1. Endometrial Ablation Techniques
Bilgin GURATES, M.D.

2. Abnormal Uterine Bleeding

3. Causes of abnormal uterine bleeding

4. 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%

5. 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.

6. Inclusion and exclusion criteria for endometrial ablation

7. 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

8. 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.

9. 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.

10. Different strategies for endometrial preparations prior to first-generation ablation

11. Equipment for hysteroscopic endometrial ablation

12. 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)

14. 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

15. 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

16. 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.

17. 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

18. 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.

19. 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.

20. 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– MHz.

21. 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

22. 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.

23. 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.

24. THANK YOU