HYSTEROSCOPY TREATMENT of ABNORMAL UTERINE BLEEDING

1. HYSTEROSCOPYTREATMENT ofABNORMAL UTERINEBLEEDING

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

3. Non Surgical TreatmentAbnormal Uterine Bleeding 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)

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

5. Loop Resection

7. Smith & NephewRotary Extractor

8. Hysteroscopic TreatmentNo Future Pregnacy Endometrial Ablation Destruction of Endometrium freeze, fry, roast, boil, broil, vaporize

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

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

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

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

13. COMPLICATIONS Perforation Distention media related Mechanical or energy injury to bowel or bladder Bleeding Infection Anesthesthetic 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 Spinal – allows monitoring sensorium with respect to hyponatremia General or deep conscious sedation with paracervical block

15. Vasopressin in Paracervical Block Less force (about ½) needed for dilation Less fluid absorbed (about 1/3) Ed’s solution= 5U (1/4 ml) vasopressin in 30ml 1% chloroprocaine or lidocaine (+3ml NaCO3). Inject 6-10ml ea. side WAIT – more than 5 min (by the clock) if procedure being done by local anesth.

16. Alternative “ParacervicalBlock”

17. Resectoscopic AblationRoller “Ball”/Wire Loop • Advantages • Readily available standard equipment • Inexpensive materials • Highest success rates* • Disadvantages • Skill development • Usually at surgery center or hospital setting

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

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

20. Ablation TechniqueRoast -”Rollerball”- 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 Apply current only when certain of ball/loop location

21. Hydro Thermal AblationBoil - (hot water)

22. Bipolar CauteryRoast - “Novasure”

23. CryoablationFreeze - “Her Option”