Microwave endometrial ablation for menorrhagia in patients with systemic disorders.

OBJECTIVE: To evaluate the effectiveness of microwave endometrial ablation (MEA) in the treatment of menorrhagia in patients with severe systemic disease or medical conditions. METHODS: Forty-two menorrhagic women undergoing systemic disorders with failure of medical management were treated with MEA under local or general anesthesia, and were followed-up for 1 year. RESULTS: The women had a mean age of 39.4 years (range, 17-49). The procedure was successfully completed in all patients, and no intraoperative complications occurred. Two cases died of their primary severe medical diseases within 2 months of treatment but these cases were not associated with MEA. Among the remaining 40 patients, 24 (60.0%) had amenorrhea within 12 months. The duration of hospitalization and the amount of blood transfusion were significantly reduced after treatment, and the quality of life of these patients was improved significantly. CONCLUSIONS: MEA is a safe and effective treatment for the management of severe menorrhagia in patients undergoing systemic illness or severe medical conditions.     

Patient outcomes following an endometrial thermal balloon ablation (thermochoice) procedure for menorrhagia in a day surgery unit

This study was carried out to assess the efficacy, complication rate and acceptability of endometrial thermal balloon ablation in a District General Hospital in the South West of England.     

微波子宫内膜消除术治疗月经过多30例分析

目的：观察微波子宫内膜消除术（MEA）治疗月经过多的效果。方法：采用英国Microsulis公司生产的微波子宫内膜消除仪，对30例月经过多的患者实施子宫内膜消除术，观察月经量等方面的变化。结果：30例中出现无月经者9例（30．0％），月经量明显减少者14例（46．7％），点滴量月经4例（13．3％），1例（3．3％）术后闭经4个月发生阴道少量出血3天后再次出现无月经，1例（3．3％）月经量减少3个月后闭经，1例（3．3％）无明显效果。结论：微波子宫内膜消除术是治疗月经过多最简单、快速、安全、有效的微创手术方法。     

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.     

Transcervical endometrial resection in women with menorrhagia: long-term follow-up

OBJECTIVE: Hysteroscopic endometrial resection is an innovative and conservative surgical technique considered, very often, as an alternative to hysterectomy. The aim of the study was to evaluate long-term efficacy of endometrial resection performed in women with menorrhagia. STUDY DESIGN: Retrospective study of 111 premenopausal women with menorrhagia, unresponsive to medical treatment, who underwent endometrial resection by resectohysteroscope (electrocautery technique supplied with a fundus rollerball electrode, with corneal areas, and with a 90 degrees loop for intrauterine walls and used with glycine 1% as distending fluid) between 1994 and 1999. RESULTS: Long-term follow-up questionnaires were completed in 106 cases, while 5 cases dropped-out (4.5%). The mean-age at menopause in our subjects was 52.8 years (17.6+/-18.4 months after operation). After 53.2+/-16.4 months, 82 patients (77.4%) showed a normal menstrual pattern or amenorrhea, while failure was recorded in 24 patients (22.6%) and 12/24 patients underwent hysterectomy. Percentage of success in the older population (>49 years) (94%) was significantly higher than in the younger population (70%). The histologic finding of only fibrosis (41.7%) correlated with failure of the technique. CONCLUSION: Our data suggest that endometrial resection by resectohysteroscope is an innovative and conservative but not exclusive surgical technique in selected younger women, while in older women endometrial resection nearly always resolves long-term menorrhagia.     

Management of menorrhagia with the levonorgestrel intrauterine system versus endometrial resection

Menorrhagia is the presenting symptom among the majority of women who undergo hysterectomy. The levonorgestrel intrauterine system (LNG-IUS) is highly effective in reducing menstrual bleeding. The aim of this randomized study was to compare the effect of endometrial resection (ER) as a surgical modality and the LNG-IUS as a hormonal modality for treating menorrhagia. This is a therapeutic, phase III randomized study that included 60 premenopausal women with excessive uterine bleeding. The patients were randomly allocated to two treatment groups – LNG-IUS or endometrial resection (ER). Uterine bleeding was quantified by the pictorial blood loss assessment score (PBAC). The degree of disturbance caused by menstrual bleeding on general well-being, work performance, physical activity and sexual activity was assessed using a visual analogue scale at screening. Initial evaluation was followed by reassessment at 6 months, and at 12 months or at discontinuation. Both groups were matched for age, duration of flow and uterine characteristics. In the LNG-IUS group, four patients discontinued treatment and, ultimately, treatment success was 77%. In the ER Group, all operations were uneventful. A significant reduction in the amount of blood loss monthly was achieved in 83% of the cases, and there was a significant improvement in the quality of life of the patients in both study groups. The difference between the two groups was not statistically significant (p=0.747). The placement of LNG-IUS has a dramatic effect in lowering bleeding intensity in menorrhagic patients, with the advantage of reversibility, and mild adverse events. It may be the first-line treatment in younger women with menorrhagia.     

Partial rollerball endometrial ablation: A modification of total ablation to treat menorrhagia without causing complications from intrauterine adhesions

Objective: Our purpose was to demonstrate that intrauterine adhesions and hematometra do not occur after a partial rollerball endometrial ablation and that menorrhagia can be successfully treated by this procedure for patients without deep adenomyosis. Study Design: Fifty patients with hysteroscopically normal-appearing cavities (without gross polyps or submucous fibroid tumors) had a partial endometrial ablation for menorrhagia and were followed up for >3 years. A partial ablation is defined as ablation of only the anterior or posterior endometrial wall and avoidance of the cornual areas. A posterior myometrial biopsy to determine the depth of adenomyosis was performed and correlated with outcome. The intrauterine cavity was evaluated postoperatively for adhesions. Results: Patients without deep adenomyosis had good outcome after partial ablation. No postoperative intrauterine adhesions were found. Conclusion: Partial endometrial ablation can successfully treat menorrhagia in patients without deep adenomyosis. It does not cause intrauterine adhesions, which may lead to hematometra and potentially delay the diagnosis of endometrial cancer. (Am J Obstet Gynecol 1999;180:1512-21.)     

Prognostic factors for the success of thermal balloon ablation in the treatment of menorrhagia

OBJECTIVE: To identify predictive factors that will ensure successful menorrhagia treatment using hot fluid balloon endometrial ablation. METHODS: This is a prospective study on patients referred for menorrhagia and treated with hot fluid thermal balloon ablation. Potential prognostic factors for assessing the success of treatment were recorded. Success was defined as patient satisfaction and no subsequent hysterectomy at 2-year follow-up. RESULTS: A total of 130 women were included in the final analysis. The cumulative rate of patients undergoing a hysterectomy after 2 years was 12%. After 2 years, 81% of the remaining patients were satisfied with the results of the treatment. Predictive factors for adverse outcome were a retroverted uterus (hazard rate ratio 3.3, 95% confidence interval [CI] 1.2, 8.6), pretreatment endometrial thickness of at least 4 mm (hazard rate ratio 3.6, 95% CI 1.3, 11), and the duration of menstruation (hazard rate ratio 1.2, 95% CI 1.0, 1.3, per day in excess of 9 days). The risk of an adverse outcome declined steadily with increasing age (hazard rate ratio 0.86, 95% CI 0.77, 0.96 per year over 42 years of age). Uterine depth and dysmenorrhea were not predictive factors, which significantly affected outcome. CONCLUSION: Young age, retroverted uterus, endometrial thickness of at least 4 mm, and prolonged duration of menstruation were associated with an increased risk of treatment failure. Uterine depth and dysmenorrhea had limited impact on the effectiveness of balloon ablation.     

Success rate, quality of life, and descriptive analysis after generalized endometrial ablation in an obese population

Objective

To describe the success rate of and the quality of life after global endometrial ablation in an obese population.

Methods

A follow-up survey was mailed to 72 women who had undergone global endometrial ablation. The survey included a menorrhagia-specific NovaSure endometrial ablation questionnaire. The mean follow-up time was 2.5 years.

Results

Forty-four women (61%) responded, with a mean body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) of 30.5. Overall, patients reported a decrease in missed social activities, in inability to perform activities of daily living, in missed work days, in bleeding tendencies, and in pain. The amenorrhea rate was 37%, and the success rate (those not requiring any further therapeutic treatment) was 86%. Patient satisfaction was 93%.

Conclusion

Global endometrial ablation improved quality of life for obese women with menorrhagia and had a high rate of satisfaction, even for patients not achieving amenorrhea. Patients with a BMI of more than 34 showed a trend toward failure and a higher rate of hysterectomy.     

Endometrial ablation with the NovaSure system in Iran

Objective

To evaluate the rate of response to treatment with the NovaSure endometrial ablation device among Iranian women with menorrhagia.

Methods

Twenty 35-50-year-old women with menorrhagia who were referred to Arash Hospital, Tehran, Iran, in 2008 were enrolled. They underwent endometrial ablation via the NovaSure system and were followed-up for 2 years.

Results

The incidence of amenorrhea was 30.0% at the end of the 2-year follow-up period. Hypomenorrhea was reported by 40.0% of women. The mean number of days of bleeding per month decreased significantly, from 30.0 ± 6.4 days before treatment to 3.1 ± 2.6 days after 2 years (P < 0.001). The severity of bleeding decreased significantly within 2 years after treatment (P < 0.001). In total, 85.0% of women were satisfied and 90.0% had responded to treatment—as defined by amenorrhea, hypomenorrhea, or return to normal menstruation.

Conclusion

The NovaSure system is effective and should be considered by gynecologists for the treatment of menorrhagia.     

Life-table analysis of the success of thermal balloon endometrial ablation in the treatment of menorrhagia

OBJECTIVE: To evaluate the change in intrauterine pressure during thermal balloon endometrial ablation and to identify risk factors associated with treatment failure. DESIGN: Prospective observational study. SETTING: University-affiliated teaching hospital. PATIENT(S): Seventy two consecutive patients with idiopathic menorrhagia refractory to medical treatment. INTERVENTION(S): Thermal balloon endometrial ablation under patient-controlled sedation. MAIN OUTCOME MEASURE(S): Change in intrauterine pressure during the treatment cycle and risk factors associated with treatment failure. RESULT(S): A spontaneous decrease in intrauterine pressure occurred in most patients (93%). The mean (+/-SD) decrease was 34.1 +/- 14.9 mm Hg, or 19.5% +/- 9.1%. The treatment failed in 10 patients (13.9%), and the mean end pressure was significantly lower in this group (131.1 +/- 14.1 mm Hg vs. 145.1 +/- 18.0 mm Hg; P=.02). The chance of success of treatment was significantly lower when the end pressure was <140 mm Hg (odds ratio, 0.42 [95% CI, 0.27 to 0.68]; P=.01), the intrauterine volume was >10 mL (odds ratio, 0.43 [95% CI, 0.22 to 0.83]; P=.058) and the uterus was retroverted (odds ratio, 0.36 [95% CI, 0.20 to 0.65]; P=.008). CONCLUSION(S): Maintaining high intrauterine pressure during the treatment cycle and correction of the retroversion may help to improve treatment success in thermal balloon endometrial ablation.     

Thermal endometrial ablation in dysfunctional uterine bleeding: an economic comparison of bipolar ablation and balloon ablation

Objective: A bipolar radio-frequency impedance-controlled endometrial ablation system is more effective than balloon ablation in the treatment of dysfunctional uterine bleeding. The aim of the present study was to compare the costs of both treatments, and to perform a cost-effectiveness analysis. Study design: An economic evaluation was set up alongside a randomised clinical trial comparing bipolar radio-frequency endometrial ablation and balloon ablation in 126 patients with dysfunctional uterine bleeding. Data on resources used for treatment and lost production time were prospectively collected, and costs of both treatments were calculated. Results: Mean direct medical costs per patient were €1638 for bipolar ablation and €1545 for thermal balloon ablation with a mean difference of €93 (95% CI €45–140, P-value 0.01). Mean indirect medical costs were just over €200 in each group. Incorporation of the costs of post-ablation hysterectomies resulted in mean costs of €2006 and €2053 in the balloon group (P-value 0.01). In the balloon group, the cost per satisfied patient was €2333 compared to €2112 in the bipolar group. Similarly, in the bipolar group the cost per amenorrhoeic patient was €4361 and in the balloon group €12831. Conclusions: The direct costs of bipolar ablation were higher than the costs of balloon ablation. However, after inclusion of the retreatment costs, bipolar ablation was less expensive than balloon ablation.     

NovaSure impedance controlled system for endometrial ablation: three-year follow-up on 107 patients

OBJECTIVE: This study was undertaken to assess the safety, efficacy, and data durability of the NovaSure ablation at 3 years after the procedure in women with menorrhagia secondary to dysfunctional uterine bleeding (DUB). STUDY DESIGN: A prospective, single-arm, observational pilot study (Canadian Task Force classification II-1) was carried out at a specialized center for gynecologic endoscopy with 107 premenopausal women with menorrhagia secondary to DUB. NovaSure ablation was performed in 107 patients. Pictorial Blood loss Assessment Chart diary sampling was used to assess menstrual blood loss. Ablation was performed without any type of endometrial pretreatment. RESULTS: No intraoperative or postoperative complications were observed. Treatment time averaged 94 seconds; 65% of the patients reported amenorrhea. Hysterectomy was avoided in 97.2% of patients at 3-year follow-up. CONCLUSION: Long-term clinical results demonstrate that the NovaSure system is a safe and effective method for treatment of women with menorrhagia secondary to DUB, yielding high amenorrhea and success rates, with low re-treatment rates.     

Long-term outcome of hysteroscopic endometrial resection with or without myomectomy in patients with menorrhagia

Objectives  To evaluate the long-term outcomes and hysterectomy rates after hysteroscopic endometrial resection with or without myomectomy for menorrhagia. Study design  Fifty-three women who had submucous myomas with intramural extension of less than 50% and smaller than 5 cm in diameter underwent endometrial resection and concomitant hysteroscopic myomectomy. Each of them was matched with a patient who had no submucous myomas and who had been treated by endometrial resection only. These two groups were compared for operative outcomes, additional procedures, outcome of menstrual bleeding and for subsequent hysterectomy, which was the endpoint of this study. Results  During the mean follow-up period of 6.5 years, 18 (34.6%) women with endometrial resection and myomectomy and 21 (39.6%) without myomectomy underwent at least one gynecological procedure. Hysterectomy was performed in 26.9% [95% confidence interval (CI) 16.8–40.3] of the patients with myomectomy and in 17.0% (95% CI 9.2–29.2) of the patients without myomectomy (P = 0.22). The main indications for hysterectomy were pain and spotting bleeding in seven out of 14 cases with myomectomy and in four out of nine with endometrial resection only. Leiomyomas were found in 12 out of the 14 women who had hysterectomy after hysteroscopic myomectomy and in four out of nine with hysterectomy after endometrial resection only (P = 0.06). Most (75.6%) of the 82 women who had not required hysterectomy had reached menopause. All the patients without hysterectomy in both groups reported amenorrhea or slight bleeding, and this response maintained for years after the treatment. Conclusion  Endometrial resection may be combined with hysteroscopic myomectomy without a significant increase or decrease in hysterectomy rates during a long-term follow-up.     

微波子宫内膜去除术治疗月经过多的远期疗效分析

目的 探讨微波子宫内膜去除术(MEA)治疗月经过多的远期疗效及影响因素.方法 选择因月经过多药物治疗无效而行MEA治疗且资料完整的患者共334例为观察对象,患者年龄29～59岁,其中合并子宫腺肌病59例.术后随访患者的月经、贫血症状的改善情况;53例患者术后进行宫腔镜检查及子宫内膜活检,观察子宫内膜组织的病理改变.术后平均随访时间64.7个月(3～96个月).结果 MEA治疗月经过多总有效率为91.3%(305/334),其中闭经率为49.7%(166/334),月经量减少或正常为41.6%(139/334);术后痛经改善的有效率为71.1%(140/197);患者对手术的满意率为91.9%(307/334);其中年龄＞40岁者,手术有效率为92.9%(196/211)、满意率为93.8%(198/211)、闭经率为64.9%(137/211),年龄≤40岁者手术有效率为88.6%(109/123)、满意率为88.6%(109/123)、闭经率为23.6%(29/123),不同年龄的患者MEA有效率、满意率、闭经率比较,差异均有统计学意义(P＜0.05).术后因症状复发(由于子宫内膜的破坏不完全导致宫角部子宫内膜岛状残留)等行再次治疗42例(12.6%,42/334),其中行二次MEA 9例,因月经过多症状复发、子宫腺肌病或子宫肌瘤最终行子宫切除术33例,子宫切除率9.9%(33/334).术后即时宫腔镜检查见宫腔内子宫内膜全部破坏,光镜下病理学改变表现为由表及里的凝固性坏死和部分平滑肌坏死层构成的热损伤带.结论 MEA治疗月经过多安全、有效;子宫内膜的不完全破坏导致宫角子宫内膜岛状残留是术后复发的重要原因.年龄、合并子宫腺肌病是影响MEA手术远期疗效的主要因素.     

Outcome of labor following previous cesarean section

Four hundred fifty-one patients who had had previous lower segment cesarean section were studied for subsequent pregnancy outcome at the University Teaching Hospital, Lusaka, Zambia. Of 319 who were allowed to go into labor, 63% succeeded in delivering vaginally, while 37% had to undergo repeat intrapartum cesarean delivery. No maternal death occurred. Scar dehiscence occurred in one case only. Parturition in otherwise obstetrically normal patients seems to be safe, and the trial of labor approach is desirable as it results in a lower number of repeat cesarean deliveries.     

Bipolar radio frequency endometrial ablation compared with balloon endometrial ablation in dysfunctional uterine bleeding: impact on patients' health-related quality of life

OBJECTIVE: To compare health-related quality of life (HRQoL) after bipolar radio frequency ablation and thermal balloon ablation in women with dysfunctional uterine bleeding. DESIGN: Randomized clinical trial. SETTING: Teaching hospital. PATIENT(S): Women suffering from dysfunctional uterine bleeding. INTERVENTION(S): Bipolar radio frequency ablation and thermal balloon ablation. MAIN OUTCOME MEASURE(S): Patients were asked to complete HRQoL questionnaires at baseline, and at 2 days, 2 weeks, 3 months, 6 months, and 12 months after surgery. The questionnaires contained the medical outcomes study Short-Form 36 (SF-36), the Self-rating Depression Scale, the Rotterdam Symptom Checklist, State-Trait Anxiety Inventory, and a structured clinical history questionnaire. RESULT(S): Data on HRQoL were available on at least two different time points in 115 of 126 randomized patients. HRQoL improved significantly over time in both groups, except for the domain of general health in the SF-36. None of the dimensions showed a significant difference between both groups, neither was there a significant interaction between time and treatment effect. CONCLUSION(S): Both methods significantly improved HRQoL in women with dysfunctional uterine bleeding. However, despite better amenorrhea and satisfaction rates after bipolar radio frequency ablation, there was no difference in HRQoL between the two groups.     

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.