Endometrial cryoablation and thermal ablation

Current treatment of dysfunctional uterine bleeding

OBJECTIVES

We performed a review of the treatment modalities for dysfunctional uterine bleeding.

METHODS

Dysfunctional uterine bleeding can be treated medically or surgically. Medical treatment consists of anti-fibrinolytic tranexamic acid, non-steroidal anti-inflammatory drugs, the combined contraception pill, progestogen, danazol, or analogues of gonadotrophin releasing hormone. The levonorgestrel releasing intra uterine device is developed for contraception, but is also effective in the treatment of dysfunctional uterine bleeding. Surgical treatment includes endometrial ablation of the first and second-generation, and hysterectomy. This review contains current available evidence on the effectiveness of these therapies.

RESULTS

Antifibrinolytic tranexamic acid is the most effective medical therapy to treat dysfunctional uterine bleeding. In general medical therapy is not as effective as endometrial resection in terms of patient satisfaction and health related quality of life. The levonorgestrel releasing intra uterine device is an effective treatment for dysfunctional uterine bleeding. No difference in quality of life was observed in patients treated with a levonorgestrel releasing intra uterine device as compared to hysterectomy. Ablation techniques of the first generation are effective and safe when used by trained surgeons, but have a learning curve. Ablation techniques of the second generation are effective, but long-term follow-up data are not available. Similarly, there are no large randomised controlled trials comparing the levonorgestrel releasing intra uterine device to first and second-generation ablation techniques. Hysterectomy, the traditional standard of care, has a relatively high complication rate, but it generates a high satisfaction rate and good health related quality of life scores.

CONCLUSION

Since none of the treatments for dysfunctional bleeding is superior to one of the others, and since all treatments have their advantages and disadvantages, counselling of patients with dysfunctional bleeding should incorporate medical approach, levonorgestrel releasing IUD, endometrial ablation and hysterectomy.

Menorrhagia: an update

Menorrhagia is defined as a 'complaint of heavy cyclical menstrual bleeding occurring over several consecutive cycles'. Objectively it is a total menstrual blood loss equal to or greater than 80 ml per menstruation. It is estimated that approximately 30% of women complain of menorrhagia. Excessive bleeding is the main presenting complaint in women referred to gynecologists and it accounts for two-thirds of all hysterectomies, and most of endoscopic endometrial destructive surgery. Thus, menorrhagia is an important healthcare problem. Its etiology, investigation, medical and surgical management are described. In approximately 50% of cases of menorrhagia no pathology is found at hysterectomy. Abnormal levels of prostaglandins or the fibrinolytic system in the endometrium have been implicated. Effective medical treatments suitable for long-term use include intrauterine progestogens, antifibrinolytic agents (tranexamic acid) and nonsteroidal anti-inflammatory agents (mefenamic acid). Over the past decade there has been increasing use of endometrial destructive techniques as an alternative to hysterectomy. Their further refinement and the advent of fibroid embolization has increased the options available to women.

Cost effective management of heavy uterine bleeding: ablative methods versus hysterectomy

The treatment of menorrhagia in the twentieth century changed after 1960 with the introduction of hormonal therapy as well as an array of laboratory, imaging and minimal access tests for more accurate diagnosis. Since 1981, hysteroscopy has been used for diagnosis as well as the control of thermoablative treatments of bleeding non-malignant endometrium, including laser, electrocoagulation and electroresection. The success rates, complications, intermediate range outcome and cost comparisons with hysterectomy favor hysteroscopic methods. But the long term data on both hysteroscopic ablation and hysterectomy are not yet complete. In an effort to simplify techniques, reduce costs, and reduce complications, a variety of non-hysteroscopic methods and devices have appeared. Only two balloon devices have satisfactory success data as well as sufficient field experience to provide some degree of reliability regarding complications, which appear to be very low. Most of the devices have had clinical trials, which suggest equivalence to hysteroscopic endometrial ablation, but the determination of clinical safety requires at least several thousand cases. However, the levels of effectiveness for most of these devices make them candidates for commercial use. Hysterectomy may move from a primary surgical treatment of menorrhagia to a second-line treatment after ablation, particularly if some of the non-hysteroscopic methods become well accepted. If they are found to be safe, the costs and ease of use for the gynecologist and patient will make them attractive as a first-line surgical option. Hysterectomy, whether abdominal, vaginal, or laparoscopic will then be applied to ablation failures or non-candidates. This has the potential to change gynecological training and practice significantly in the future.