Endometrial Ablation Techniques Bilgin GURATES, M.D.

Abnormal Uterine Bleeding

Causes of abnormal uterine bleeding

Current treatment options for abnormal uterine bleeding MEDICAL THERAPY Levonorgestrel intra-uterine system (LNGIUS), Non-steroidal anti-inflammatory drugs, Antifibrinolytic drugs, Progestogens, Oral contraceptives Danazol The levonorgestrel-releasing intrauterine system is more effective, and has been shown to be as effective as endometrial ablation. It could be argued that endometrial surgery is only appropriate for those women who are not suitable (i.e.polyps, fibroids) or for women who do not wish to have treatment with the intrauterine system. at best, oral medication reduces menstrual blood loss by only 50%

Current treatment options for abnormal uterine bleeding SURGICAL THERAPY ENDOMETRIAL RESECTION/ABLATION HYSTERECTOMY OTHER Myomecyomy Polypectomy ....................... The idea of destroying the endometrium and creating an iatrogenic ‘Asherman’s syndrome’ as a treatment for dysfunctional bleeding.

Inclusion and exclusion criteria for endometrial ablation

Endometrial Ablation Techniques First-generation endometrial ablation: hysteroscope Loop (Hallez in 1985) Roller-ball (DeCherney and Polan in 1983) Laser(Goldrath in 1981) Second-generation endometrial ablation: non-hysteroscopic Hot liquid balloons(Cavaterm, ThermaChoice, Menotreat) Microwave Hydro Therm Ablator(BEI, Enabl) Cryotherapy (Her Option, Soprano) Electrode: mesh – NovaSure Laser interstitial hyperthermy Photodynamic therapy

First-generation endometrial ablation: Loop Roller-ball Laser effective and safe alternatives to hysterectomy dysfunctional uterine bleeding reduction in menstrual blood loss dysmenorrhoea, correction of anaemia improvement in quality of life. lower morbidity, shorter hospitalisation and faster recovery, reduced treatment costs. As a result, the 1st generation ablation techniques are recognized as the ‘‘gold standard’’ ablation methods.

First-generation endometrial ablation: All these techniques are aimed at normalising menorrhagia, making periods lighter, shorter and less painful; amenorrhoea can not be achieved reliably by any ablation technique, and hysterectomy remains the only realistic option even now if this endpoint is desired.

Different strategies for endometrial preparations prior to first-generation ablation

Equipment for hysteroscopic endometrial ablation

Loop endometrial resection Advantages Provides endometrial tissue for histology Suitable if endometrium is thick Submucous fibroids or polyps can be excised at the same time Disadvantages The most skill dependent of the three techniques Greatest risk of uterine perforation Need to use electrolyte free distension media (with monopolar resectoscope)

Rollerball endometrial ablation Advantages Easier to learn and perform than resection Less risk of uterine perforation, fluid absorption and haemorrhage than endometrial resection Shorter operating time than laser ablation Disadvantages No endometrial specimen for histology Cannot treat submucous fibroids (unless using rollerbar or barrel) Use of monopolar energy which is less safe than bipolar Need to use non-physiologic distension media

Endometrial laser ablation Advantages Tissue coagulation to 5–6 mm Perforation less likely than resection Small fibroids or polyps can be vaporised Disadvantages Expensive capital and running costs Slowest of all the techniques Greater risk of fluid overload than with electrosurgery Need for special laser safety procedures and guidelines

COMPARATIVE STUDIES OF HYSTEROSCOPIC ENDOMETRIAL ABLATION fluid overload uterine perforation amenorrhoea failure rate subsequently undergoing hysterectomy satisfaction rates repeat ablation Laser ablation 5.1% 0.65% 56% 7%, 5% 93% 11% Loop resection 1.5% 2.47% 48% 6-30% 9% 70 to 94% 6% Roller-ball ablation 1.2% 2.1% 46% 10% 5.5% 90% 16.4% The most important determinant of the success and safety of hysteroscopic methods of endometrial ablation is not the technique per se but the experience of the operator.

Second-generation endometrial ablation: Hot liquid balloons(Cavaterm, ThermaChoice, Menotreat) Microwave Hydro Therm Ablator(BEI, Enabl) Cryotherapy (Her Option, Soprano) Electrode: mesh – NovaSure Laser interstitial hyperthermy (ELITT Gynelase) Photodynamic therapy

Hot liquid balloons The advantages of the ThermaChoice balloon device include portability, ease of use, and short learning curve. The small-diameter catheter requires minimal cervical dilatation (5 mm) and allows treatment under minimal analgesia/anesthesia requirements, including no local anesthesia or IV sedation.

The HydroThermAblator Disadvantages of the HTA system include cervical dilatation to 8mm, the requirement for pretreatment, reduced portability, the need for hysteroscopic equipment and potential thermal burns.

Microwave endometrial ablation The system consists of an 8-mm diameter reusable probe which is inserted into the uterus. Microwaves are short high-frequency radio waves. They are part of the electromagnetic spectrum with a wavelength of 0.3–30 cm and a frequency of 300– 300 000 MHz.

Novasure The Novasure endometrial ablation system consists of a single-use device and a radiofrequency controller. It is a three-dimensional, triangular-shaped bipolar ablation device. cerival dilatation to 7.5 mm

Endometrial cryoablation The Her Option In-Office Cryoablation Therapy system is ideal for in-office procedures. The unique analgesic properties of cryotherapy, small-diameter probe size, and the ease of use make it appropriate for use in an office setting. This cryosurgical system is compressor driven and uses a new mixed gas coolant to generate temperatures of –90° to –100°C.

THIRD-GENERATION ENDOMETRIAL ABLATION TECHNOLOGIES The idea of injecting a gel or solution via a small-diameter catheter, to destroy the endometrium globally in an office setting, using no analgesia, is so attractive that several such agents are currently undergoing feasibility and safety evaluation.

THANK YOU