than 8 days) duration of menstrual bleeding were associated with anovulation (18% and 23%, respectively). Women with anovulatory cycles were less likely to report heavy menstrual bleeding as compared with those with ovulatory cycles. Heavy bleeding was not associated with steroid hormone concentrations but was associated with obesity and with the self-reported presence of leiomyomata. CONCLUSIONS: Among women in the early menopause transition, abnormalities in timing of menstrual bleeding (cycle intervals or bleeding duration) have a hormonal basis and are frequently associated with anovulation. In contrast, abnormally heavy periods do not appear to have a steroid hormonal basis and are less likely after anovulatory cycles. Heavy periods are associated with obesity and leiomyomata. LEVEL OF EVIDENCE: II.     

Diagnosis and treatment of menorrhagia

One-third of all women experience heavy menstrual bleeding at some point in their life. In western countries, about 5% of women of reproductive age will seek help for menorrhagia annually. Half of all women who consult for hypermenorrhea have some uterine abnormality, most often fibroids (among patients under 40 years of age) and endometrial polyps (above 40 years of age). Appropriate treatment considerably improves the quality of life of these patients, and it is important to make a rigorous assessment of the patient to provide the best treatment options. This guideline provides instructions on how to examine and treat women of fertile age who have menorrhagia. The subject's own assessment of the amount of menstrual blood loss does not generally reflect the true amount. All patients should undergo a pelvic examination and, if the menstrual pattern has changed substantially or if anaemia is present, a vaginal sonography should be carried out as the most important supplemental examination. Vaginal sonography combined with an endometrial biopsy is a reliable method for diagnosing endometrial hyperplasia or carcinoma, but it is insufficient for diagnosing endometrial polyps and fibroids; these can be diagnosed more reliably by sonohysterography or hysteroscopy. Non-steroidal anti-inflammatory drugs and tranexamic acid reduce menstrual blood loss by 20-60%, and the effectiveness of a hormonal intrauterine system (IUS) is comparable with that of endometrial ablation or hysterectomy. Cyclic progestogens do not significantly reduce menstrual bleeding of women who ovulate. Treatment should be started with one of the drug therapies, i.e. the IUS, tranexamic acid, anti-inflammatory drugs, or oral contraceptive. Drug treatment should be used and evaluated before surgical interventions are considered. With an effective training and feedback system, it is possible to organise the diagnostics, medical treatment and follow-up of heavy menstrual bleeding in the primary health care setting or in outpatient clinics, which reduces the burden on specialist health care.     

Cost-effectiveness and quality of life associated with heavy menstrual bleeding among women using the levonorgestrel-releasing intrauterine system

Objective

To review the literature for economic and health-related quality of life outcomes data associated with the use of the levonorgestrel-releasing intrauterine system (LNG-IUS) in the management of heavy menstrual bleeding.

Methods

We searched the MEDLINE and EMBASE databases simultaneously using the Ovid interface to review the literature in a systematic manner for economic and health-related quality of life outcomes data associated with the use of the LNG-IUS in women with heavy menstrual bleeding. Articles were then selected for further review based on the relevance of their titles and/or abstracts. We identified 17 articles for inclusion in this review.

Results

Treating heavy menstrual bleeding with the LNG-IUS was found to be cost-effective in various countries and settings. Moreover, irrespective of the measuring instrument used, health-related quality-of-life outcomes were found to be improved to a degree similar to that achieved with endometrial ablation or hysterectomy. In some cases, the LNG-IUS appeared to be more effective and less costly than the surgical options.

Conclusion

The LNG-IUS is a cost-effective treatment option for heavy menstrual bleeding when pharmacologic treatment is indicated.     

Endocavitary surgical procedures, an alternative to myomectomy in patients with symptomatic fibroids

Endometrial ablation can be used in heavy menstrual bleeding due to symptomatic submucosal myomas in women without desire of pregnancy. Those methods used alone, lead to an improvement on bleeding but results are not as good as in women without myomas. They can be associated with hysteroscopic myomectomy and, then, the results on bleeding are better than myomectomy alone. Second generation endometrial ablation methods must be used preferentially as they present less surgical complications than first generation methods. As the pregnancies that may occur after endometrial ablation have high risk of complications, a contraceptive mean is highly recommended after surgery. Transcervical sterilisation by intratubal insert (Essure) can also be proposed, but for women with Essure placed before endometrial ablation, only Thermachoice and bipolar resection have proven their safety. Finally, economical outcomes of endometrial ablation in myomas haven't been assessed yet.     

Clinical implications of disturbances of uterine vascular morphology and function

Menstrual disturbances are one of the most common problems presenting to the gynaecologist. In order for the endometrium to bleed, vessels must break down. Disruption in the regulation of endometrial vascular growth and function has been found in association with spontaneous and sex steroid-induced disturbances of menstrual bleeding. Although circulating oestrogens and progestogens influence the endometrial vessels, this effect appears to be indirect, and regulation is primarily via local factors. Deficient vasoconstriction and haemostasis with excessive fibrinolysis is seen in menorrhagia. Breakthrough bleeding in users of progestogen-only contraceptives is associated with increased superficial vascular fragility and disruptions in the supporting basement membrane. Blood vessels in uterine fibroids are abnormal in distribution and appearance. Adenomyosis is also commonly associated with menstrual disturbance, and alterations in vascular distribution suggest altered angiogenesis. Successful human embryo implantation requires endometrial vascular breakdown. Excessive thrombosis associated with the antiphospholipid syndrome may interfere with this re-modelling and compromise implantation. Arteriovenous malformations are a rare but important cause of excessive or irregular vaginal bleeding. Abundant vessels with abnormal morphology, associated with aberrant angiogenesis can be seen, and embolization of these vessels may be an effective conservative treatment. Improved understanding of the regulation of the uterine vasculature is likely to lead to targeted therapies to prevent unscheduled vascular breakdown and to control menstrual disturbance at an endometrial level.     

Emerging indications for the levonorgestrel-releasing intrauterine system (LNG-IUS)

The levonorgestrel intrauterine system (LNG-IUS), originally designed for long-term contraceptive use, has been on the Scandinavian market for approximately 20 years. Novel clinical indications for the LNG-IUS, derived mainly from investigator-initiated studies, are emerging. These include heavy menstrual bleeding associated with uterine fibroids, endometriosis, adenomyosis, as well as endometrial hyperplasia. In both cohort and randomized studies, the LNG-IUS is effective in decreasing heavy menstrual bleeding, also in women diagnosed with uterine fibroids. In randomized studies the LNG-IUS has shown comparable clinical efficacy to GnRH analogues or progestins for the symptomatic treatment of endometriosis. Experience with LNG-IUS in adenomyosis is based on prospective cohort studies. Dysmenorrhea has been reported to decrease in all women, and uterine volume was seen to diminish in some of these studies. In the treatment of endometrial hyperplasias, including atypical hyperplasia, the LNG-IUS is equal or superior to treatment with systemic progestins. Further studies are needed to examine the full potential of the LNG-IUS in such common clinical situations.     

Abnormal uterine bleeding: medical treatment with vaginal danazol and five-year follow-up

STUDY OBJECTIVE: To evaluate the clinical efficacy and patient satisfaction of long-term danazol delivered vaginally as treatment for heavy menstrual bleeding. DESIGN: Prospective study (Canadian Task Force classification II-3). SETTING: University hospital. PATIENTS: Twenty premenopausal women with endometrial hyperplasia or endometrial polyps. INTERVENTION: After curettage or hysteroscopic-directed biopsies, women used one 200-mg tablet of danazol vaginally every day, continuing the therapy as long as they were totally satisfied with it. MEASUREMENTS AND MAIN RESULTS: Women were instructed to keep a diary of menstrual bleeding and to rate blood loss on a visual analog scale from zero (no blood loss) to 10 (gushing-type bleeding). They were seen every month for 3 months, then every 3 months for 9 months, and then every 6 months for 4 years for Papanicolau smear, pelvic examination, and transvaginal ultrasonography. They were asked to bring their diary of menstrual bleeding. They were asked about side effects and their satisfaction with the therapy. Peripheral blood was drawn for blood count and serum chemistries. Hysteroscopic-directed biopsies were repeated after 3 months of therapy in women with endometrial hyperplasia. The severity of blood loss was significantly reduced in all women after 3 months of treatment. All women with endometrial hyperplasia had regression of hyperplastic endometrium. None of the women with endometrial polyps had sonographic signs of recurrence during therapy. Only 10 women (50%) completed 1-year follow-up, and only 5 women (25%) completed 5-year follow-up. CONCLUSION: These results suggest that long-term administration of vaginal danazol after curettage or hysteroscopic-directed biopsy is both efficacious and safe in women with heavy menstrual bleeding, but the rate of discontinuance is high.     

Resección endometrial en el tratamiento de la hemorragia uterina disfuncional

ObjectivesTo annalize the effectiveness of endometrial resection as a treatment of heavy menstrual bleeding or menorrhagiaSubjects And MethodThe study included 100 patients needing treatment for menorrhagia. We measured patients satisfaction and change in symptomsResultsWe obtained a percentage of 82% of improvement in hemorrhagic menstrual bleeding and satisfaction rates of 76%ConclusionEndometrial resection is and alternative to hysterectomy that could be offered to pre-perimenopausal women in who, medical treatment failed     

Risk Categories for Abnormal Endometrial Biopsy in Dysfunctional Uterine Bleeding

Objective: this study was designed to examine the clinical utility of risk factors for postmenopausal endometrial adenocarcinoma in predicting abnormal endometrial biopsy in premenopausal women diagnosed with dysfunctional uterine bleeding (DUB). The second purpose was to develop risk categories for abnormal endometrial biopsy in women with DUB.Design: prospective observational study.Setting: gynaecology department of a large teaching hospital.Population: women complaining of premenopausal abnormal gynaecological bleeding.Methods: women were included in the study if they experienced abnormal gynaecological bleeding due to either DUB or small fibroids. The risk factors for endometrial cancer that were tested included menstrual cycle irregularity, diabetes, nulliparity, hypertension, obesity (weight ≥ 100 kilograms or Body Mass Index > 33) and age ≥ 40 years. Logistic regression was used to investigate the relative importance of each risk factor.Main outcome measures : the correlation of abnormal endometrial histology with risk factors for endometrial cancer.Results: six hundred women were studied. Sixty-nine patients were excluded. The results from 531 patients with either DUB alone (467) or bleeding associated with small fibroids (64) were analysed. Thirty-four (6.4%) patients had abnormal endometrial biopsies. Menstrual cycle irregularity was the only statistically significant independent risk factor for an abnormal biopsy. No specific subtype of irregular menstrual pattern predicted an increased prevalence of abnormal endometrial biopsy.Conclusions: premenopausal women diagnosed with DUB whose menstrual cycles are regular have a negligible risk of developing endometrial hyperplasia, and can safely be spared the discomfort and risk of complications associated with endometrial biopsy.     

Endometrial ablation in England-coming of age? An examination of hospital episode statistics 1989/1990 to 2004/2005

OBJECTIVE: To observe numbers and trends in endometrial ablation performed for heavy menstrual bleeding (HMB) in England. DESIGN: Examination of National Health Service (NHS) Hospital Episode Statistics. Number of hysterectomies and endometrial ablation procedures performed each year from 1989/1990 to 2004/2005. RESULTS: Hysteroscopic endometrial ablation peaked in 1992/1993 before falling significantly to a low in 1997/1998. Since then the total number of procedures has increased by 250% and of the 9701 endometrial ablations performed in 2004/2005 over half (5457) are now second-generation techniques. CONCLUSIONS: Endometrial ablation is now more common than hysterectomy for heavy menstrual bleeding and second-generation methods are now more commonly performed than hysteroscopic endometrial ablation. There is every indication that endometrial ablation will continue to increase in practice in England.     

Mechanism of action of the levonorgestrel-releasing intrauterine system in the treatment of heavy menstrual bleeding

Objective

To assess the efficacy and adverse effects, and reveal the effective pathway of the levonorgestrel-releasing intrauterine system (LNG-IUS) in the treatment of heavy menstrual bleeding.

Methods

In a prospective single-center study in Istanbul, Turkey, the LNG-IUS was inserted in 60 patients diagnosed with heavy menstrual bleeding between January 2008 and June 2010. Menstrual bleeding pattern, coagulation parameters, uterine arterial blood flow, endometrial thickness, and uterine and ovarian volumes were assessed pre-insertion, and at 6 and 12 months.

Results

Forty-nine women completed the study. When compared with pre-insertion values, the LNG-IUS led to improvements in hemoglobin and marked decreases in visual bleeding scores, endometrial thickness, and fibrinogen levels (P < 0.001); platelet count, international normalized ratio, prothrombin time, activated partial thromboplastin time, and uterine volume also decreased (P < 0.05). No significant change in ovarian volumes, or uterine artery resistive and pulsatility indices was observed at 6 or 12 months compared with pre-insertion values.

Conclusion

The decline in menstrual blood loss among LNG-IUS users was associated with local progestogenic effects and aggravation of intrinsic and extrinsic coagulation pathways. Although the LNG-IUS is a highly effective method for treating heavy menstrual bleeding, care must be taken when a patient has thromboembolic risk factors.     

Implications of obesity on surgical management of infertility and heavy menstrual bleeding

This review on the impact of obesity on reproductive health will concentrate on two key areas: infertility and heavy menstrual bleeding. The pathophysiology involved in these common problems is discussed. The management of infertility is discussed, in particular the management of anovulation associated with polycystic ovarian syndrome. There is also a focus on the surgical management of infertile obese women in the form of diagnostic laparoscopy, highlighting the key concerns and risks involved. Medical and surgical management of heavy menstrual bleeding is discussed including the many varied issues involved in hysterectomy of the obese woman.     

Treatment of heavy menstrual bleeding associated with uterine leiomyoma with the levonorgestrel-releasing intrauterine system

Heavy menstrual bleeding is an increasingly common health problem. The levonorgestrel-releasing intrauterine system (LNG-IUS) has been advocated for the treatment of heavy menstrual bleeding as an alternative to surgery. Based on this established indication and theoretical potential of targeted endometrial solution of myoma-related bleeding, we evaluated the efficiency of LNG-IUS in treating selected cases presenting with heavy menstrual bleeding in the presence of uterine leiomyomas. This study included 68 patients with history of heavy menstrual bleeding and ultrasound-proved submucous uterine leiomyoma. Uterine bleeding was done by the semiquantitative pictorial blood loss assessment score. The 5-dimensional EuroQol was chosen as the primary measure of effectiveness on health-related quality of life. Patients were re-evaluated at 3, 6, 9, and 12 month. After 12 months of follow-up, a significant reduction of menstrual flow was observed up to amenorrhea (in 11 cases). No significant effect for the LNG-IUS on the volume of fibroids or the uterine volume was observed. A significant improvement of the quality of life (measured by EQ index) was observed. Side effects were reported in ten cases. Eight cases required removal of the IUS for different reasons. So this study shows that in selected cases of uterine leiomyomas, Mirena LNG-IUS is an effective therapy directed towards the local steroid environment of the endometrium for control of the bleeding with no valuable effect on the myomas themselves.     

Microwave endometrial ablation versus endometrial resection: a randomized controlled trial

OBJECTIVE: To compare menstrual status, satisfaction, and acceptability of microwave endometrial ablation with transcervical endometrial resection for the treatment of heavy menstrual bleeding. METHODS: Women were randomized to either endometrial ablative method. Menstrual status, satisfaction, acceptability, and changes in health-related quality of life were obtained by a self-completed questionnaire. Case note review and personal communication identified further surgery rates at 2 years after each procedure. RESULTS: Among the original 263 women who underwent endometrial ablation, 249 (95%) returned questionnaires at 2 years. Menstrual status in both groups was similar, although the amenorrhea rate was higher after microwave endometrial ablation. Seventy-nine percent of women were either completely or generally satisfied after microwave ablation compared with 67% after transcervical endometrial resection. Health-related quality-of-life scores remained higher than at recruitment for both treatments. Hysterectomy rates were similar at 2 years (11.6% after microwave endometrial ablation and 12.7% after transcervical endometrial resection), and no repeat endometrial ablative procedures were required. CONCLUSION: Microwave endometrial ablation is an effective alternative to transcervical endometrial resection for dysfunctional uterine bleeding.     

Treatment Modalities in Adolescents Who Present with Heavy Menstrual Bleeding

Study Objective

On this study we sought to determine the relationship of bleeding disorders to iron deficiency anemia. Additionally, this study was undertaken to examine all current treatment modalities used in a menorrhagia clinic with respect to heavy menstrual bleeding management to identify the most effective options for menstrual management in the setting of an underlying bleeding disorder.