Morphological changes in hysterectomies after endometrial ablation.

Electrosurgical ablation of the endometrium is a therapeutic choice for those patients having abnormal uterine bleeding. When ablation is followed by a hysterectomy, tissue damage due to thermal effect can be seen. From a total of 350 women with endometrial ablation, 12 required subsequent hysterectomy. The histological features found in these specimens are described and related to the elapsed time between the two surgical procedures. The mean elapsed time between ablation and hysterectomy was 19 +/- 17.3 months. Scarring with formation of additional endometrial cavities was seen in five cases, and endocervical stenosis in two cases. In seven patients, endometrial regrowth was seen at hysterectomy. Necrosis, granulomatous and foreign-body giant cell reaction, eosinophilic infiltrate and pigment-containing macrophages in the myometrium were seen in the long-term post-ablation hysterectomies. Necrosis was seen in short period post-ablation hysterectomies. Six of the seven patients with endometrial regeneration had adenomyosis in the hysterectomy specimen. Endometrial ablation induces thermal effects in the endometrium and granulomatous reaction with foreign-body giant cell reaction, fibrosis and deposition of pigment within macrophages in the myometrium. Adenomyosis is a possible explanation for endometrial regeneration in cases of ablation failure.     

Pathophysiology of adenomyosis

Adenomyosis refers to endometrial glands and stroma locatedhaphazardly deep within the myometrium. Similar histologicalalterations may be found in extra-uterine locations such asthe rectovaginal septum. The aetiology and pathogenic mechanism(s)responsible for adenomyosis are poorly understood. Both humanand experimental studies favour the theory of endomyometrialinvagination of the endometrium, although the de-novo developmentof adenomyosis from Müllerian rests in an extrauterinelocation is a possibility. The prerequisite for adenomyosismay be triggered or facilitated by either a 'weakness of thesmooth muscle tissue or an increased intrauterine pressure orboth. Relatively high oestrogen concentrations and impairedimmune-related growth control in ectopic endometrium may benecessary for the maintenance of adenomyosis. Smooth musclecell hyperplasia and hypertrophy are a reflection of reactivechange secondary to ectopic endometrial proliferation. Furtherstudies are needed for insight into the precise aetiology andpathogenesis of adenomyosis. Adenomyosis is a relatively frequentendomyometrial pathology discovered in multiparous women between40 and 50 years of age. About 2/3 of women are symptomatic withmenorrhagia and dysmenorrhoea; 80% of adenomyotic cases areassociated with leiomyomata uteri; and in women with endometrialadenocarcinoma, adenomyosis is relatively often seen. Definitediagnosis is made on hysterectomy specimens, although attemptsare made at securing preoperative diagnosis by magnetic resonanceimaging and myometrial biopsies. Definite treatment of symptomaticwomen is hysterectomy.     

Prevalence and risk factors of adenomyosis at hysterectomy.

BACKGROUND: The present study was performed to evaluate the prevalence and possible associated risk factors for adenomyosis. METHODS: Medical records were retrieved and histo-pathological material re-examined for 549 consecutive women undergoing hysterectomy in a two-year period from 1990-1991. RESULTS: The prevalence of adenomyosis in the study varied from 10.0-18.2%, depending on different diagnostic criteria. The presence of endometrial hyperplasia at the time of hysterectomy was the only variable significantly associated with adenomyosis (OR = 3.0; 95% CI: 1.2-8.3). No statistically significant association was found between adenomyosis and previous caesarean section, endometrial curettage or evacuation of the uterus. Furthermore, we did not see any significant association between adenomyosis and pain-related symptoms, indication for hysterectomy, age, parity or number of myometrial samples. CONCLUSIONS: Our study stresses the need for precise diagnostic criteria for adenomyosis, and furthermore indicates that endometrial hyperplasia and adenomyosis may have a common aetiology.     

Histologic findings in hysterectomies after endometrial ablation

BackgroundEndometrial ablation for abnormal uterine bleeding is used as a less invasive alternative to hysterectomy, however, in cases of treatment failure hysterectomy may be finally performed. The histologic changes in these post-treatment uteri are not well-described.ObjectiveTo describe the histological findings in post-endometrial ablation uteri.Study designDuring a ten-year period, 321 patients were treated with endometrial ablation. Twenty-five patients (7.8%), 10 treated with NovaSure® and 15 treated with ThermaChoice® endometrial ablation were finally subjected to hysterectomy mostly due to persistent uterine bleeding. Histologic features of these hysterectomies are described.ResultsThe patients’ age ranged from 33 to 73 years (mean 44.5) and 34–53 (mean 42) for the NovaSure® and ThermaChoice® group, respectively. The time from endometrial ablation to hysterectomy was 2–24 months (mean 8.8) and 2–60 months (mean 23.2) for the two groups, respectively (p = 0.01). Hysterectomies performed later (mean 22 months) showed no fibrosis (p = 0.04) compared with those performed earlier (mean 5 months). Endometrial lining was found more frequently in hysterectomies performed later (mean 13 months) than those performed earlier (mean 2 months, p = 0.0004). Abundant necrotic tissue of myometrial origin was found in 28% of the cases, but it was not associated with the time of hysterectomy (p = 0.2). A zonation effect and vascular changes also seen. Granulomatous reaction was not found. Ten patients (40%) harbored adenomyosis and another three (12%) extensive leiomyomas/diffuse leiomyomatosis.ConclusionNecrosis, fibrosis and vascular changes are found during the first year of post-thermal uterine effect. Hysterectomies performed later show less prominent changes and almost normal endometrial lining. Adenomyosis is found in an important part of post-endometrial ablation hysterectomies.     

Abnormal uterine bleeding: the importance of uterine cavity visualization

Abnormal uterine bleeding is a common gynaecological problem.It is usually due to local pathology such as uterine myoma,endometrial polyp, or to anovulatory bleeding. Occasionally,it is a manifestation of a systemic disease. In this issue ofHuman Reproduction Update, Livingstone and Fraser discuss themechanism of abnormal uterine bleeding. They correctly statethat there are many causes of abnormal uterine bleeding andthat its mechanism is complex. Abbott and Garry discuss the treatment of abnormal uterine bleeding.They imply that the success rate of medical treatment is inferiorto that of surgical treatment. One of the accepted surgicaltreatments is endometrial ablation. If the first generationendometrial ablation is done under hysteroscopic control, someof the second generation techniques including the balloon technique,microwave endometrial ablation and others are performed blindly.These are acceptable techniques, providing a hysteroscopic evaluationof the uterine cavity is incorporated. Anecdotally, myself andothers have encountered a suspicious lesion just prior to anendometrial ablation that turned out to be endometrial cancer.This underscores the importance of visualization of the endometrialcavity prior to endometrial ablation. Without hysteroscopy,it is also difficult to ascertain the completeness of the ablation.Hysteroscopy is a powerful and yet simple technique to perform.I recommend hysteroscopy examination before and after non-hysteroscopicendometrial ablation. Missed intact endometrium after ablationcan then be removed. This is in disagreement with some thatpromote ‘office endometrial ablation’ without anyvisualization of the uterine cavity. Performing the procedureblindly is equivalent to returning to the old era of missingendometrial lesions with blind curettage. Approximately 10–15% of women require another surgeryfollowing endometrial ablation. Women with uterine myoma oradenomyosis tend to be in the ablation-failure group. Here,either uterine artery embolization or hysterectomy can be offered.Because the underlying pathology is above the cervix, a laparoscopicsupracervical hysterectomy is a viable option. I hope that the papers contained in this issue will provokemore research on the subject and will assist readers in themanagement of women with abnormal uterine bleeding.     

Intrauterine light delivery for photodynamic therapy of the human endometrium

Photodynamic therapy is currently being evaluated as a minimallyinvasive procedure for endometrial ablation not requiring anaesthesia.Light penetration depths at 630, 660 and 690 nm and the optimalconfiguration of intrauterine light-diffusing fibres were determinedin 14 human uteri to assist in the design of a light intrauterinedevice. Post-menopausal ex-vivo uteri showed a significantlylower light penetration depth than pre-menopausal uteri. Witha single central diffusing fibre inserted, the fluence ratemeasured in the uterine wall at the most remote point of thecavity decreased to 1.1 ± 0.4% of that measured at closestproximity, whereas it decreased to only 40.0 ± 9.0% withthree fibres. Distension of the uterine cavity with 2 ml ofan optically clear fluid increased the fluence rate at the fundusbetween the fibres at a depth of 2 mm by a factor of 4. We concludethat in normal-sized pre-menopausal uterine cavities, threediffusing fibres will deliver an optical dose above the photodynamicthreshold level at a depth of 4 mm, even in the most remoteareas, in <30 min without causing thermal damage. For distortedand elongated cavities, either slight distension of the cavityor the insertion of a fourth diffusing fibre is required.     

Thermal balloon ablation versus endometrial resection for the treatment of abnormal uterine bleeding.

This study compares the clinical efficacy and safety of a thermal uterine balloon system with hysteroscopic endometrial resection in the treatment of dysfunctional uterine bleeding. In all, 147 women were treated by two experienced gynaecological surgeons: one performed 73 thermal balloon ablations and the other 74 endometrial resections between November 1994 and April 1998. The inclusion criteria were similar in both groups. The operative time was reduced significantly with the uterine balloon technique. There were no intra-operative complications in either group and postoperative morbidities were minimal and not statistically different. Multivariate analysis noted two prognostic factors associated with failures: retroverted uterus with thermal balloon ablation and age under 43 years with endometrial resection. The overall success rate did not differ significantly between the two groups 83.0 +/- 5% for balloon ablation and 76.3 +/- 6% for endometrial resection. Uterine balloon ablation appears to be as efficacious as endometrial resection. The former is much easier to perform, making the technique readily reproducible, especially by those with limited expertise in hysteroscopic surgery, and thus more widely applicable and safer.     

Functional characterization of somatic point mutations of the human estrogen receptor alpha (hERalpha) in adenomyosis uteri

Endometriosis and adenomyosis uteri are chronic, benign diseases caused by the presence of endometrial tissue in ectopic locations, e.g. peritoneal or deep inside the myometrial wall of the uterus and/or in the rectovaginal septum. Although adenomyosis might be considered as a special form of endometriosis, both conditions differ with respect to clinical symptoms and treatment. Induction of a hypo-estrogenic state alone or in combination with surgical removal of the extra-uterine lesion is mostly sufficient for treatment of peritoneal endometriosis. By contrast, adenomyosis uteri rarely responds to hormonal therapy and usually requires a hysterectomy for cure. Consequently, the role of steroid hormone receptors with respect to the aetiology of either condition is still a matter of discussion. Using PCR/single strand conformation polymorphism analysis, we identified somatic estrogen receptor (ER) alpha gene mutations in three out of 55 samples from adenomyosis uteri. Functional characterization revealed that two of the mutant ERalpha proteins display severely impaired DNA-binding and transactivation properties secondary to an altered response to estrogens or changes in epidermal growth factor-mediated ligand-independent activation. Although the exact mechanism remains unknown, we suggest that mutation-related silencing of estrogen responsiveness might render endometriotic cells resistant to hypo-estrogenic conditions thereby accounting for failure of estrogen-ablative therapy in adenomyosis.     

Uterine endometrial thermal balloon therapy for the treatment of menorrhagia: long-term multicentre follow-up study

BACKGROUND: Initial reports from observational and randomized trials of uterine endometrial thermal balloon therapy (UBT) suggested good results as judged by return to eumenorrhoea or less and patient satisfaction. Long-term follow-up data remained limited by the small numbers of patients and duration of follow-up. We present long-term (4-6 years) follow-up data from a cohort of women previously treated with UBT for menorrhagia. METHODS: Of the 260 questionnaires sent to women eligible for long-term follow-up from 10 centres, 188 (72%) replies were received. The primary outcome measure was avoidance of hysterectomy. RESULTS: In women who responded to the questionnaire, 25 had undergone hysterectomy and 21 had had repeat ablation. At 4-6 years after UBT, the probability of avoiding hysterectomy was 86% of all women, and of avoiding re-ablation was 88% of non-hysterectomized women. Overall, the probability of avoiding any surgery was 75%. Women with an axial or retroverted uterus were at greater risk of hysterectomy or re-ablation. Among the participants, 47% of the non-hysterectomized women were amenorrhoeic, 30% were hypomenorrhoeic, 13.6% were eumenorrhoeic and 8.5% had heavy periods. CONCLUSIONS: This is the first long-term follow-up report of a second-generation endometrial ablation procedure and confirms our initial experience. The high rate of hysterectomy avoidance over 5 years or more is very encouraging for this technology.     

Surgical and medical treatment of adenomyosis

The treatment of adenomyosis has been limited by the difficultyand delay associated with the diagnosis, often not until afterhysterectomy. Magnetic resonance imaging, high resolution vaginalultrasound and uterine biopsy have improved early detectionof adenomyosis. Drug therapy may be effective in controllingsymptoms but the frequent coexistence of endometriosis and thelack of controlled studies make their efficacy difficult toquantify. Conservative surgery involving endomyometrial ablation,laparoscopic myometrial electrocoagulation or excision has provento be effective in >50% of patients, although follow-up hasbeen restricted to 3 years. Hysterectomy will still be necessaryin severe cases of adenomyosis. Early diagnosis may improvetreatment. Investigations are indicated in women with menstrualpain or menorrhagia not responding to drug therapy.     

Current treatment of dysfunctional uterine bleeding

OBJECTIVES: We performed a review of the treatment modalities for dysfunctional uterine bleeding. METHODS: Dysfunctional uterine bleeding can be treated medically or surgically. Medical treatment consists of anti-fibrinolytic tranexamic acid, non-steroidal anti-inflammatory drugs, the combined contraception pill, progestogen, danazol, or analogues of gonadotrophin releasing hormone. The levonorgestrel releasing intra uterine device is developed for contraception, but is also effective in the treatment of dysfunctional uterine bleeding. Surgical treatment includes endometrial ablation of the first and second-generation, and hysterectomy. This review contains current available evidence on the effectiveness of these therapies. RESULTS: Antifibrinolytic tranexamic acid is the most effective medical therapy to treat dysfunctional uterine bleeding. In general medical therapy is not as effective as endometrial resection in terms of patient satisfaction and health related quality of life. The levonorgestrel releasing intra uterine device is an effective treatment for dysfunctional uterine bleeding. No difference in quality of life was observed in patients treated with a levonorgestrel releasing intra uterine device as compared to hysterectomy. Ablation techniques of the first generation are effective and safe when used by trained surgeons, but have a learning curve. Ablation techniques of the second generation are effective, but long-term follow-up data are not available. Similarly, there are no large randomised controlled trials comparing the levonorgestrel releasing intra uterine device to first and second-generation ablation techniques. Hysterectomy, the traditional standard of care, has a relatively high complication rate, but it generates a high satisfaction rate and good health related quality of life scores. CONCLUSION: Since none of the treatments for dysfunctional bleeding is superior to one of the others, and since all treatments have their advantages and disadvantages, counselling of patients with dysfunctional bleeding should incorporate medical approach, levonorgestrel releasing IUD, endometrial ablation and hysterectomy.     

Adenomyosis involved by endometrial adenocarcinoma is a significant risk factor for deep myometrial invasion

Adenomyosis is commonly seen in association with endometrial adenocarcinoma where it may or may not be involved by malignancy. This study of grade 1 endometrioid adenocarcinoma investigates whether patients with cancer-positive adenomyosis are at a different risk for deep myometrial invasion compared with those with cancer-negative adenomyosis. Ninety-three hysterectomy specimens with FIGO (International Federation of Gynecologists and Obstetricians) grade 1 endometrial endometrioid adenocarcinoma associated with adenomyosis were studied. Four experienced gynecologic pathologists retrospectively reviewed all hematoxylin and eosin-stained sections. Myometrial invasion was confirmed by CD10-negative staining around glands with jagged outline surrounded by inflamed desmoplastic stroma. Adenomyosis was involved by adenocarcinoma in 46 cases, whereas it was carcinoma-negative in 47 cases. Myometrial invasion was found in significantly more carcinoma-positive adenomyosis cases (n = 42, 91.3%) than with carcinoma-negative adenomyosis cases (n = 30, 63.8%) (chi(2) = 12.10; P = .0005). Moreover, myometrial invasion in the outer half was also seen in significantly more carcinoma-positive adenomyosis cases (n = 16, 34.8%) than with carcinoma-negative adenomyosis cases (n = 3, 6.4%) (chi(2) = 11.53; P = .0007). Among all cases of FIGO grade 1 endometrial endometrioid adenocarcinoma associated with adenomyosis, the ones that extend in the adenomyosis gain more invasive advantage, probably through increasing the surface area of its interface with the adjacent myometrium. When compared with tumors that do not involve adenomyosis, these tumors are not only more likely to invade the myometrium but are significantly more prone to achieve deep invasion into the outer half.     

Endometrial ablation to control excessive uterine bleeding

The use of surgical techniques is described for the management of dysfunctional uterine bleeding by endometrial ablation as alternatives to hysterectomy. Current approaches include the neodymium yttrium aluminium garnet (Nd:YAG) laser and resection by electrosurgery using a ball-end electrode. Of 484 patients treated since 1985, 361 (74%) became amenorrhoeic with only occasional spotting 68 (14%) reported satisfactory results with 55 (12%) reporting an unsatisfactory outcome.     

The effect of hysterectomy on serum CA 125 levels in patients with adenomyosis and uterine fibroids

The human endometrium has been reported to release CA 125 intissue culture, and elevated levels have been found in patientswith endometriosis and adenomyosis. The serum levels of CA 125were measured in 22 women undergoing hysterectomy for adenomyosis(n = 11) or fibroids (n = 11) of the uterus. In 20 patients(91%) the pre-operative CA 125 level was normal (<35 U/ml).All patients with adenomyosis had a normal pre-operative serumCA 125 concentration. Five weeks after the operation the CA125 levels did not differ from the pre-operative levels. Ourresults show that the uterine contribution to the serum CA 125level is minimal, and do not confirm the initial enthusiasmconcerning the possible use of levels as an aid in the diagnosisof adenomyosis.     

Modern surgical approaches to female reproductive tract

Laparoscopic and hysteroscopic surgery have changed the management of many gynaecological disorders. Procedures that previously required a long duration of hospitalization can now be done on an outpatient basis or with a short hospital stay. Surgical treatment remains the definitive and universal treatment of ectopic pregnancy and it can be safely done by laparoscopy. Most reproductive operations are done by laparoscopy and the results appear to be similar to those obtained with laparotomy. Those needing a laparotomy will be better treated by in-vitro fertilization. Laparoscopic ovarian drilling is a viable alternative for infertile women with polycystic ovarian syndrome. Most ovarian cysts and endometriosis should be treated by laparoscopy. Although uterine myomas can be removed by laparoscopy, the uterine integrity after the procedure is questionable. Surgery should be reserved for women who have completed their family or those with pedunculated or shallow intramural myomas. Alternatively, a laparoscopically assisted myomectomy can be done. For laparoscopic hysterectomies for benign lesions, supracervical hysterectomy appears to be a good option. Hysteroscopy has changed our management, particularly for abnormal uterine bleeding. A submucous myoma and polyp can be removed by hysteroscopy and, as an alternative to hysterectomy, endometrial ablation can be done. In the future, most procedures will be done by endoscopy and laparotomy will be reserved only for selected cases.     

A cost-utility analysis of hysterectomy, endometrial resection and ablation and medical therapy for menorrhagia

BACKGROUND: Four types of treatment [hysterectomy, endometrial resection/ablation, levonorgestrel-releasing intrauterine system (LNG-IUS) and oral medical therapy] are available for management of menorrhagia. The objective of this study was to compare the cost and quality-adjusted life-years (QALYs) gained by these four treatment alternatives. METHODS: A Markov model was designed to simulate the healthcare resource utilization and QALYs of the four treatment alternatives for patients presenting with menorrhagia over 5 years. Clinical inputs were estimated from literature, and the cost analysis was conducted from the perspective of healthcare provider in Hong Kong. RESULTS: The base-case analysis showed that the hysterectomy group was the most effective (4.725 QALYs) alternative with the highest cost (USD6878, 1USD=7.8HKD). The incremental cost per additional QALY (ICER) gained by hysterectomy was USD23 500. The probability of extra surgery in the endometrial resection/ablation was an influential factor. Probabalistic sensitivity analysis of 10,000 simulations of the Monte Carlo model showed that the hysterectomy group gained higher number of QALYs than the LNG-IUS, oral medical treatment and endometrial resection/ablation groups, 99, 99 and 98% of the time, and it was more costly than the other three groups over 85% of the time. CONCLUSIONS: Hysterectomy appears to be cost effective, with ICER less than USD50,000, for management of menorrhagia.     

Concomitant well-differentiated adenocarcinoma and leiomyosarcoma of the uterus

We describe a case of a concomitant well-differentiated endometrial endometrioid adenocarcinoma and leiomyosarcoma of the uterus in a 66-year-old woman who presented with a 6-month history of vaginal bleeding. The patient underwent total hysterectomy for endometrial carcinoma diagnosed by endometrial biopsy. Gross examination of the specimen revealed an endometrial mass bulging into the endometrial cavity and an underlying well-circumscribed nodule separated from the endometrial mass by a myometrial band. Frozen section performed at the time of the total hysterectomy rendered a diagnosis of malignant mixed-müllerian tumor. Histologic examination of the permanent sections revealed well-differentiated endometrial endometrioid adenocarcinoma clearly separated from a high-grade leiomyosarcoma. Differential diagnosis included malignant mixed-müllerian tumor. However, no admixture of carcinomatous and sarcomatous elements was present. There were no heterologous elements. To the best of our knowledge, no similar case has been described in the English literature.     

The effect of hysterectomy and endometrial ablation on follicle stimulating hormone (FSH) levels up to 1 year after surgery

Objectives: In this study the hypothesis was tested, that in premenopausal patients FSH-levels would rise after `simple hysterectomy'. As endometrial ablation is not supposed to compromise ovarian bloodflow, there would be no such change in ablated patients. Methods: Between January 1995 and April 1996, consecutive premenopausal patients with dysfunctional uterine bleeding who were scheduled for hysterectomy or endometrial ablation were asked to participate in the study. Bloodsamples were drawn before surgery, six weeks, six months and one year after surgery. FSH and oestradiol (E2) were assayed. In all patients data about length and weight were collected to calculate Body Mass Index (BMI). Every visit patients filled in a questionnaire, containing questions about typical climacteric complaints, combined in a five-point scale. Results: Except for a significant difference in preoperative FSH-level between both groups, there were no significant differences regarding age, Body Mass Index (BMI), oestradiol (E2) or the percentage of women with vasomotor complaints. Compared to the preoperative starting level, six weeks, six months and one year after surgery a significant rise in serum FSH in the hysterectomy group, as well as in the ablation group was found. However there was no significant difference in FSH increase between both groups. One third of the patients in both groups had typical climacteric complaints as flushing and nocturnal sweating. Conclusions: Assaying serum FSH-levels before and after uterine surgery and comparing hysterectomized patients and patients after endometrial ablation, we found a significant rise in FSH-level up to one year after surgery in both groups postoperatively, indicating impaired ovarian function. There was no difference in FSH-levels between both groups.Therefore major uterine surgery (hysterectomy, ablation) may prelude an earlier onset of menopause.     

Endometriosis: The relationship of endometriosis to endometrial sonographic studies prior to administration of human chorionic gonadotrophin in patients undergoing in-vitro fertilization and embryo transfer

The objective of this prospective comparative study was to investigatethe relationship of endometriosis to endometrial thickness andsonographic echo pattern prior to the administration of humanchorionic gonadotrophin (HCG). Patients were matched by ageand ovarian stimulation protocol. A total of 210 patients undergoingin-vitro fertilization (IVF) and embryo transfer at a university-relatedIVF centre were enlisted. Of these, 105 women with laparoscopicconfirmation of endometriosis were compared to an equal numberof patients with laparoscopic confirmation of no endometriosis.Mean endometrial thickness did not differ between the groups(12.7 ± 2.9 versus 12.2 ± 2.5 mm). The distributionof echo patterns was also the same, irrespective of diagnosis.Evaluation of clinical pregnancy rates showed no reduction inpatients with endometriosis, regardless of stage, nor when comparingpatients to controls. Endometriosis has no effect on the endometrialthickness or echo pattern measured by sonography prior to administrationof HCG or the pregnancy rates following IVF and embryo transfer.     

Uterine thermal balloon therapy under local anaesthesia for the treatment of menorrhagia: a pilot study

This study evaluates the use of local anaesthesia in a subset of patients undergoing uterine thermal balloon endometrial ablation for the treatment of menorrhagia. Out of 51 patients with dysfunctional uterine bleeding, 18 were included for uterine balloon therapy under local anaesthesia. Inclusion criteria were dysfunctional bleeding with absence of organic lesions in the uterine cavity, adequate relaxation and pain control during physical examination and diagnostic hysteroscopy, and patient desire to avoid a general anaesthetic. Paracervical block was performed with 20 ml of dilute 1% lignocaine HCl with epinephrine 1:200,000. Success of the procedure was defined as amenorrhoea, hypomenorrhoea, or eumenorrhoea. The median follow-up period was 13.9 +/- 5 months and 11 patients (61%) had follow-up of >1 year. Treatment led to a significant decrease in menstrual flow, duration, and pad count in all patients (P < 0.0001). No intra- operative complications occurred. A pain scale (level 1-10) was used to evaluate the patients' tolerance of the procedure (mean 3.8 +/- 1.3). In light of these successful and well tolerated procedures, thermal balloon endometrial ablation, utilizing local anaesthesia, appears practical as an office-based therapy.