Endometrial hydrothermablation: A comparison of short-term clinical effectiveness in patients with normal endometrial cavities and those with intracavitary pathology

Classification of menstrual bleeding disorders

There exists a spectrum of potential causes of abnormal uterine bleeding (AUB) in nonpregnant reproductive-aged women. In some instances the abnormal bleeding may emanate from definable pathologic entities in the endometrial cavity such as polyps or submucous leiomyomas (fibroids), while in others, it may occur secondary to coagulopathies or disorders of local or systemic hemostasis. If the patient is subjected to a rigorous evaluation more than one potential contributor may be identified, a circumstance that challenges the clinician since entities such as polyps, leiomyomas, and adenomyosis may frequently be asymptomatic, even in women with AUB. The bench or clinical investigator may also be influenced by the existence of the multiplicity of potential causes that could confound the results of research. This paper describes FIGO's (Fédération Internationale de Gynécologie et d'Obstétrique) new PALM-COEIN classification of causes of AUB in the reproductive years (Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia-Coagulopathy, Ovulatory disorder, Endometrial, Iatrogenic, Not yet classified). This system is designed to assist clinicians in the evaluation of patients, investigators in the design and interpretation of research and faculty in the education of medical students and residents/trainees. Additionally, given the longstanding existence of a confusing array of conflicting definitions, the manuscript describes the FIGO standardized terminology for both normal menstruation and AUB symptoms.

AAGL practice report: practice guidelines for the diagnosis and management of submucous leiomyomas

Submucous leiomyomas or myomas are commonly encountered by gynecologists and specialists in reproductive endocrinology and infertility with patients presenting with 1 or a combination of symptoms that include heavy menstrual bleeding, infertility, and recurrent pregnancy loss. There exists a variety of interventions that include those performed under hysteroscopic, laparoscopic and laparotomic direction; an evolving spectrum of image guided procedures, and an expanding number of pharmaceutical agents, each of which has value for the appropriately selected and counseled patient. Identification of the ideal approach requires the clinician to be intimately familiar with a given patient's history, including her desires with respect to fertility, as well as an appropriately detailed evaluation of the uterus with any one or a combination of a number of imaging techniques, including hysteroscopy. This guideline has been developed following a systematic review of the evidence, to provide guidance to the clinician caring for such patients, and to assist the clinical investigator in determining potential areas of research. Where high level evidence was lacking, but where a majority of opinion or consensus could be reached, the guideline development committee provided consensus recommendations as well.

Developing minimally invasive surgery centers within kaiser permanente: the integrated multidisciplinary experience of los angeles

Minimally invasive surgical therapies are growing in type and volume of interventions. As one of the largest health delivery organizations in the US, Kaiser Permanente staff must be aware that the proliferation of these technologies has occurred in parallel within many surgical specialties, with a large variation in level of implementation between different regions and even within regions. In Los Angeles, we have developed the Minimally Invasive Surgery Center, encompassing a multidisciplinary, integrated approach. It unites the effort and expertise of many outstanding practitioners within the organization and consolidates the achievements of many surgical specialties. It also brings together the elements needed to provide the highest level of care to our patients in a safe, efficient, cost-effective environment, with minimal morbidity and best long-term outcome.

Does hydrothermal ablation avoid hysterectomy? Long-term follow-up

OBJECTIVE

We sought to assess the long-term success rate of the HydroThermAblator system (HTA).

STUDY DESIGN

We conducted a retrospective cohort study of 376 patients who underwent HTA at our hospital during an 8-year period, following case note review and distribution of a validated menorrhagia questionnaire.

RESULTS

The mean age of patients was 43 years. Operative complications included 3 women (0.8%) who experienced intraoperative burns. Of the 248 (66%) returned questionnaires, satisfaction rates were high at 77%. The amenorrhea rate was 38%, with a further 37% of women reporting a substantial decrease in their blood loss. In all, 29 (11%) women underwent subsequent hysterectomy for persistent menorrhagia or dysmenorrhea. Younger women had a significantly higher chance of proceeding to subsequent (P < .05) hysterectomy.

CONCLUSION

This study confirms the long-term patient satisfaction with HTA and that the overall probability of proceeding to subsequent hysterectomy over 8 years was only 11%.

The effectiveness of endometrial ablation with the Hydro ThermAblator (HTA) for abnormal uterine bleeding

OBJECTIVE

We sought to determine the overall effectiveness and risk factors for failure of hydrothermal ablation in the management of abnormal uterine bleeding.

STUDY DESIGN

We performed a retrospective cohort analysis of patients who underwent hydrothermal ablation for abnormal uterine bleeding at our institution from July 2005 through February 2008. Variables analyzed included patient demographics, insurance status, body mass index, bleeding pattern, obstetric history, prior medical therapy and duration, uterine characteristics, and tobacco use history.

RESULTS

In all, 159 patients were identified and 142 charts were eligible for evaluation. A total of 45 patients (31.6%) had return of preablation vaginal bleeding. Menometrorrhagia was a significant predictor for failure (P = .027) and subsequent hysterectomy (P = .0025). Younger age (P = .044), tobacco use (P = .042), and Medicaid/Medicare insurance status (P = .039) were also associated with a higher risk of failure.

CONCLUSION

Women who are younger, use tobacco products, and have menometrorrhagia are more likely to fail hydrothermal ablation.

Abnormal uterine bleeding: a review of patient-based outcome measures

OBJECTIVE

To summarize and evaluate the patient-based outcome measures (PBOMs) that have been used to study women with abnormal uterine bleeding (AUB).

DESIGN

Systematic review.

SETTING

Original articles that used at least one PBOM and were conducted within a population of women with AUB.

PATIENT(S)

Women with AUB.

INTERVENTION(S)

The titles, abstracts, and studies were systematically reviewed for eligibility. The PBOMs used in eligible studies were summarized. Essential psychometric properties were identified, and a list of criteria for each property was generated.

MAIN OUTCOME MEASURE(S)

"Quality" of individual PBOMs as determined using the listed criteria for psychometric properties.

RESULT(S)

Nine hundred eighty-three studies referenced AUB and patient-reported outcomes. Of these, 80 studies met the eligibility criteria. Fifty different instruments were used to evaluate amount of bleeding, bleeding-related symptoms, or menstrual bleeding-specific quality of life. The quality of each of these instruments was evaluated on eight psychometric properties. The majority of instruments had no documentation of reliability, precision, or feasibility. There was no satisfactory evidence that any one instrument completely addressed all eight psychometric properties.

CONCLUSION(S)

Studies of women with AUB are increasingly using PBOMs. Many different PBOMs were used; however, no single instrument completely addressed eight important measurement properties.

Second-generation endometrial ablation – an overview

Various methods exist to destroy the endometrium as a treatment for menorrhagia. This chapter discusses the rationale, evidence, indications, and long-term safety and efficacy of the current techniques. It also discusses endometrial ablation in the context of its clinical utility in comparison with the existing alternative treatments.

Management of Heavy Menstrual Bleeding: Is Hysterectomy the Radical Mastectomy of Gynecology?

Both hysterectomy for heavy menstrual bleeding and radical mastectomy for breast cancer are steeped in the history of surgery and have recently been challenged as being too radical for the disorder at hand. Radical mastectomy has largely been replaced with local removal of the tumor with subsequent radiation and/or chemotherapy. Alternatives to hysterectomy include a number of medical interventions, most notably intrauterine progestin-releasing systems, and endometrial ablation, a procedure that has a relatively high success rate and one that is now feasible for many women in an office or procedure room setting. However, although radical mastectomy rates have dropped precipitously, hysterectomy rates, at least in the United States remain relatively stable. Determining the proportion of hysterectomies that are done for heavy menstrual bleeding is difficult, largely because of coding issues, so it is difficult to measure the impact of new medical and minimally invasive surgical procedures. Nevertheless, it seems clear that many women are not exposed to the plethora of options to hysterectomy, a fact that may reflect a number of issues that may include training, skill, and financial incentives or disincentives. Clearly, options to hysterectomy are not a panacea, but if women are empowered to select from all of the options available, the rate of hysterectomy for bleeding should decrease while maintaining, or even enhancing the patient's satisfaction with care.

The Hydro ThermAblator

The Hydro ThermAblator system is a unique approach to endometrial ablation, employing constant direct visual control via hysteroscopy combined with a 'no-touch' gravity flow of heated saline that treats the entire endometrial surface regardless of its topography. The automated controller helps to ensure reproducible results without the necessity for high operator skill. The system employs a safety feature that monitors the fluid level constantly within a closed system, so that loss of fluid through unsuspected uterine perforation occurring during dilatation can be diagnosed even though it may not be visually apparent to the operator. Results as judged by patient satisfaction, amenorrhoea rates and/or return to normal menstrual flow are excellent.

A systematic review evaluating health-related quality of life, work impairment, and health-care costs and utilization in abnormal uterine bleeding

OBJECTIVES

Abnormal uterine bleeding (AUB) impacts women's health-related quality of life (HRQoL) and puts a heavy economic burden on society. To date, this burden has not been systematically studied. We conducted a systematic review of the medical literature to evaluate the impact of AUB on HRQoL and to quantify the economic burden of AUB from a societal perspective.

METHODS

We searched the PubMed and Cochrane databases, and article bibliographies for the period up to July 2005. Teams of two reviewers independently abstracted data from studies that reported outcomes of interest: prevalence, HRQoL, work impairment, and health-care utilization and costs associated with AUB.

RESULTS

The search yielded 1009 English-language articles. Ninety-eight studies (including randomized controlled trials, observational studies, and reviews) that met the inclusion and exclusion criteria underwent a full-text review. The prevalence of AUB among women of reproductive age ranged from 10% to 30%. The HRQoL scores from the 36-item Short-Form Health Survey Questionnaire (SF-36) suggested that women with AUB have HRQoL below the 25th percentile of that for the general female population within a similar age range. The conservatively estimated annual direct and indirect economic costs of AUB were approximately $1 billion and $12 billion, respectively. These figures do not account for intangible costs and productivity loss due to presenteeism.

CONCLUSIONS

The burden of AUB needs further and more thorough investigation. Additional research should prospectively evaluate the impact of AUB and the value of treatment provided to help guide future health resource allocation and clinical decision-making.

Endometrial Ablation: Where Have We Been? Where Are We Going?

Endometrial ablation (EA) is targeted destruction of the endothelial surface of the uterine cavity. The procedure was originally designed as a less invasive alternative to hysterectomy for the symptom of heavy menstrual bleeding unrelated to structural pathology of the uterus, that was not responsive to medical therapy. More recently it has become apparent that the procedure can be performed in the presence of submucous leiomyomas, providing they meet a number of size and location criteria. The first EA serie as published in Germany in the 1930s, but the procedure did not attract much attention until the latter part of the 20th century. Currently, EA can be performed under endoscopic direction with the neodymium:yttrium alumnum garnet laser, with a radiofrequency resectoscope, or with an expanding array of nonresectoscopic EA systems. It is apparent that most but not all of the complications associated with resectoscopic endometrial ablation are eliminated with nonresectoscopic endometrial ablation, but serious morbidity has been reported with all of the newer systems to date. Success and patient satisfaction seem to be enduring in the majority of well-selected patients treated in clinical trials, but repeat surgery, usually hysterectomy, is performed in 25% to 40% by 5 years after surgery. Increased efficiencies should be realized if the procedure could be moved to an office setting.

Use of the NovaSure Impedance Controlled Endometrial Ablation System in patients with intracavitary disease: 12-month follow-up results of a prospective, single-arm clinical study

STUDY OBJECTIVE

To assess the safety and effectiveness of the NovaSure Impedance Controlled Endometrial Ablation System for the treatment of excessive uterine bleeding in premenopausal and postmenopausal women with intracavitary disease (polyps or myomas) up to 3 cm.

DESIGN

Prospective, single-arm study. (Canadian Task Force Classification II-2.)

SETTING

Academic medical center.

PATIENTS

This clinical study was conducted in 65 women with menometrorrhagia with confirmed (type I and II) submucous myomas up to 3 cm with and without polyps.

INTERVENTION

Patients were treated with the NovaSure System and received no hormonal or mechanical pretreatment to thin the endometrial lining or as a uterine pathologic condition shrinking agent.

MEASUREMENTS AND MAIN RESULTS

All patients were diagnosed with intracavitary disease during office hysteroscopy. Patients completed menstrual questionnaires at the initial screening and at 1 year after treatment. Twelve-month results demonstrated that the NovaSure System was effective in reducing excessive uterine blood loss. Success (defined as reduction to normal bleeding) was observed in 95% (95% CI: 86%-99%) of patients, with 69% (95% CI: 56%-80%) reporting amenorrhea at 1 year after treatment. The median treatment time (time of energy delivery) was 78 seconds (range 61-120 seconds). All patients underwent the procedure under local or intravenous sedation. No intraoperative or postoperative adverse events were reported. There was a significant decrease in premenstrual symptoms and dysmenorrhea at 12 months after the procedure. Ninety-five percent (95% CI: 86%-99%) of patients were satisfied with the procedure.

CONCLUSION

Clinical results of this study demonstrate that the NovaSure System is safe and effective in treatment of patients with menometrorrhagia caused by intracavitary disease up to 3 cm.

Endometrial ablation for heavy menstrual bleeding

PURPOSE OF REVIEW

This review evaluates the currently available evidence regarding resectoscopic endometrial ablation (REA) and the various nonresectoscopic endometrial ablation (NREA) techniques used for heavy menstrual bleeding.

RECENT FINDINGS

Laser endometrial ablation is now used infrequently, largely because of procedure time, but also because of the cost and training associated with the technique. REA can be performed in a wider spectrum of endometrial cavity configurations than NREA and, at least in expert hands, remains the gold standard. Each of the five available types of NREA device possesses advantages and disadvantages over the others with respect to variables such as treatment time, required cervical dilation, and size and configuration of the endometrial cavity. All provide acceptable results that are comparable to that of REA in expert hands. Serious complications seem to be less common with NREA, but uterine perforation and bowel or other visceral injury can still occur. When endometrial-ablation patients were followed for up to 5 years, repeat surgery rates ranged from 20 to 40%, thereby eroding both the direct and indirect treatment-related resource utilization. Levonorgestrel-releasing intrauterine devices demonstrate similar clinical and patient-satisfaction outcomes to endometrial ablation but can be inserted in the office and allow maintenance of fertility.

SUMMARY

Both REA and NREA provide at least short- to intermediate-term options to hysterectomy for patients with heavy menstrual bleeding and normal or near-normal endometrial cavities. Consequently, the ideal candidates are likely those who are within 5 years of menopause.