1. HYSTEROSCOPY TREATMENT of ABNORMAL UTERINE BLEEDING

2. Diagnostic Considerations Irregular bleeding : usually annovulatory, hormones often successful (?) Irregular bleeding : usually annovulatory, hormones often successful (?) Heavy periods-menorrhagia: often fibroids or polyps Heavy periods-menorrhagia: often fibroids or polyps Always sample endometrium prior to ablation Always sample endometrium prior to ablation

3. Non Surgical Treatment Abnormal Uterine Bleeding Levonorgestrel Intra Uterine Device – Same success rate (70%) as ablation at 3 years (27% surgery) Levonorgestrel Intra Uterine Device – Same success rate (70%) as ablation at 3 years (27% surgery) Hormonal Therapy – Only 10% success at 3 years (77% surgery) Hormonal Therapy – Only 10% success at 3 years (77% surgery)

4. Hysteroscopic Treatment AUB Future pregnancy desired Future pregnancy desired Resect fibroids or polypsResect fibroids or polyps

5. Loop Resection

7. Smith & Nephew Rotary Extractor

8. Hysteroscopic Treatment No Future Pregnacy Endometrial Ablation Destruction of Endometrium freeze, fry, roast, boil, broil, vaporize freeze, fry, roast, boil, broil, vaporize

9. Indications for Ablation Does not want more children and will use future contraception Does not want more children and will use future contraception Patient perceived heavy bleeding Patient perceived heavy bleeding Not required, but usually failed medical treatment Not required, but usually failed medical treatment

10. Pre-Op Laboratory Studies Electrolytes if patient on diuretics or cardiac meds Electrolytes if patient on diuretics or cardiac meds Complete blood count Complete blood count Coag. Panel if history of bleeding tendencies Coag. Panel if history of bleeding tendencies Document normal Pap smear and normal endometrial sample within 6 months Document normal Pap smear and normal endometrial sample within 6 months

11. Pre-Op Considerations Misoprostol 200mcg intravaginal or laminaria night before Misoprostol 200mcg intravaginal or laminaria night before Antibiotics (?) e.g. doxycyclene 100mg twice daily x 3d Antibiotics (?) e.g. doxycyclene 100mg twice daily x 3d

12. Pre-Op Preparation GnRh agonist (Lupron,etc.) GnRh agonist (Lupron,etc.) Induce amenorrhea to treat anemia if presentInduce amenorrhea to treat anemia if present Suction currettage or do immediately after period Suction currettage or do immediately after period Purpose – decrease endometrial thickness & more uniform cavity for deeper destructionPurpose – decrease endometrial thickness & more uniform cavity for deeper destruction Ablation is technically easierAblation is technically easier

13. COMPLICATIONS Perforation Perforation Distention media related Distention media related Mechanical or energy injury to bowel or bladder Mechanical or energy injury to bowel or bladder Bleeding Bleeding Infection Infection Anesthesthetic Anesthesthetic Spread endometrial cancer Spread endometrial cancer

14. Therapeutic Hysteroscopy Anesthesia Local - Paracervical block plus fentanyl 100 mcg IV or ibuprofen 600 mg with diazepam 5mg po 1hr before Local - Paracervical block plus fentanyl 100 mcg IV or ibuprofen 600 mg with diazepam 5mg po 1hr before Spinal – allows monitoring sensorium with respect to hyponatremia Spinal – allows monitoring sensorium with respect to hyponatremia General or deep conscious sedation with paracervical block General or deep conscious sedation with paracervical block

15. Vasopressin in Paracervical Block Less force (about ½) needed for dilation Less force (about ½) needed for dilation Less fluid absorbed (about 1/3) Less fluid absorbed (about 1/3) Ed’s solution= 5U (1/4 ml) vasopressin in 30ml 1% chloroprocaine or lidocaine (+3ml NaCO 3 ). Inject 6-10ml ea. side Ed’s solution= 5U (1/4 ml) vasopressin in 30ml 1% chloroprocaine or lidocaine (+3ml NaCO 3 ). Inject 6-10ml ea. side WAIT – more than 5 min (by the clock) if procedure being done by local anesth. WAIT – more than 5 min (by the clock) if procedure being done by local anesth.

16. Alternative “Paracervical Block”

17. Resectoscopic Ablation Roller “Ball”/Wire Loop Advantages Advantages Readily available standard equipmentReadily available standard equipment Inexpensive materialsInexpensive materials Highest success rates*Highest success rates* Disadvantages Disadvantages Skill developmentSkill development Usually at surgery center or hospital settingUsually at surgery center or hospital setting

18. Operating Room Setup Resection At least 18 liters mannitol, sorbitol or glycine available if fibroids present At least 18 liters mannitol, sorbitol or glycine available if fibroids present Hysteroscopy pouch to suction or graduated bucket Hysteroscopy pouch to suction or graduated bucket 1 Person assigned to calculate intake & output every 5 min (timer) 1 Person assigned to calculate intake & output every 5 min (timer) Vasopressin available for paracervical block Vasopressin available for paracervical block

19. Equipment Resection/Ablation Resectoscope: 27 or 24 Fr. dual channel (or else over dilate cervix) Resectoscope: 27 or 24 Fr. dual channel (or else over dilate cervix) Extra wire loops & grooved rollerbarrels Extra wire loops & grooved rollerbarrels Extra connecting wire Extra connecting wire Electrosurgical unit: 100-200 watt cutting & 90–120 watt coag. Electrosurgical unit: 100-200 watt cutting & 90–120 watt coag.

20. Ablation Technique Roast -”Rollerball”- Start at 140 watts cut &/or 100 watts coag. current (setting will vary on make of equipt. & size/type roller ball) Start at 140 watts cut &/or 100 watts coag. current (setting will vary on make of equipt. & size/type roller ball) Always keep the ball/loop in motion, slowly, towards you Always keep the ball/loop in motion, slowly, towards you Apply current only when certain of ball/loop location Apply current only when certain of ball/loop location

21. Hydro Thermal Ablation Boil - (hot water)

22. Bipolar Cautery Roast - “Novasure”

23. Cryoablation Freeze - “Her Option”