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IN THE NAME OF GODEndometrial AblationDr Safoura Rouholamin

AUBAUB affects up to 50 percent of premenopausal womenHeavy menstrual bleeding is a common problem. one in 20 women of reproductive age consults her practitionerIn the past, by the age of 55 one in five women had had a hysterectomy

Hysterectomy is second only to cesarean section among surgical interventions in women of fertile age

In fact, 90% of hystrectomies are performed in cases of abnormal uterine bleeding

Treatments for heavy menstrual bleedingMedical: tranexamic acid mefenamic acid combined OCPprogestin agentGnRh agonistsMirena (The levonorgestrel IUD)

Treatments for heavy menstrual bleedingSurgical:

Endometrial Ablationhysterectomy

Endometrial Ablation

Resectoscopic techniquesNon-Resectoscopic techniques

Resectoscopic techniquesResectoscopic techniques are performed under hysteroscopic visualization, using resectoscopic instruments to ablate or resect the endometriumIn current practice, non-resectoscopic endometrial ablation is performed in most cases. resectoscopic ablation: shape or size of the uterine cavity will not accommodate a non-resectoscopic device or if the patient has had multiple cesarean deliveries, to avoid ablating over the hysterotomy scarThere are currently four techniques(1) endometrial dessication with an electrosurgical rollerball or rollerbarrel (2) resection with a monopolar or bipolar loop electrode (3) radiofrequency vaporization(4) laser vaporization

Hysteroscopy: Resectoscopic instrumentsAll methods dessicate the endometrium to the level of the basalis. The rollerball and rollerbarrel use thermal energy for heating the tissue to a temperature between 60 to 90C, which dessicates and destroys the tissue. No tissue is removed. Thermal energy is also used with the monopolar and bipolar loop electrodes. loop electrodes also resect the endometrium beyond the basalis layer to the myometrium. The resected tissue is sent to pathology for histologic diagnosis..

The vaporizing electrodes and laser fibers use high energy to rapidly heat the intracellular water to 100C, causing vaporization of tissue. No tissue is removed.Rollerball endometrial ablation is the most commonly used resectoscopic ablation method. Wire loop endomyometrial resection requires advanced hysteroscopic skills because of the risk of perforation, bleeding, and fluid absorption. Laser and vaporizing electrode ablation are not commonly performed due to expense of the equipment these methods requirestart the desiccation at the cornua and then move to the anterior fundal wall due to bubble formation in the uterine cavity. Complete the ablation on the posterior wall since the bubbles formed will be anterior. Activate the current and bring the rollerball towards the surgeon.Avoid dessication of the cervico-uterine junction since this may result in cervical stenosis or uterine occlusion.Most women with successful endometrial ablation will have a reduction in uterine blood flow, but not amenorrheaPATIENT SELECTION

The primary indication :treatment of ovulatory menorrhagia in premenopausal womenAblation is usually used to treat women with chronic menorrhagia. It may also be used for acute abnormal uterine bleeding in hemodynamically stable women in whom medical therapy is contraindicated or unsuccessfulEndometrial ablation is not indicated for women who wish to be amenorrheic for nonmedical reasonsThe endometrium must be destroyed or resected to the level of the basalis, which is approximately 4 to 6 mm deep, depending upon the stage of the menstrual cycleLayers of the endometrium: Late proliferative phase of menstrual cycle

endometrial sampling should be performed in all women prior to undergoing endometrial ablationContraindicationsContraindications:PregnancyKnown or suspected endometrial hyperplasia or cancerDesire to preserve fertilityActive pelvic infectionIntrauterine device (IUD) in placePrevious transmyometrial uterine surgeryrelatively contraindicationpostmenopausalcongenital uterine anomalies (bicornuate uterus)uterine cavity length that is greater than 10 to 12 cmsevere myometrial thinningEndometrial ablation in women with thinning of the myometrium may result in injury to the adjacent viscera (bladder, bowel) if the energy used for ablation passes through the uterine tissue

Zarek S, Sharp HTGlobal. endometrial ablation devices. Clin Obstet Gynecol. 2008;51(1):167.There are no data to establish the minimum myometrial thickness required to prevent such complications.There is no evidence that prior cesarean delivery increases the risk of complications associated with endometrial ablation

Gangadharan A, Revel A, Shushan AEndometrial thermal balloon ablation in women with previous cesarean delivery: pilot study. J Minim Invasive Gynecol. 2010 May;17(3):358-60.

Risk factors for endometrial cancerMany of the reports of endometrial cancer after endometrial ablation have been in women with chronic anovulationand/orendometrial hyperplasia Women with these conditions are also often obese or have diabetesand/orhypertension and thus may have contraindications to some medical therapies (eg, steroid hormones, antifibrinolytics) and be at increased risk of complications if they undergo major surgery.

We suggest that progestin supplementation be offered to prevent hyperplasia until ovulation is reestablished or menopause occurs in the presence of chronic anovulatory states.Correction of anovulation is the optimal approach to treatment for these women. In women in whom this is not possible, other treatment options (eg, progestins) may be preferable to endometrial ablation.

tamoxifenWe suggestnotperforming endometrial ablation in women who are taking tamoxifen. Such women are at an increased risk of endometrial cancer, and ablation may interfere with the later diagnosis of this disorder.

Capuano I, Caporale A, Vagnetti P, Di Domenico A, Felicetti M, Torella M, Borrelli AL.[Endometrial ablation versus hysterectomy in women treated with tamoxifen]. Minerva Ginecol. 2007;59(5):499.Lynch syndrome (hereditary nonpolyposis colorectal cancer) are at a markedly increased risk of endometrial cancer and are advised to undergo hysterectomy after they have completed childbearing.Abnormal uterine bleeding in this population should not be treated with endometrial ablation.Leiomyomas or polypsEndometrial ablation in women with intracavitary (submucosal or intramural myomas that protrude into the uterine cavity) fibroids is controversial.Comparative data show that non-resectoscopic devices are less effective in women with intracavitary fibroids than in those with a normal uterine cavityGlasser MH, Zimmerman JD.The HydroThermAblator system for management of menorrhagia in women with submucous myomas: 12- to 20-month follow-up. J Am Assoc Gynecol Laparosc. 2003;10(4):521.AdenomyosisAdenomyosis (uterine adenomyomatosis) is not a contraindication to endometrial ablation, although women with this condition may have a lower treatment success rate.

El-Nashar SA, Hopkins MR, Creedon DJ, St Sauver JL, Weaver AL, McGree ME, Cliby WA, Famuyide AO.Prediction of treatment outcomes after global endometrial ablationObstet Gynecol. 2009;113(1):97.ParityNulliparity is not a contraindication to endometrial ablation. Grand multiparity appears to be a risk factor for treatment failure.In the retrospective study of 816 women described in the preceding paragraph, women with a parity of 5 compared to 2 cm were excluded from the FDA approval studiesNo irregularly shaped cavitiesOutcomefive or more years reduced uterine bleeding (97 to 98 percent) amenorrhea (75 to 97 percent) low rates of repeat ablation (1 to 4 percent) hysterectomy (3 to 8 percent)

Novasure ablation does not require endometrial preparation

Microwave Endometrial Ablation (MEA)9.2 GHz, 30 watt, microwave systemthis energy will produce a tissue temperature of 75 to 85C at a depth of 6 mm.the surgeon moves the probe from cornu to cornu and across the lower uterine segment until the entire endometrium has reached the desired temperature. Total treatment time is three to five minutes the probe is reusable.hysteroscopic evaluation before and after ablation, in contrast with other non-resectoscopic ablation devices.Uterine requirementsDiameter of device 8.5 mmSounded cavity length 6 to 12 cm is advised by the manufacturer, although the device was studied in women with a cavity length of up to 14 cmWomen with submucosal leiomyomas that do not obstruct treatment access were included in the studies for FDA approval

Microwave endometrial ablation

OutcomeA randomized trial compared MEA with endometrial resection in 263 women Excessive intraoperative bleeding occurred in five women in the resection group and none in the MEA groupIn women followed for 10 or more years, those treated with MEA compared with resection had similar rates of amenorrhea (83 and 88 percent). The rate of repeat ablation was similar in women treated with MEA compared with resection (1 versus 2 percent)however, the hysterectomy rate differed significantly (17 versus 28 percent).

The manufacturer of MEA advises extra precautions that are not advised for the other non-resectoscopic devices:

including preoperative measurement of the thickness of the myometrium (, the FDA trial required that ultrasound be performed prior to the procedure and that the myometrium be at least 1 cm in thickness in all areas) pre- and postoperative hysteroscopy

Hot liquid filled balloonsThermaChoice (FDA-approved )Cavaterm Thermablate EAS are available only outside the United Statessilicon balloon ,inserted through the cervix into the uterine cavity via a probe The balloon is expanded to a pressure of 160 to 220 mmHg with either 5 percent dextrose in water (ThermaChoice), glycine (Cavaterm), or glycerine (Thermablate EAS). For ThermaChoice and Cavaterm, the fluid is heated to approximately 68 to 87C and ablation requires 8 to 10 minutes. Thermablate uses a higher temperature (173C) and has shorter ablation time (two minutes) thermachoice

Cryoablationliquid nitrogen or by differential gas exchangeAn elliptical ice ball approximately 3.5 by 5 centimeters forms around the probe when it is cooled to less than -90C. At the edge of the ice ball, the tissue temperature is 0C, which is nondestructive. A temperature of 20C is lethal to tissue; this temperature is reached approximately 3 to 5 mm from the edge of the ice ball. Therefore, the endometrial tissue exposed to this low temperature, including the basalis layer of the endometrium is permanently destroyed.

The number of ice balls that must be created to destroy the entire uterine cavity is dependent upon the size of the cavity. Intraoperative ultrasonography is used to monitor probe placement and depth of tissue freezing. (two to three ice balls are sufficient )Each freeze cycle takes two to six minutesUterine requirementsUterine parameters for Her Option ablation are:Diameter of device 5.5 mmSounded cavity length 4 to 10 cmWomen with intramural leiomyomas 2 cm in diameter were included in the FDA approval studies; women with pedunculated fibroids or endometrial polyps were excludedEndometrial cryoablation

Circulating hot water (hydrothermal)which a hysteroscope sheath is inserted into the uterine cavity under direct hysteroscopic visualization Heated isotonic saline is administered into the uterus through the sheath. To maintain a low uterine distension pressure (