Endometrial Ablation Techniques

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

2. AbnormalUterineBleeding

3. Causes of abnormal uterine bleeding

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

5. Current treatment options for abnormaluterine 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. EndometrialAblationTechniques • First-generation endometrial ablation:hysteroscope • Loop (Hallez in 1985) • Roller-ball (DeCherneyand Polan in 1983) • Laser(Goldrath in 1981) • Second-generation endometrialablation: non-hysteroscopic • Hot liquid balloons(Cavaterm, ThermaChoice, Menotreat) • Microwave • Hydro ThermAblator(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 • reductionin menstrual blood loss • dysmenorrhoea, • correction of anaemia • improvement inquality of life. • lower morbidity, • shorter hospitalisation and faster recovery, • reduced treatment costs. • As a result, the 1stgeneration ablation techniques are recognized as the ‘‘gold standard’’ ablation methods.

9. First-generation endometrial ablation: • All these techniques are aimed at • normalisingmenorrhagia, • making periods lighter, • shorter and • less painful; • amenorrhoeacan not be achieved reliably by any ablationtechnique, and • hysterectomy remains the only realistic option even now if this endpointis 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 monopolarresectoscope)

14. Rollerball endometrial ablation • Advantages • Easier to learn and perform than resection • Less risk of uterine perforation, fluid absorption and haemorrhage than endometrialresection • 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 HYSTEROSCOPICENDOMETRIAL ABLATION 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 endometrialablation: • Hot liquid balloons(Cavaterm, ThermaChoice, Menotreat) • Microwave • Hydro ThermAblator(BEI, Enabl) • Cryotherapy (Her Option, Soprano) • Electrode: mesh – NovaSure • Laser interstitial hyperthermy (ELITTGynelase) • Photodynamic therapy

18. Hot liquid balloons • The advantages of theThermaChoiceballoon deviceinclude portability, ease of use, and short learning curve. • The small-diameter catheter requires minimal cervicaldilatation (5 mm) and allows treatment under minimalanalgesia/anesthesia requirements, including no localanesthesia or IV sedation.

19. The HydroThermAblator • Disadvantages of the HTA system include cervicaldilatation to 8mm, the requirement for pretreatment,reduced portability, the need for hysteroscopicequipmentand potential thermal burns.

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

21. Novasure • The Novasure endometrial ablation system consists of a single-use device and a radiofrequencycontroller. • It is a three-dimensional, triangular-shaped bipolarablation device. • cerival dilatation to 7.5 mm

22. Endometrial cryoablation • The Her Option In-Office Cryoablation Therapy systemis ideal for in-office procedures. The unique analgesicproperties of cryotherapy, small-diameter probe size, andthe ease of use make it appropriate for use in an officesetting. • This cryosurgical systemis compressor driven anduses a new mixed gas coolant to generate temperatures of–90° to –100°C.

23. THIRD-GENERATION ENDOMETRIALABLATION TECHNOLOGIES • The idea of injecting a gel or solution via a small-diametercatheter, to destroy the endometrium globally in an officesetting, using no analgesia, is so attractive that several suchagents are currently undergoing feasibility and safetyevaluation.

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