Second-generation endometrial ablation techniques

Clinical and health service implications of second generation endometrial ablation devices

PURPOSE OF REVIEW

This review evaluates the current evidence on the efficacy, safety and cost-effectiveness of the ever-increasing number of second-generation endometrial ablation devices.

RECENT FINDINGS

The literature covered by this review includes (1) evidence on long-term benefit, avoidance of hysterectomy and improvement in quality of life, (2) applicability of these techniques in the outpatient environment under local or no anaesthesia, (3) frequency and nature of early and delayed complications associated with these devices, (4) impact on clinical practice and the health service, and (5) implications for research.

SUMMARY

Where appropriate, second-generation devices are rapidly becoming the first-line surgical choice for the management of heavy menstrual bleeding. This has both cost-savings and negative implications for the health service. There is also emerging evidence that improvement in quality of life is more relevant to women than amenorrhoea rates. What has come to light from this review is the lack of accurate data on adverse events rate, and the urgent need for a better appreciation of the frequency and nature of complications.

Hysteroscopic surgery

Hysteroscopy and visually directed endometrial sampling have replaced blind curettage for the diagnosis of endometrial disease. Hysteroscopy can be used to detect endometrial cancer and various premalignant lesions, as well as to diagnose intrauterine polyps and submucous fibroids. It can also be used to locate lost intrauterine devices, assess the shape and size of the endometrial cavity during an infertility work-up and to visualise intrauterine septae and adhesions. If the hysteroscopist possesses special skills and training, it can be used to perform intrauterine sterilisation by occluding the tubal ostia. The ability to perform endometrial ablation as an alternative to hysterectomy in patients with menorrhagia has led to reduction in the number of hysterectomies performed. Long-term follow-up has confirmed the success of this procedure, but it is not without complications. The inherent dangers and complications of endometrial ablation and the considerable skill and training it requires has led to the development of numerous second-generation devices, which can involve balloons that are heated with circulating fluid, impedance-controlled endometrial ablation or surface electrodes, heated fluid running through the hysteroscope under direct vision or the use of microwaves or cryotherapy. This chapter reviews the techniques, potential complications and evidence for the effectiveness of the common diagnostic and therapeutic hysteroscopic procedures.

Endometrial laser intrauterine thermotherapy for the treatment of dysfunctional uterine bleeding: the first British experience

Forty patients due to undergo endometrial ablation as a treatment for dysfunctional uterine bleeding were recruited to assess the efficacy and safety of endometrial laser intrauterine thermo-therapy using the gynelase. At 12 months the average menstrual score reduction was 88%, the amenorrhoea rate was 70%, and the hypomenorrhoea rate 16%. Four women (10%) have had a hysterectomy for persistent menorrhagia, and one (3%) for pelvic pain. One patient (3%) has had a further endometrial laser ablation. There were no major complications. and 34 patients (85%) were most satisfied with the treatment. The system is easy to use and has a short learning curve.