Nd:YAG laser endometrial ablation: histological aspects of uterine healing.

Laser ablation of the endometrium performed under hysteroscopic control is a novel procedure for the conservative management of menorrhagia in cases of dysfunctional uterine bleeding. The effect this has on the uterine cavity and the mechanism of reepithelialisation and endometrial regeneration have been examined by means of histological examination of endometrial biopsies and four hysterectomy specimens obtained for various indications at varying time intervals after laser endometrial ablation. During the first 3 months, fragments of necrotic and granulation tissue are found surrounded by a limited polymorph response. By 3 months, the uterine cavity appears to be completely reepithelialised. After 6 months, areas of normal-appearing endometrium may persist, but in other areas there is an attenuated cuboidal surface epithelium closely applied, to the underlying myometrium. Stromal fibrosis reminiscent of Asherman syndrome is also apparent.     

Dilatation and curettage fails to detect most focal lesions in the uterine cavity in women with postmenopausal bleeding

OBJECTIVE: To determine the prevalence of focally growing lesions in the uterine cavity in women with postmenopausal bleeding and endometrium > or = 5 mm and the extent to which such lesions can be correctly diagnosed by D&C. METHODS: In a prospective study, 105 women with postmenopausal bleeding and endometrium > or = 5 mm at transvaginal ultrasound examination underwent diagnostic hysteroscopy, D&C and hysteroscopic resection of any focally growing lesion still left in the uterine cavity after D&C. Twenty-four women also underwent hysterectomy. If the histological diagnosis differed between specimens from the same patient, the most relevant diagnosis was considered the final one. RESULTS: Eighty percent (84/105) of the women had pathology in the uterine cavity, and 98% (82/84) of the pathological lesions manifested a focal growth pattern at hysteroscopy. In 87% of the women with focal lesions in the uterine cavity, the whole or parts of the lesion remained in situ after D&C. D&C missed 58% (25/43) of polyps, 50% (5/10) of hyperplasias, 60% (3/5) of complex atypical hyperplasias, and 11% (2/19) of endometrial cancers. The agreement between the D&C diagnosis and the final diagnosis was excellent (94%) in women without focally growing lesions at hysteroscopy. CONCLUSION: If there are focal lesions in the uterine cavity, hysteroscopy with endometrial resection is superior to D&C for obtaining a representative endometrial sample in women with postmenopausal bleeding and endometrium > or = 5 mm.     

Adenomyosis Following Endometrial Rollerball Ablation

Summary: Two cases of adenomyosis following endometrial ablation using a rollerball electrode are reported. In both patients the endometrial ablation was performed for severe menorrhagia in the absence of uterine pathology. The endometrium was not prepared. After the operation, the women had persistent light menstruation for 7 to 9 months which then became heavy. They also developed progressive dysmenorrhoea and uterine enlargement. Abdominal hysterectomy was subsequently performed and adenomyosis was confirmed on histological examination. Prior endometrial preparation with hormone therapy may reduce the risk of incomplete destruction of the endometrium and therefore reduce the risk of postablation adenomyosis.     

Sonohysterographic Appearances of Endometrial Carcinoma: An In Vitro Study of Uterine Specimens

Objective: To determine the sonohysterographic appearances of endometrial carcinoma by sonohysterographic examination of uterine specimens.Methods: A prospective study of sonohysterographic examination on 30 uteri obtained immediately after hysterectomy from women 30 to 86 years of age, diagnosed preoperatively with endometrial carcinoma. The transducer was applied directly on the serosal surface of the anterior uterine wall for sonographic visualization. Sonographic examination was performed initially to assess the endometrial thickness, followed by infusion of normal saline into the endometrial cavity through a Foley catheter inserted into the cervix and repeat sonographic evaluation to characterize endometrial carcinoma.Results: The mean (± SD) endometrial thickness on initial sonographic examination was 11.4 (± 6.6) mm. Sonohysterographic examination demonstrated 15 uteri to have large, irregular polyploid masses arising from the endometrium, 6 uteri to have focal endometrial thickening, 4 uteri to contain benign-appearing polyp(s), 2 uteri to contain benign-appearing polyp(s) with focal endometrial thickening, and 3 uteri to have normal endometria.Conclusion: The sonohysterographic appearance of endometrial carcinoma is variable. Although the majority of endometrial carcinomas appeared as large, irregular polyploid masses, a completely normal sonohysterographic appearance may occur.     

Adenocarcinoma diagnosed at endometrial ablation

Background: Endometrial ablation is a surgical alternative to hysterectomy. Cases exist in the literature of endometrial adenocarcinoma found at endometrial ablation. If endometrial cancer is occult it might not be detected during ablation, especially if destructive techniques are used.Case: A 41-year-old woman had a history of menorrhagia. A previous D&C showed benign proliferative endometrium. Investigations for menorrhagia found no abnormalities. The diagnosis was dysfunctional uterine bleeding. Endometrial ablation was done and the pathologic examination of the resected endometrium found focal, well-differentiated adenocarcinoma of the endometrium.Conclusion: This case shows the importance of patient selection, evaluation, and surveillance after endometrial ablation. Resection of the endometrium is superior to destructive techniques because it provides tissue for pathologic evaluation. We recommend close postoperative surveillance in such cases.     

Endometrial ablation for intractable uterine bleeding: hysteroscopic resection

Twenty-one patients with intractable uterine bleeding were treated by resectoscopic ablation of the endometrium. All the patients were worked up thoroughly to rule out hormonal or anatomic reasons for their bleeding. In addition, various hormonal regimens were tried to stop the bleeding. Our technique used the modified urologic resectoscope, which is inserted into the uterine cavity. The entire endometrial cavity was ablated using 30 W of coagulating current. Of the 21 patients treated, 14 had blood dyscrasias, four were poor anesthetic risks, and three refused hysterectomy. There were no complications from the procedure. Three patients died from their primary disease, and all the rest, except for one, remained amenorrheic. We conclude that the use of the resectoscope for endometrial ablation is a successful, efficient, safe, and readily available way to treat intractable uterine bleeding.     

Endometrial cancer following endometrial resection

Endometrial ablation has emerged as a viable alternative to hysterectomy in the treatment of medically intractable dysfunctional uterine bleeding. However, this procedure cannot guarantee complete removal of the entire endometrium. Cases of endometrial cancer after endometrial ablation have been reported in the literature. We reviewed the cases of patients who underwent hysteroscopic endometrial ablation by endometrial resection for abnormal uterine bleeding from 1994 to 2005 at the Department of Obstetrics and Gynecology, Polyclinique, Clermont-Ferrand University. Of the 3769 patients having had hysteroresections, four developed endometrial cancer after complete endometrial ablation (1.06 out of 1000). All four of these patients showed histological evidence of endometrial polyps at endometrial resection, and all of them presented risk factors for endometrial carcinoma, such as obesity and/or arterial hypertension. Endometrial cancer after hysteroscopic endometrial ablation is a rare but possible occurrence, even a long time after the operation. Close monitoring of patients who have undergone endometrial ablation for endometrial polyps and who present risk factors, such as obesity or hypertension, even after apparent total ablation of the endometrium is strongly recommended, independently of the presence of abnormal bleeding that can represent a late symptom of advanced endometrial cancer.     

Circumscribed endometrial stromatosis of the uterus with marked epitheliogenesis

A 75-year-old female suffered from continuous abnormal genital bleeding; endometrial biopsy was interpreted as stromal hyperplasia. Simple total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. A circumscribed tumor covered by atrophic endometrium was found in the uterine fundus, bulging into the endometrial cavity; histological pictures revealed endometrial stromatosis with marked epitheliogenesis having a papillary formation and sex-cord-like differentiation. No recurrence or metastasis was detected postoperatively.     

Endometrial Dye Instillation: A Novel Approach to Histopathologic Evaluation of Morcellated Hysterectomy Specimens

The purpose of this prospective pilot case study was to determine whether instillation of trypan blue dye into the uterine cavity before laparoscopic hysterectomy and morcellation aids in gross identification of endometrium. The most common commercially available trypan blue stain, VisionBlue was used in this study. Instillation was performed at the beginning of the procedure using an embryo transfer catheter. A sterile solution of trypan blue, 0.5 mL, was instilled transcervically into the uterine cavities in 12 patients before laparoscopic hysterectomy with uterine morcellation. The morcellated specimens were sent for routine gross pathologic and histologic examination. It was concluded that intrauterine instillation of trypan blue stained the endometrium, thus aiding the pathologist in identification of the endometrium in morcellated uterine specimens.     

Pathological findings associated with the presence of a mirena intrauterine system at hysterectomy.

The Mirena intrauterine system (IUS) has improved the options available to women with menorrhagia. However, in some women, IUS treatment fails to reduce menstrual flow, and surgical treatment, including hysterectomy, is necessary. We have reviewed the histopathological findings on the uteri of 44 women undergoing hysterectomy because of menorrhagia after unsuccessful IUS treatment to assess whether a potentially unresponsive cohort could be identified. A retrospective review of 44 hysterectomy specimens was performed between October 1999 and April 2006 on women who underwent unsuccessful treatment of menorrhagia with the IUS. The patients' ages ranged from 30 to 53 years (median age, 43 years; all were premenopausal). Most women (60%) had the expected appearance of atrophy of the endometrial glands and pseudodecidual stromal reaction. Thirty hysterectomy specimens contained benign leiomyomata with associated reduced reactivity in the uterine cavity and incomplete suppression of the endometrium. In some cases (n = 10), the fibroids had displaced the IUS in the uterine cavity. Fourteen specimens showed adenomyosis, of which 8 also contained fibroids. In addition to leiomyomas, 1 specimen had an atypical polypoid adenomyoma and 1 had a benign adenomatoid tumor. Two specimens had endometrial hyperplasia for which the IUS was unsuccessful in controlling bleeding. Two specimens showed intrauterine misplacement of the IUS. Only 6 women (13.6%) had no histological abnormalities. Most women (86%) undergoing hysterectomy because of abnormal uterine bleeding with a Mirena IUS in situ had uterine abnormalities, as revealed by pathological review. Although recent reports have indicated that the IUS can be used successfully in the treatment of menorrhagia due to uterine fibroids, most cases of hysterectomies in this series after failed IUS suppression of menorrhagia contained uterine fibroids.     

Hysteroscopic endometrial ablation using free heated saline for the treatment of menorrhagia

STUDY OBJECTIVE: To assess the safety and efficacy of hysteroscopic endometrial ablation using controlled intrauterine instillation and circulation of heated (90 degrees C) saline. DESIGN: Phase II clinical study (Canadian Task Force classification II-2). SETTING: Preliminary study performed in an outpatient ambulatory surgery center of a university hospital. PATIENTS: Twenty women with menorrhagia of benign causes. INTERVENTION: Hysteroscopic endometrial ablation. MEASUREMENTS AND MAIN RESULTS: There were no complications. At no time did fluid leak from the fallopian tubes or cervix during treatment. Six patients had concurrent laparoscopy to measure serosal temperatures and to observe fimbriae directly during the 10-minute treatment. Serosal and endocervical temperatures were not elevated. Eighteen women kept evaluable menstrual diaries for 2 months before and 12 months after surgery. Ten women (55.6%) became amenorrheic, four (22.1%) hypomenorrheic, and three (16.7%) returned to normal periods after 12 months of follow-up. One woman (5.6%) reported a 75% decrease in menstrual flow but continued to be menorrhagic by definition. One patient subsequently underwent hysterectomy for simple endometrial hyperplasia. CONCLUSION: This procedure appears to be a safe method of globally ablating the endometrium, resulting in effective treatment of menorrhagia.     

Postmenopausal endometrial pathologies with tamoxifen treatment: comparison between hysteroscopic and hysterectomy findings.

Histological findings of endometrial specimens collected by hysteroscopy from 261 postmenopausal breast cancer patients with tamoxifen treatment (group I) and from endometrial specimens obtained following hysterectomy from 40 similar patients (group II) were compared. This comparison was performed in order to assess whether endometrial pathologies are more frequently diagnosed in specimens collected by hysterectomy than by those collected during hysteroscopy in such patients. Overall positive endometrial histological findings were significantly more common in group II patients than in group I patients (82.5 and 24.5%, respectively; p < 0.0001). Atrophic endometrium was significantly more common in group I patients than in group II patients (75.5 and 15.0%, respectively; p < 0.0001). All other different endometrial pathologies, except for proliferative endometrium, were significantly more common in group II patients than in group I patients (endometrial hyperplasia = 17.5 and 4.2%, respectively; p < 0.0003; endometrial polyps = 30.0 and 11. 5%, respectively; p < 0.006; endometrial polyps with hyperplasia = 17.5 and 4.2%, respectively; p < 0.0003; endometrial carcinoma = 15. 0 and 0.4%, respectively; p < 0.0001). These findings suggest that in postmenopausal breast cancer patients treated with tamoxifen, the frequency of various endometrial histological findings and of overall positive endometrial histological findings were significantly higher in specimens collected by hysterectomy than in specimens obtained by hysteroscopy.     

Endometrial cryoablation with ultrasound visualization in women undergoing hysterectomy

STUDY OBJECTIVES: To evaluate tissue effects of cryosurgical endometrial ablation in women just before hysterectomy, characterize ultrasound monitoring of freezing, determine the feasibility of a new probe-angling procedure, and assess the safety profile by monitoring serosal surface temperatures. DESIGN: Single arm safety study enrolling ten women at two centers (Canadian Task Force classification II-2). SETTING: Two clinical sites. Patients. Ten women scheduled for hysterectomy. INTERVENTION: Hysterectomy with a new cryosurgical device (First Option, CryoGen, Inc., San Diego, CA) that achieves surface temperatures below -90 inverted exclamation mark C to freeze endometrium. MEASUREMENTS AND MAIN RESULTS: The freeze protocol involved angling the probe toward each cornu. Maximum ice front diameter at the end of the first angled freeze ranged from 24 to 34 mm, and maximum ice ball diameter at the end of the second freeze ranged from 28 to 37 mm. The margin between the advancing ice front and serosal surface was monitored by ultrasound. In all cases the margin was safe and no reduction in serosal surface temperatures occurred. Depth of necrosis ranged from 9 to 12 mm as determined by tetrazolium staining and electron microscopy, and there was no full-thickness myometrial destruction. Total endometrial destruction was achieved. CONCLUSION: Cryosurgical ablation of the endometrium with the First Option system with angled freezes and ultrasound monitoring appears to be feasible and safe given our preliminary data.     

Endometrial ablation with the neodymium:Yag laser

The current study was designed to evaluate Nd:Yag laser endometrial ablation as an alternative to hysterectomy in women with uncontrolled benign uterine bleeding. The subjects were candidates for hysterectomy, had benign endometrial histology, had failed hormonal therapy and/or D&C, and did not desire future childbearing. Medication was given to render the endometrium atrophic, and treatment was carried out using a "touch" technique. Forty-two treated patients have been followed 3-36 months, with a success rate of 81%. Fourteen (33%) are amenorrheic and 13 (31%) estimate that they have less than 25% of their pretreatment flow. Those with uterine size over 10 cm or large submucous fibroids were usually excluded because of technical difficulty in performing the procedure. Treatment outcome was not related to patient weight, uterine size, or small intrauterine abnormalities. Twelve patients had medical conditions that were relative contraindications for hysterectomy, and 11 were treated successfully. Endometrial ablation with the Nd:Yag laser is an effective alternative to hysterectomy in patients with uncontrolled benign uterine bleeding.     

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.     

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.     

Endometrial ablation versus hysterectomy in women treated with tamoxifen

AIM: The aim of our study is the assessment of the importance of the endometrial ablation versus hysterectomy in patients treated with tamoxifen for previous breast cancer. METHODS: Fifty-eight outpatients in therapy with tamoxifen for 1 year were controlled in the Department of Gynaecology of the University of Naples. We have selected these patients in two groups: group A, with 28 women with abnormal uterine bleeding and endometrial thickness >8 mm and group B, with 30 normal endometrium asymptomatic women. All patient of group A and 18 of group B were treated with endometrial ablation. RESULTS: Next follow-up showed normal hysteroscopy figures in 89% of cases and 5% of cases needed a hysterectomy for new abnormal uterine bleeding and cytology. CONCLUSION: Our results show the utility of endometrial ablation especially in selected cases in therapy with tamoxifen for previous breast cancer.     

Endometrial thermal balloon ablation by a simple technique using Foley’s catheter with or without pre ablation endometrial curettage to treat cases with intractable menorrhagia

ObjectivesTo assess the efficacy and safety of endometrial thermal ablation by a technique using Foley’s catheter to treat cases with intractable menorrhagia and to compare between results with and without pre procedure curettage.Study designProspective randomized controlled study.Patients and methodsForty eight patients aged from 39 to 52 years complaining of menorrhagia not responding to treatment for at least 6 months were included in the study, pre ablation endometrial curettage was done for 24 randomly selected cases (group 1) and ablation without curettage for the other 24 cases (group 2). A latex silicon coated Foley’s catheter with 30–50 ml capacity was tested and inserted into uterine cavity then inflated by a variable volume of boiling saline as the uterine cavity permits under moderate pressure and replaced every 2 min with a new boiling saline, for 8 min duration. Then follow up for 6 months and hysteroscopic examination were done to detect endometrial scarring.Outcome measuresPatients satisfaction, menstrual outcome, hysteroscopic diagnosed scarred endometrium.ResultsThis study showed a satisfaction rate of 83.3%, improvement in menstrual bleeding (79.2%) and hysteroscopic diagnosed scarring of the endometrium (75%). Cases in group 1 had a significantly higher satisfaction rate (95.8%) than in group 2 (70.8%) and significantly lower incidence of persistent menorrhagia after ablation than cases in group 2 (4.2% versus 37.5%, respectively). Hysteroscopic diagnosed endometrial scarring was significantly higher in group 1 (91.7%) versus (53.8%) for group 2.ConclusionEndometrial thermal balloon ablation by a technique using Foley’s catheter is a safe, simple, cheap and effective procedure as an alternative to hysterectomy for treatment of menorrhagia in properly selected cases. Pre ablation endometrial curettage increases the satisfaction rate and improves menstrual outcome.     

Reoperative hysteroscopic surgery in the management of patients who fail endometrial ablation and resection

STUDY OBJECTIVE: To determine the safety and efficacy of reoperative hysteroscopic surgery for women who fail endometrial ablation and resection. DESIGN: Retrospective chart review and follow-up (Canadian Task Force classification II-2). SETTING: Private office practice. PATIENTS: Twenty-six women who had undergone endometrial ablation or resection and experienced failure characterized by intolerable pain, bleeding, or asymptomatic hematometra. INTERVENTION: Sonographically guided hysteroscopic endomyometrial resection. MEASUREMENTS AND MAIN RESULTS: Mean length of time from initial treatment for abnormal uterine bleeding and reoperative hysteroscopic surgery was 41.2 +/- 47.9 months. Five (19.2%) women required simple dilatation and 21 (80.8%) required endocervical resection to achieve access to the uterine cavity. There were no operative complications. Mean operating time was 20.3 +/- 9.5 minutes. Mean specimen weight was 6.7 +/- 4.9 g. Adenomyosis was present in 15 (57.7%) specimens. Women were followed for a mean of 23.2 +/- 22.7 months. Twenty-three (88.5%) achieved satisfactory results and avoided hysterectomy. Three women (11.5%) eventually required hysterectomy because of recurrent pain or bleeding. CONCLUSION: Reoperative hysteroscopy is useful in managing women after failed endometrial ablation and resection. It produces excellent results in achieving amenorrhea and relief of cyclic pelvic pain, thereby avoiding hysterectomy in most patients.     

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.