Hysteroscopy in the management of abnormal uterine bleeding

The ever-increasing value of diagnostic and operative hysteroscopy for patients with AUB serves as an appropriate, although belated, tribute to Pantaleoni who in 1869 dared to look inside a woman's uterus. Future generations of women and their physicians will be indebted to this physician-pioneer. Contemporary instrumentation permits the gynecologist to acquire quickly the basic skills necessary for routine performance of office-based hysteroscopy. With increasing experience, operative hysteroscopic techniques, including resection of polyps, myomata, and endometrial ablation, can be easily mastered.

Timing of hysterectomy surgery during the menstrual cycle--impact of menstrual cycle phase on rate of complications: preliminary study

To determine the relationship between the timing of a hysterectomy performed during the menstrual cycle phase and the postoperative complication rate in women who had undergone surgery for dysfunctional uterine bleeding, the authors examined the charts of 24 patients for the 3-month period immediately after the hysterectomy. Twelve of the women were in the follicular phase, and 12 were in the luteal phase at the time they had undergone the hysterectomy. Patients were classified by operative pathology report. No significant differences (P < or = 0.05) were found between the two groups with respect to age, weight, para status, pathology, preoperative and postoperative hemoglobin levels, operation time, blood loss, days before return to full functioning, days in hospital, and uterine morphology. Further prospective studies with longer follow-up time are needed to obtain more conclusive indications regarding the optimal timing of hysterectomy during the menstrual cycle.

Expectant, medical, or surgical treatment of spontaneous abortion in first trimester of pregnancy? A pooled quantitative literature evaluation

BACKGROUND

Spontaneous abortion is a common problem in everyday clinical practice, accounting for 15 to 20 percent of all recognized pregnancies. The traditional treatment of this problem has been surgical, emptying the uterus by dilatation and curettage (D&C). Recent therapeutic and laboratory advances call surgical therapy into question for many patients. It is believed that this pooled quantitative literature evaluation is the first with the goal to clarify the roles of expectant, medical, and surgical treatment of this common problem.

METHODS

The literature review was focused on published studies in the English language of outcomes of therapy for spontaneous abortion in the first trimester. We looked for both observational and randomized controlled trials. A successful outcome of treatment required that three criteria be met: vaginal bleeding stopped by 3 weeks, products of conception fully expelled by 2 weeks, and absence of complications. Pooled weighted average success estimates and standard errors were determined for each study; 95 percent confidence intervals were calculated for each form of treatment. Sensitivity analysis compared randomized controlled trials with observational studies for both expectant and surgical treatment.

RESULTS

Of the 31 studies retrieved, 18 met inclusion criteria, including 9 involving expectant treatment (545 pooled patients), 3 for medical treatment (prostaglandin or antiprogesterone agents) (198 pooled patients), and 10 for surgical treatment (D&C) (1408 pooled patients). Successful outcomes were found in 92.5 percent of patients receiving expectant treatment, in 93.6 percent of those undergoing D&C, and in 51.5 percent of patients receiving medical treatment.

CONCLUSIONS

Expectant management of spontaneous abortion in the first trimester is safe and effective for many afebrile patients whose blood pressure and heart rate are stable and who have no excess bleeding or unacceptable pain. Transvaginal sonographic studies might be useful in patient selection, and serial chorionic gonadotropin monitoring should be considered while observing the initial course of expectant treatment. Currently there is insufficient evidence to support medical therapy of spontaneous abortion, and further research is needed to clarify the more limited role of surgical treatment.

Uterine ultrasonographic changes with gonadotropin-releasing hormone agonists

OBJECTIVES

Our purpose was to assess the changes in uterine volume and uterine artery pulsatility index in response to gonadotropin-releasing hormone agonist treatment in women undergoing hysterectomy for nonfibroid-related uterine bleeding.

STUDY DESIGN

A double-blind, placebo-controlled randomized trial of 51 women awaiting hysterectomy in a gynecology outpatient clinic was conducted. The women were treated for 8 weeks with either leuprolide acetate depot or placebo. Vaginal ultrasonographic examinations were performed before and after treatment. The paired t test was used for statistical analysis.

RESULTS

In those allocated to therapy with gonadotropin-releasing hormone agonist the mean uterine volume decreased by 34% and the uterine artery pulsatility index increased from 2.25 to 2.7. No significant changes were seen in the placebo group. The intersonographer variability was low and there was a high correlation between uterine size as measured by ultrasonography before hysterectomy and that measured postoperatively.

CONCLUSIONS

Treatment with gonadotropin-releasing hormone agonists leads to uterine shrinkage and an increase in the uterine artery pulsatility index even in the absence of uterine fibroids.

Doppler velocimetry of the uterine arteries after hysteroscopic rollerball endometrial ablation

The aim of this study was to document the Doppler indices [pulsatility index (PI) and resistance index (RI)] of the uterine arteries in 30 patients who underwent hysteroscopic rollerball endometrial ablation for dysfunctional uterine bleeding by transvaginal pulsed Doppler sonography, and to reveal whether treatment failures (persistent menometrorrhagia) can be predicted by the blood flow characteristics of the uterine arteries in advance. On the basis of the outcome of patients at the end of the first postoperative year, the Doppler indices of the uterine arteries were meaningful 1 year after the operation when PI (1.32 +/- 0.11; mean +/- SD) and RI (0.71 +/- 0.04) in six menometrorrhagic patients were statistically different from PI (2.19 +/- 0.28; 1.95 +/- 0.36 and 1.82 +/- 0.37) and RI (0.87 +/- 0.06; 0.82 +/- 0.06 and 0.81 +/- 0.04) in normally menstruating, amenorrhoeic and hypomenorrhoeic patients respectively (P < 0.05). On the other hand, the patients who would be menometrorrhagic one year after the operation had a thicker endometrium in the first post-operative month. These findings suggest that the angiogenetic role of the persistent endometrial islands after endometrial ablation needs at some time to be reflected as changes in the Doppler parameters of the uterine arteries.

Uterine fluid irrigation and absorption in hysteroscopic endometrial ablation

OBJECTIVE

To compare two techniques of irrigation flow control with regard to risk of absorption of uterine irrigation fluid during operative hysteroscopy.

METHODS

We compared two techniques of uterine irrigation fluid outflow management-passive gravity outflow and direct connection of the outflow to wall suction-in a randomized controlled trial involving 40 women undergoing hysteroscopic endometrial ablation. The amount of fluid absorbed by each subject was calculated, as were operating time, uterine size, and endometrial pharmacologic preparation. Endometrial thickness and operator view were graded visually by the surgeon.

RESULTS

The median (range) amount of irrigation fluid absorbed was 450 mL (0-2300) in the group in which passive gravity outflow was used and 0 mL (700 mL excess outflow to 300 mL absorption) in the group in which direct connection of the outflow to wall suction was used (P < .001). None of the other variables that might have influenced uterine irrigation fluid absorption (operating time, uterine size, pharmacologic endometrial preparation, or endometrial thickness) differed between the two groups.

CONCLUSION

Connecting the outflow of the uterine irrigation system to wall suction is a simple and effective method of reducing the risk of fluid absorption during endometrial ablation.

[Surgical hysteroscopy or hysterectomy in the treatment of benign uterine lesions. What to choose in 1998?]

In the past, the treatment of benign uterine lesions required, in many instances, a hysterectomy. These days, most cases can be successfully treated by hysteroscopy. To be reliable, this technique must lead to a significant reduction in the number of hysterectomies performed for benign uterine lesions. The electroresection technique is preferred to that using the Nd-YAG laser because of its lower cost and its equivalent efficacy. By using the uterine perfusion pump device, the risk of resorption syndrome can be reduced to its minimum. Submucosal myomas < 1 cm, benign endometrial hyperplasia and adenomyosis are the commonest benign lesions treated. Dysfunctional uterine bleeding can also be treated by an endometrectomy. A preoperative workup includes a transvaginal ultrasound and a biopsy. This ensures that only benign lesions that are accessible to a hysteroscopy will be submitted to this technique and that no cases of endometrial cancer or atypical hyperplasia would be ignored. This study presents 270 cases of operative hysteroscopy with a follow-up to 4 years. 82.8% of myomatous lesions were treated with success. The results for patients with benign endometrial polyps or benign endometrial hyperplasia are also excellent with only 4.6% and 5.6% rate of secondary surgery respectively. Adenomyosis does not appear to be a good indication for hysteroscopy as only 37% of patients did not need a definitive hysterectomy. Rates of operative complications (post-operative bleeding, uterine perforation, resorption syndrome and difficulty of access) are acceptable and get less frequent as the surgeon experience increases.

[Placenta accreta. Bleeding and disseminated intravascular coagulation following Cesarean section]

A case of placenta accreta in a 30-year old woman with one prior caesarean section is presented. The operative course of her second caesarean section was complicated by mild atonia. The postoperative course was complicated by mild atonia, which was followed by excessive vaginal and intraabdominal bleeding due to atonia and disseminated intravascular coagulation. An abdominal hysterectomy was performed. Risk factors, antenatal diagnostic methods, complications and different treatment aspects are discussed.

Cystic adenomyosis of the uterus: MRI

Adenomyosis of the uterus is most often seen as focal or diffuse thickening of the myometrial junctional zone on MRI. We describe the morphologic features and signal characteristics of the rarer cystic form of the disease, as revealed by MRI. We conclude that cystic adenomyosis of the uterus is characterized by a well-circumscribed cystic lesion within the myometrium that demonstrates hemorrhage in differential stages of organization on MR images.

[Dilatation and curettage in women with abnormal uterine bleeding--an analysis of the histopathological findings]

The aim of this study is to analyse the histopathologic findings from the uterine cavity and the cervical canal among women who attended the gynecologic clinic of HMI Pleven for abnormal uterine bleeding. The study is retrospective and for a ten month period--from 01.03, 1996 to 31.12, 1996. After dilation and curettage under general anaesthesia histologic examination of the material was done in 161 women aged 19 to 73 years. The patients were divided according to the pathomorphologic findings from the uterine cavity into 9 groups and into 5--according to the findings from the cervical canal. The analysis of the data shows that the peak of abnormal uterine bleeding is 48 years, and that of endometrial carcinoma--51 years. The relative ratio of pathologic findings from the uterine cavity, including endometrial polyps, simple, adenomatous and atypical hyperplasia and carcinoma of the endometrium is 47.2%.

Endometrial carcinoma after endometrial ablation: high-risk factors predicting its occurrence

Our purpose was to review reported cases of endometrial carcinoma after endometrial ablation and to evaluate high-risk factors predicting its occurrence. We present guidelines for the treatment of abnormal uterine bleeding unresponsive to medical therapy in this high-risk group of patients. Eight detailed reports on endometrial carcinoma after endometrial ablation were reviewed. The indications, methods of treatment, follow-up, and associated high-risk factors for endometrial carcinoma were analyzed. A focused list of high-risk factors for endometrial carcinoma was developed on the basis of the data collected. Guidelines were established to enable surgeons to minimize the risks of subsequent uterine cancer in women with abnormal uterine bleeding that is unresponsive to medical therapy (ie, candidates for ablation). Women who had endometrial carcinoma develop after ablation had predictive high-risk factors for subsequent neoplasia, and all eventually underwent a hysterectomy. Women with abnormal uterine bleeding and high-risk factors for endometrial carcinoma who did not respond to medical treatment may safely undergo endometrial ablation but must have a preablation biopsy indicating normal endometrium. Persistent hyperplasia unresponsive to hormonal therapy should influence the selection of a hysterectomy. Careful screening of patients before undergoing endometrial destructive procedures is prescient because minimally invasive, nonhysteroscopic ablative techniques are now emerging.

Hematometra secondary to anticoagulant rodenticide toxicity

An adult, intact female Australian shepherd presented for frank vaginal bleeding of unknown duration. The only coagulation profile abnormality upon presentation was mild prolongation of the partial thromboplastin time (PTT). The uterus was removed at surgery and contained a large amount of coagulated blood. Clotting profiles were markedly abnormal 48 hours postoperatively. Serum analysis was positive for brodifacoum, an anticoagulant rodenticide. Preoperative coagulation was most likely normalized by vitamin K1 therapy administered prior to presentation. The only manifestation of anticoagulant rodenticide was hematometra. Rodenticide intoxication should be considered in the differential diagnosis list of hematometra or metrorrhagia.

Emergency endometrial ablation for life-threatening uterine bleeding as a result of a coagulopathy

The clinician has few medical and surgical options for managing life-threatening uterine hemorrhage. Hormone therapy often fails to arrest the bleeding. Hysterectomy under these emergency circumstances is also not optimal. Emergency endometrial ablation was successful in stopping exsanguinating uterine hemorrhage in three women and may be an important alternative in management of this disorder.

Alternatives to hysterectomy for benign conditions

Hysterectomy is the second most commonly performed major operation in the United States. Approximately one in three women will have this operation, resulting in 590,000 procedures per year. The most common indications for hysterectomy are leiomyomata uteri, abnormal uterine bleeding, endometriosis, pelvic pain, and pelvic organ prolapse. Although hysterectomy is an appropriate therapeutic option for some women with these conditions, in many instances less radical alternatives may be offered. Leiomyomata may be managed expectantly if symptoms are not bothersome; for women with troubling leiomyomata symptoms, alternatives to hysterectomy include: endoscopic removal or destruction of myomas, arterial embolization, or hormonal therapy to inhibit or modify bleeding. Endometriosis and abnormal uterine bleeding of leiomyomata are both amenable to hormonal therapy. Pelvic pain is most effectively approached with a thorough evaluation (particularly for nongynecologic illness), with specific therapy directed at the cause of the pain. Pelvic organ prolapse may respond symptomatically to pelvic floor exercises, or to the use of a pessary. After alternatives to removal of the uterus are discussed, the informed woman may decide that hysterectomy is the option best suited to her. It is unusual for hysterectomy to be her only option.

The effect of hysterectomy and endometrial ablation on follicle stimulating hormone (FSH) levels up to 1 year after surgery

OBJECTIVES

In this study the hypothesis was tested, that in premenopausal patients FSH-levels would rise after 'simple hysterectomy'. As endometrial ablation is not supposed to compromise ovarian bloodflow, there would be no such change in ablated patients.

METHODS

Between January 1995 and April 1996, consecutive premenopausal patients with dysfunctional uterine bleeding who were scheduled for hysterectomy or endometrial ablation were asked to participate in the study. Bloodsamples were drawn before surgery, six weeks, six months and one year after surgery. FSH and oestradiol (E2) were assayed. In all patients data about length and weight were collected to calculate Body Mass Index (BMI). Every visit patients filled in a questionnaire, containing questions about typical climacteric complaints, combined in a five-point scale.

RESULTS

Except for a significant difference in preoperative FSH-level between both groups, there were no significant differences regarding age, Body Mass Index (BMI), oestradiol (E2) or the percentage of women with vasomotor complaints. Compared to the preoperative starting level, six weeks, six months and one year after surgery a significant rise in serum FSH in the hysterectomy group, as well as in the ablation group was found. However there was no significant difference in FSH increase between both groups. One third of the patients in both groups had typical climacteric complaints as flushing and nocturnal sweating.

CONCLUSIONS

Assaying serum FSH-levels before and after uterine surgery and comparing hysterectomized patients and patients after endometrial ablation, we found a significant rise in FSH-level up to one year after surgery in both groups postoperatively, indicating impaired ovarian function. There was no difference in FSH-levels between both groups. Therefore major uterine surgery (hysterectomy, ablation) may prelude an earlier onset of menopause.

Endometrioma of the abdominal wall following combined abdominoplasty and hysterectomy: case report and review of the literature

An unusual case is reported of abdominal wall endometrioma presenting in a lower abdominal scar following a combined hysterectomy and abdominoplasty performed 5 years earlier. Current diagnostic methods and recommended surgical management are outlined.

Endometrial ablation versus hysterectomy: STOP-DUB

Dysfunctional uterine bleeding (DUB) is a common clinical condition that frequently leads to hysterectomy. Endometrial ablation --a "minimally invasive" surgical technique that removes or destroys the endometrial lining of the uterus -- is a conservative alternative to hysterectomy for DUB. While endometrial ablation has lower immediate costs and shorter recovery than hysterectomy, symptoms are not always resolved. Available data from studies with admittedly incomplete follow-up suggest that up to one quarter of patients treated with endometrial ablation require repeat ablation or subsequent hysterectomy to stop DUB. This suggests that the short-term advantages of endometrial ablation may be offset by possible longer-term disadvantages. The Surgical Treatments Outcomes Project for Dysfunctional Uterine Bleeding (STOP-DUB) is a randomized trial designed to compare endometrial ablation against hysterectomy. The primary outcomes address issues of importance to women, such as quality of life and resolution of symptoms that led to surgery. Other outcomes include subsequent surgery and cost-effectiveness of the procedures. The study's target enrollment is 800 women--400 in each treatment group -- from 20 clinical centers throughout the US. The women will be followed for 2 years after surgery. Part of the STOP-DUB is a parallel observational study that involves women who do not choose surgery or who are not eligible for the randomized trial but could become eligible with time. It is anticipated that the result of this research will provide important information to women and their health care professionals as they consider the relative merits of surgical treatments for DUB.

Open randomised study of use of levonorgestrel releasing intrauterine system as alternative to hysterectomy

OBJECTIVES

To assess whether the levonorgestrel intrauterine system could provide a conservative alternative to hysterectomy in the treatment of excessive uterine bleeding.

DESIGN

Open randomised multicentre study with two parallel groups: a levonorgestrel intrauterine system group and a control group.

SETTING

Gynaecology departments of three hospitals in Finland.

SUBJECTS

Fifty six women aged 33-49 years scheduled to undergo hysterectomy for treatment of excessive uterine bleeding.

INTERVENTIONS

Women were randomised either to continue with their current medical treatment or to have a levonorgestrel intrauterine system inserted.

MAIN OUTCOME MEASURE

Proportion of women cancelling their decision to undergo hysterectomy.

RESULTS

At 6 months, 64.3% (95% confidence interval 44.1 to 81.4%) of the women in the levonorgestrel intrauterine system group and 14.3% (4.0 to 32.7%) in the control group had cancelled their decision to undergo hysterectomy (P < 0.001).

CONCLUSIONS

The use of the levonorgestrel intrauterine system is a good conservative alternative to hysterectomy in the treatment of menorrhagia and should be considered before hysterectomy or other invasive treatments.

[Prevention and diagnosis of encapsulated endometrium after endometrial ablation]

Endometrial ablation for dysfunctional uterine bleeding has become more common in Denmark in recent years. New symptoms and diseases may arise due to morphological changes in the uterus after the operation. Despite thoroughness during surgery, residual endometrial tissue can be trapped in pockets during the healing process. In this paper two cases of encapsulated endometrial tissue are presented in women who had undergone endometrial resection. Prophylactic aims, diagnoses and treatments are suggested to minimise the risk of residual endometrial tissue in terms of concealing the symptoms of a developing adenocarcinoma.

[Use of ultrasonography as a first-line investigation of the uterus. Results of a prospective study]

OBJECTIVE

To assess the effectiveness of hysterosonography as a first line investigation for uterine bleeding in perimenopausal women.

METHODS

185 women were enrolled in a prospective study. They underwent a hysterosonography indicated for abnormal uterine bleeding or follow-up of a treatment with tamoxifene. Patients with a normal cavity or atrophia were scheduled for a diagnostic hysteroscopy or a hormonal therapy. Patients with uterine cavity abnormalities were scheduled for surgery (operative hysteroscopy or hysterectomy). All the patients were clinically followed after the hysterosonography or the surgery. Results of hysterosonography were compared to data issued from the clinical follow-up or to pathological results when available.

RESULTS

Hysterosonography was achieved in 179 patients. In all but 1 case, hysterosonography was well tolerated by the patients. We had no complication during or after the examination. Hysterosonography had a high sensitivity and specificity in the discrimination of women with normal cavity or atrophia from the ones with intrauterine lesions (respectively 96.4% and 98.3%). Hysterosonography was also accurate in the distinction of polyps from sub-mucosal myomas (sensitivity 88.2 à 90.3%, specificity: 98.6 à 95%). The measurement and localization of the lesions were accurate in an equal manner with both procedures. Hysterosonography had similar results in women treated with tamoxifene, but the failure frequency was significantly higher (13% vs 1.8%) (p < 0.05).

CONCLUSIONS

Hysterosonography appears as a reliable tool for the investigation of abnormal uterine bleeding in perimenopausal women. It can distinguish women who just need a medical therapy from the ones who will require a surgical exploration. It is easy to learn, and well tolerated by the women. Hysterosonography is more sensitive and specific than transvaginal sonography in the follow-up of patients treated with Tamoxifene.

Endometrial resectoscopic ablation in patients with menometrorrhagia as a side effect of anticoagulant therapy

OBJECTIVE

The study was conducted to examine the effect of endometrial ablation therapy for patients suffering from coagulation abnormalities and presenting with failed medical treatment for menometrorrhagia.

STUDY DESIGN

Eleven patients with a mean age of 42 years (range 39-45) and with coagulation disorders in whom medical therapy for abnormal uterine bleeding was unsuccessful, were treated by the ablation procedure under video monitoring. Complications, length of hospitalisation and long-term follow-up were noted. The age of the patients ranged from 39-45 years. Menstrual characteristics were scored, but blood loss before and after the procedure was not quantified.

RESULTS

Uterine fibroids were found in two patients. The duration of the ablation procedure was 20 min and was prolonged for 30 to 40 min when fibroids were diagnosed. During the operation, no excessive bleeding was noted in ten patients and postoperative recovery was rapid in all. After a one-year follow-up the overall satisfaction of the patients was high (10/11).

CONCLUSIONS

Our initial experience with a selected group of patients suffering from coagulation abnormalities is promising. Bearing in mind the risks of a major operation in this group of patients, endometrial ablation should be seriously considered.