Clinical trial of the uterine thermal balloon for treatment of menorrhagia

Risk of Hysterectomy After Endometrial Ablation: A Systematic Review and Meta-analysis

OBJECTIVE

To assess the risk of hysterectomy after nonresectoscopic endometrial ablation in patients with heavy menstrual bleeding.

DATA SOURCES

The EMBASE, MEDLINE, ClinicalTrials.gov and Cochrane databases were searched for eligible articles from inception until June 13, 2022. We used combinations of search terms for endometrial ablation and hysterectomy.

METHODS OF STUDY SELECTION

Articles included in the review described the incidence of hysterectomy at a specific point in time after ablation with a minimum follow-up duration of 12 months.

TABULATION, INTEGRATION, AND RESULTS

The literature search yielded a total of 3,022 hits. A total of 53 studies met our inclusion and exclusion criteria, including six retrospective studies, 24 randomized controlled trials, and 23 prospective studies. A total of 48,071 patients underwent endometrial ablation between 1992 and 2017. Follow-up duration varied between 12 and 120 months. Analyses per follow-up moment showed 4.3% hysterectomy rate at 12 months of follow-up (n=29 studies), 11.1% at 18 months (n=1 study), 8.0% at 24 months (n=11 studies), 10.2% at 36 months (n=12 studies), 7.6% at 48 months (n=2 studies), and 12.4% at 60 months (n=6 studies). Two studies reported a mean hysterectomy rate at 10 years after ablation of 21.3%. Minimal clinically relevant differences in hysterectomy rates were observed among the different study designs. Furthermore, we found no significant differences in hysterectomy rate among the different nonresectoscopic endometrial ablation devices.

CONCLUSION

The risk of hysterectomy after endometrial ablation seems to increase from 4.3% after 1 year to 12.4% after 5 years. Clinicians can use the results of this review to counsel patients about the 12% risk of hysterectomy 5 years after endometrial ablation.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42020156281.

Prognostic Factors for the Failure of Endometrial Ablation: A Systematic Review and Meta-analysis

OBJECTIVE

To provide an overview of prognostic factors predicting failure of second-generation endometrial ablation.

DATA SOURCES

MEDLINE, EMBASE, the Cochrane Library, and ClinicalTrials.gov were systematically searched from 1988 until February 2019. The search was conducted without language restrictions using the following search terms: "endometrial ablation," "prognosis," "predict," "long term," "late onset," "outcome."

METHODS OF STUDY SELECTION

The literature search provided a total of 990 studies. All types of studies reporting about prognostic factors of second-generation endometrial ablation failure were included.

TABULATION, INTEGRATION, AND RESULTS

After screening for eligibility, 56 studies were included in this review, of which 21 were included in the meta-analysis. In these 56 studies, 157,830 women were included. We evaluated 10 prognostic factors: age, myomas, history of tubal ligation, body mass index, parity, preexisting dysmenorrhea, caesarean delivery, bleeding pattern, uterus position, and uterus length. Meta-analysis was performed for the primary outcome (surgical reintervention) to estimate summary treatment effects. Younger age (aged 35 years or younger, odds ratio [OR] 1.68, 95% CI 1.19-2.36; aged 40 years or younger, OR 1.58, 95% CI 1.30-1.93; aged 45 years or younger OR 1.63, 95% CI 1.28-2.07), prior tubal ligation (OR 1.46, 95% CI 1.23-1.73), and preexisting dysmenorrhea (OR 2.12, 95% CI 1.41-3.19) were associated with an increased risk of surgical reintervention. Studies investigating the prognostic factors myomas and obesity showed conflicting results.

CONCLUSION

Younger age, prior tubal ligation and preexisting dysmenorrhea were found to be associated with failure of endometrial ablation. Obesity and the presence of large submucous myomas may be associated with failure, as well, though more research is necessary to estimate the influence of these factors. It is important to take the results of this review into account when counselling women with heavy menstrual bleeding.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42019126247.

Abnormal Uterine Bleeding

Abnormal uterine bleeding is a frequent condition in Gynecology. It may impact physical, emotional sexual and professional aspects of the lives of women, impairing their quality of life. In cases of acute and severe bleeding, women may need urgent treatment with volumetric replacement and prescription of hemostatic substances. In some specific cases with more intense and prolonged bleeding, surgical treatment may be necessary. The objective of this chapter is to describe the main evidence on the treatment of women with abnormal uterine bleeding, both acute and chronic. Didactically, the treatment options were based on the current International Federation of Gynecology and Obstetrics (FIGO) classification system (PALM-COEIN). The etiologies of PALM-COEIN are: uterine Polyp (P), Adenomyosis (A), Leiomyoma (L), precursor and Malignant lesions of the uterine body (M), Coagulopathies (C), Ovulatory dysfunction (O), Endometrial dysfunction (E), Iatrogenic (I), and Not yet classified (N). The articles were selected according to the recommendation grades of the PubMed, Cochrane and Embase databases, and those in which the main objective was the reduction of uterine menstrual bleeding were included. Only studies written in English were included. All editorial or complete papers that were not consistent with abnormal uterine bleeding, or studies in animal models, were excluded. The main objective of the treatment is the reduction of menstrual flow and morbidity and the improvement of quality of life. It is important to emphasize that the treatment in the acute phase aims to hemodynamically stabilize the patient and stop excessive bleeding, while the treatment in the chronic phase is based on correcting menstrual dysfunction according to its etiology and clinical manifestations. The treatment may be surgical or pharmacological, and the latter is based mainly on hormonal therapy, anti-inflammatory drugs and antifibrinolytics.

Patient satisfaction with thermal balloon ablation for treatment of menorrhagia

OBJECTIVE

The purpose of this study was to determine whether satisfaction in women who have undergone the thermal balloon ablation (TBA) procedure for menorrhagia at the Penn State Milton S. Hershey Medical Center is consistent with initial published studies.

STUDY DESIGN

Two hundred sixteen patients were mailed a survey regarding patient satisfaction, postoperative bleeding patterns, and need for additional surgery. The follow-up interval was 13-60 months.

RESULTS

The survey response rate was 88%. Eighty-nine percent of women were satisfied with the results of their procedure. After 3-5 years, 37% of women reported amenorrhea and 44% reported minimal/light bleeding. Only 9% of women eventually required hysterectomy.

CONCLUSION

This study confirms a patient satisfaction rate in our institution that is consistent with initial published studies.

Second-generation endometrial ablation technologies: the hot liquid balloons

Hysteroscopic endometrial ablation (HEA) was introduced in the 1980s to treat menorrhagia. Its use required additional training, surgical expertise and specialized equipment to minimize emergent complications such as uterine perforations, thermal injuries and excessive fluid absorption. To overcome these difficulties and concerns, thermal balloon endometrial ablation (TBEA) was introduced in the 1990s. Four hot liquid balloons have been introduced into clinical practice. All systems consist of a catheter (4-10mm diameter), a silicone balloon and a control unit. Liquids used to inflate the balloons include internally heated dextrose in water (ThermaChoice, 87 degrees C), and externally heated glycine (Cavaterm, 78 degrees C), saline (Menotreat, 85 degrees ) and glycerine (Thermablate, 173 degrees C). All balloons require pressurization from 160 to 240 mmHg for treatment cycles of 2 to 10 minutes. Prior to TBEA, preoperative endometrial thinning, including suction curettage, is optional. Several RCTs and cohort studies indicate that the advantages of TBEA include portability, ease of use and short learning curve. In addition, small diameter catheters requiring minimal cervical dilatation (5-7 mm) and short duration of treatment cycles (2-8 min) allow treatment under minimal analgesia/anesthesia requirements in a clinic setting. Following TBEA serious adverse events, including thermal injuries to viscera have been experienced. To minimize such injuries some surgeons advocate the use of routine post-dilatation hysteroscopy and/or ultrasonography to confirm correct intrauterine placement of the balloon prior to initiating the treatment cycle. After 10 years of clinical practice, TBEA is thought to be the preferred first-line surgical treatment of menorrhagia in appropriately selected candidates. Economic modeling also suggested that TBEA may be more cost-effective than HEA.

Thermal balloon endometrial ablation: a systematic review

OBJECTIVE

The aim of our study is to review the role of thermal balloon endometrial ablation (TBEA) as an alternative in treating abnormal uterine bleeding.

METHODS

Articles relevant to our review and relevant references from the initially identified articles on the field that were archived by May 2007, were retrieved from Pubmed.

RESULTS

Success rates ranged from 83 up to 94%, with patient's satisfaction ranging from 57 up to 94%. Persisted menorrhagia could reach 17% in some studies.

CONCLUSION

TBEA is an effective alternative method used in the treatment of menorrhagea which results in a significant reduction in menstrual bleeding and high satisfaction rates. However, a longer follow-up is required to determine the role of such a treatment.

Bilateral cornual abscess after endometrial ablation following Essure sterilization

Endometrial ablation is used extensively to treat dysfunctional bleeding. Since the introduction of Essure tubal sterilization, this permanent contraception method has been widely used. Both endometrial ablation and Essure sterilization are procedures reported to have only a few complications. We describe a serious infectious complication shortly after an endometrial ablation in a patient with Essure microinserts in situ. To our knowledge, this complication has not been reported before in patients with Essure microinserts in situ. We suggest administering prophylactic antibiotics before endometrial ablation in women with Essure microinserts in situ.

An in vitro uterine perfusion model for investigating endometrial cryoablation

STUDY OBJECTIVES

To build a simple in vitro uterine perfusion model for investigating the clinical effectiveness of endometrial ablation.

DESIGN

Comparative laboratory and in vivo study (Canadian Task Force classification II-2).

SETTING

University teaching hospital.

PATIENTS

Women undergoing hysterectomy for menorrhagia with uteri of normal shape and size.

INTERVENTIONS

A single 5-minute freeze, followed by an active thaw was applied to the endometrial cavity of uteri in vivo and in the in vitro perfusion model.

MEASUREMENTS AND MAIN RESULTS

Endometrial/myometrial temperature change was measured continuously during the cryosurgical procedure. Depth of cell death was measured using nicotinamide adenine dinucleotide diaphorase enzyme assay. There was no significant difference in temperature change and depth of cell death in endometrial/myometrial tissue between in vivo and in vitro perfusion experiments.

CONCLUSIONS

The in vitro perfusion model described is a useful tool for investigating endometrial cryoablation and has potential for investigating and developing other intrauterine surgical modalities.

Uterine Balloon Therapy : An Alternative Therapy for Menorrhagia

BACKGROUND

Menorrhagia is a common problem in women of reproductive age. Its aetiology in the absence of organic pathology, hormonal or haematological disorders remains largely unknown. Traditional medical therapy may not be beneficial in the long run. Hysterectomy for this condition is an invasive over treatment. First generation endometrium ablation techniques aimed at destroying the endometrium, were associated with life threatening complications. The second generation endometrial ablation techniques like uterine thermal balloon therapy have reduced these problems.

METHODS

Fifty patients were selected for the procedure between 2002 and 2005. The patients qualified for the procedure if they had completed their family, had normal pelvic ultrasound findings, benign endometrial histology, normal PAP smear and clinically a normal size or bulky uterus.

RESULTS

50% patients were in the age group of 35-45 years. 28(56%) procedures were done under local anaesthesia and 22(44%) under general anaesthesia. The patients were followed up for a period of 3 to 29 months (median 16 months). Seven(14%) had amenorrhoea and 40(80%) had normal periods or hypomenorrhoea. Three(6%) patients continued to have menorrhagia and were considered failures. 94% patients were satisfied with the procedure and there were no complications in this series. Conclusions : Uterine balloon therapy is a simple, safe and effective method for the treatment of menorrhagia in selected patients.

Thermachoice endometrial balloon ablation: a possible alternative to hysterectomy

The purpose of the present audit was to assess the effectiveness and safety of thermal balloon ablation of the endometrium for the treatment of menorrhagia and also to assess patients' satisfaction following the treatment. A total of 50 women successfully underwent endometrial ablation using the Thermachoice balloon system for the treatment of menorrhagia at Caerphilly Miners' District Hospital, Caerphilly, South Wales, UK in the period between September 2000 and December 2002. All cases were performed under a general anaesthetic. There was no equipment failure in this study. No major intra-operative or postoperative complications were noted. However, a post-procedure complication rate of 4% was reported. All cases were discharged within 24 h. Cases were reviewed 3, 6, 12 and 24 months postoperatively. All 50 women attended for follow-up after 3 months. However, two cases were lost for follow-up at 6 months. The number increased to three cases after 12 months and seven cases after 24 months. At each visit, women were interviewed with emphasis on their menstrual history after treatment and the need for further therapy - if any. Women were asked to respond on a four-point ordinal scale to assess satisfaction with treatment (very satisfied, satisfied, dissatisfied or very dissatisfied). Symptomatic improvement was checked by asking participating women to grade the heaviness of their menstrual blood loss as none (amenorrhoea), lighter than before (hypomenorrhoea), or same as before (persistent menorrhagia). Improvement was defined as amenorrhoea or hypomenorrhoea, while procedure failure was defined as persistent menorrhagia. A statistically significant (p = 0.0001) difference was found between pre- and post-treatment heaviness and duration of menstrual flow, as well as the incidence of anaemia. The success rate was maintained over the follow-up period with a range of 86 - 92%. Patient satisfaction was also high at 86%. However, in view of persistent menorrhagia, six patients out of 43 (14%) required further treatment.

The medium- and long-term outcome of endometrial ablative techniques

OBJECTIVE

To determine the medium-term (1-3 years) and long-term (3-5 years) outcome for women who underwent endometrial ablative techniques. To determine the uptake of these operations and the outcome results.

STUDY DESIGN

The hospital records of all women who underwent either Uterine Balloon Therapy (UBT) or VESTA (Multiple Electrode Device) since our commencement of use of these procedures in the Rotunda Hospital, Dublin were reviewed. Medium-term assessment was by retrospective analysis of the patient records for the incidence of complications and the necessity of further medical and surgical treatment. Long-term outcome was assessed by completion of a questionnaire by all patients. Demography, complications, patient satisfaction, new symptomatology and the need for further treatment were assessed. Forty-four women who underwent UBT and 40 women who had VESTA ablation formed our study group.

RESULTS

Our main outcome measures were assessment of the amenorrhoea rate and patient satisfaction in the long-term. Medium-term follow-up revealed a 90% success rate. Long-term follow-up showed on overall treatment success of 80% and a patient satisfaction rate of 73%.

CONCLUSION

Both UBT and VESTA were associated with high rates of amenorrhoea and patient satisfaction in the long-term.

Outpatient thermal balloon ablation of the endometrium

OBJECTIVE

To determine the feasibility and potential efficacy of thermal balloon ablation of the endometrium in the outpatient setting without the need for general anesthesia or conscious sedation.

DESIGN

Prospective observational study.

SETTING

Outpatient hysteroscopy clinic in a university-affiliated teaching hospital.

PATIENT(S)

Fifty-three consecutively recruited women with menorrhagia that was unresponsive to medical treatment.

INTERVENTION(S)

Thermal balloon endometrial ablation using local anesthetic without conscious sedation.

MAIN OUTCOME MEASURE(S)

Procedure feasibility, change in menstrual symptoms, and patient satisfaction and quality of life (Menorrhagia Utility Scale and EuroQol) at 6-month follow-up.

RESULT(S)

Thermal balloon ablation was successfully completed in 50 (94%) of 53 women. The three failed procedures consisted of one case in which the woman could not tolerate the procedure because of severe discomfort, one case of equipment failure, and one case in which the balloon catheter could not be inserted into the uterine cavity. Completed outcome questionnaires were returned by 49 (98%) of 50 treated women. Improvement in menstrual loss was experienced by 39 (80%) of 49 women, and satisfaction with the outcome of treatment on menstrual symptoms was reported by 33 (67%) of 49 women. Significantly higher condition-specific quality-of-life scores were associated with treatment satisfaction.

CONCLUSION(S)

Thermal balloon ablation of the endometrium is feasible in the outpatient setting. Improvement in menstrual symptoms and satisfaction with the outcome of treatment appear to be comparable to published inpatient data. Further studies are required to determine the cost-effectiveness of outpatient compared with inpatient thermal balloon therapy.

Prediction of successful menorrhagia treatment after thermal balloon endometrial ablation

BACKGROUND

Thermal balloon endometrial ablation (TBEA) is a non-hysteroscopic technique, which relies on a combination of heat and pressure within the uterine cavity to destroy endometrium and superficial myometrium. It is a simple, easy and minimally invasive procedure with an equivalent effectiveness to hysteroscopic endometrial ablation.

OBJECTIVES

To evaluate the effectiveness of TBEA in the treatment of menorrhagia and to identify the possible predictive factors for a successful outcome after 2-year follow-up.

METHODS

A prospective study was conducted, including 45 patients suffering from serious menorrhagia. Under local anesthesia with i.v. sedation, the Therma-Choice trade mark (Gynecare, Somerville, NJ, USA) balloon was inserted transcervically and after inflation in the endometrial cavity with 5% dextrose, it was heated to 87 degrees C for an 8-minute treatment cycle.

RESULTS

There were no intraoperative complications and postoperative morbidity was minimal. At 2-year follow-up the overall improvement of menstrual pattern was 85%; with reported 29% amenorrhea, 23.5% hypomenorrhea and 32.5% euomenorrhea. Menorrhagia persisted in 15% of patients. Multiple logistic regression analysis of the factors that could affect the outcome showed that the chance for a successful treatment increased significantly with increased age (P = 0.044), shorter uterine depth (P = 0.049) and adequate balloon pressure (P = 0.027). These were the predictive factors for successful outcome. However, parity, uterine volume and endometrial thickness were not predictive factors.

CONCLUSION

At 2-year follow-up, thermal balloon endometrial ablation is effective in menorrhagia treatment. Increased age, shorter uterine depth and adequate balloon pressure can be predictive factors for successful treatment.

Efficacy and satisfaction rate comparing endometrial ablation by rollerball electrocoagulation to uterine balloon thermal ablation in a randomised controlled trial

OBJECTIVE

To compare two methods of endometrial ablation, hysteroscopic rollerball electrocoagulation (RBE) and non-hysteroscopic uterine balloon thermal ablation (Thermachoice trade mark ), regarding efficacy for reducing dysfunctional uterine bleeding and patients satisfaction rate.

METHODS

A randomised controlled study was performed in a teaching hospital at the department of gynaecology. One hundred and thirty-seven premenopausal women with dysfunctional uterine bleeding proved by validated menstrual score list were included. Endometrial ablation by a hysteroscopic or non-hysteroscopic method was performed by one gynaecologist.

RESULTS

Reduction of menstrual blood loss was significantly more successful at 24 months for thermal ablation with uterine balloon. Success rate measured by menstrual score < 185 for rollerball and thermal balloon ablation are equivalent at 12 and 24 months post-operatively. Satisfaction of the patients for both methods at 24 months post-operatively is not significantly different (respective 75% for rollerball and 80% for uterine balloon).

CONCLUSIONS

Endometrial ablation by uterine balloon thermal ablation (Thermachoice trade mark ) is equally effective as hysteroscopic RBE of the endometrium.

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.

Endometrial Ablation with a Thermal Balloon: The First 10 Years

Thermal balloon endometrial ablation (BEA) was introduced approximately 10 years ago as the first automated replacement for hysteroscopic endometrial ablation (HEA) in women with chronic abnormal uterine bleeding. Putative advantages included similar or improved clinical outcomes, and reduction of both adverse outcomes and the total cost of care, all with reduced requirements for operator skill. The published literature contains 1191 cases of BEA performed with instruments from 4 manufacturers, including a number of randomized clinical trials (RCTs) comparing the devices with HEA, usually performed by experts. In comparative RCTs, clinical and health-related quality of life outcomes as well as patient satisfaction and rate of subsequent uterine surgery appear similar in follow-up intervals that ranged from 1 to 5 years. There is a suggestion of reduced risk of adverse events with BEA, but the differences are small. There are no rigorous evaluations of resource use. The level of surgeon expertise in HEA arms of available RCTs potentially improves quality and decreases complications over what might be expected in the general population. Thus BEA seems equivalent to HEA when performed by expert surgeons with respect to most outcomes. Effectiveness studies of the two interventions should be conducted in community settings and should evaluate resource use.

Life-table analysis of the success of thermal balloon endometrial ablation in the treatment of menorrhagia

OBJECTIVE

To evaluate the change in intrauterine pressure during thermal balloon endometrial ablation and to identify risk factors associated with treatment failure.

DESIGN

Prospective observational study.

SETTING

University-affiliated teaching hospital.

PATIENT(S)

Seventy two consecutive patients with idiopathic menorrhagia refractory to medical treatment.

INTERVENTION(S)

Thermal balloon endometrial ablation under patient-controlled sedation.

MAIN OUTCOME MEASURE(S)

Change in intrauterine pressure during the treatment cycle and risk factors associated with treatment failure.

RESULT(S)

A spontaneous decrease in intrauterine pressure occurred in most patients (93%). The mean (+/-SD) decrease was 34.1 +/- 14.9 mm Hg, or 19.5% +/- 9.1%. The treatment failed in 10 patients (13.9%), and the mean end pressure was significantly lower in this group (131.1 +/- 14.1 mm Hg vs. 145.1 +/- 18.0 mm Hg; P=.02). The chance of success of treatment was significantly lower when the end pressure was <140 mm Hg (odds ratio, 0.42 [95% CI, 0.27 to 0.68]; P=.01), the intrauterine volume was >10 mL (odds ratio, 0.43 [95% CI, 0.22 to 0.83]; P=.058) and the uterus was retroverted (odds ratio, 0.36 [95% CI, 0.20 to 0.65]; P=.008).

CONCLUSION(S)

Maintaining high intrauterine pressure during the treatment cycle and correction of the retroversion may help to improve treatment success in thermal balloon endometrial ablation.

Endometrial ablation by rollerball electrocoagulation compared to uterine balloon thermal ablation. Technical and safety aspects

OBJECTIVE

To compare two methods of endometrial ablation, hysteroscopic rollerball electrocoagulation (RBE) and non-hysteroscopic uterine balloon thermal (UBT) ablation (Thermachoice), regarding intra- and post-operative technical complications and safety aspects.

STUDY DESIGN

A randomised controlled study in a teaching hospital, 139 pre-menopausal women with dysfunctional uterine bleeding proved by a validated menstrual score list were enclosed. Endometrial ablation by a hysteroscopic or non-hysteroscopic method was performed.

RESULTS

Rollerball electrocoagulation carries a significantly higher risk of intra-operative complications compared to uterine balloon thermal ablation and is a significantly more time consuming procedure. Post-operative complication rates in both groups were low, but post-operative analgesics were prescribed significantly more in the uterine balloon group.

CONCLUSION

Endometrial ablation by uterine balloon thermal ablation (Thermachoice) is a safe and simple non-hysteroscopic procedure.

Efficacy of thermal balloon ablation in patients with abnormal uterine bleeding

OBJECTIVE

The purpose of this study was to assess changes in menstrual pattern, quality of life, and patient satisfaction after thermal balloon ablation for abnormal uterine bleeding.

STUDY DESIGN

One hundred forty-one women who underwent thermal balloon ablation in our institution initially had their charts reviewed for demographics, procedure data, clinical history, and follow-up. Thereafter, a telephone interview was conducted to assess postprocedural menstrual pattern, quality of life, and patient satisfaction. Data were compared with the use of appropriate tests for categoric or continuous variables and logistic regression.

RESULTS

The median follow-up time was 18 months, and a telephone interview was obtained for 119 of 141 patients. A reduction in days per cycle (9.6 vs 3.1 days, P<.0001) and in pads per day (12.8 vs 2.5 pads/d, P<.0001) and an improvement in self-reported quality of life scores (2.8 vs 9.0, P<.0001) were observed after thermal balloon ablation. Hysterectomy was required in 21 of 141 patients (15%). Assessment of the level of satisfaction showed that 96% of patients were satisfied or very satisfied with the procedure. No major complications or deaths were related to thermal balloon ablation.

CONCLUSION

Thermal balloon ablation is a safe and efficient method to treat abnormal uterine bleeding. It reduces the menstrual flow, improves the quality of life, and remarkably fulfills expectations in selected patients.

The Role of ThermaChoice™ and MEA™ in Managing Dysfunctional Uterine Bleeding

Menorrhagia and dysfunctional uterine bleeding are com-mon indications for referral to a gynecologist. One in 20 women aged 30-49 will consult her general practitioner every year com-plaining of heavy uterine bleeding. Over 70,000 hysterecto-mies are performed annually in the UK with menorrhagia being the commonest indication. In up to 30% of these cases the uterus is anatomically normal. To these women, heavy uterine bleed-ing brings considerable stress and disruption to their social, domestic and professional lives. In the UK, the cost of primary care prescriptions for the treatment of menorrhagia was esti-mated in 1998 to be around £7 million. Gynecologists have looked at less radical but effective alternatives to hysterectomy for the treatment of heavy uterine bleeding. While the MISTLE-TOE* audit had demonstrated a pivotal role for less extreme yet successful interventions than hysterectomy for the treatment of bleeding problems, there were some setbacks. Special skills are needed to perform rollerball and diathermy loop resections of the endometrium. As well as the risk of serious intra-opera-tive complications the techniques are relatively time consum-ing to perform. In the MISTLETOE audit there were two direct deaths as a consequence of the procedure and 1.26% of patients required emergency surgery. This review looks at two new in-terventions available for clinical use, in the short term they have both proven to be successful and safe in the management of heavy uterine bleeding. Individually, they offer distinct advan-tages in the successful treatment of heavy uterine bleeding with-out the disadvantages of major surgery or medical treatment. They are both relatively easy to learn and do not require ad-vanced hysteroscopic skills. A major step forward is the suit-ability for outpatient setting.

Endometrial ablation with a new thermal balloon system

STUDY OBJECTIVE

To assess the efficacy of Thermablate EAS, a new, simple, hand-held, portable endometrial ablation instrument, in the treatment of menorrhagia.

DESIGN

Retrospective observational study (Canadian Task Force classification II-1).

SETTING

Urban hospital and private clinic facilities in Bombay, India.

PATIENTS

Sixteen women with menorrhagia.

INTERVENTION

Endometrial ablation with the Thermablate EAS.

MEASUREMENTS AND MAIN RESULTS

Follow-up at 6 months showed eight patients (50%) to have amenorrhea and six (38%) hypomenorrhea. The only failure was in a patient with cystic hyperplasia. No complications occurred.

CONCLUSIONS

Thermablate EAS is a promising instrument for endometrial ablation.

Patient-controlled sedation for outpatient thermal balloon endometrial ablation

STUDY OBJECTIVE

To evaluate the effectiveness, safety, and patient satisfaction with patient-controlled sedation during thermal balloon endometrial ablation.

DESIGN

Prospective observational study (Canadian Task Force classification II-2).

SETTING

University-affiliated teaching hospital.

PATIENTS

Thirty consecutive women with idiopathic menorrhagia refractory to medical treatment.

INTERVENTION

Thermal balloon endometrial ablation under patient-controlled sedation with a mixture of propofol and alfentanil through an analgesia pump.

MEASUREMENTS AND MAIN RESULTS

Pain was assessed using a descriptive pain score and the procedure was divided into four stages for assessment: catheter insertion, preheating phase, treatment cycle, and end of treatment. Patient satisfaction was assessed using the 8-item client satisfaction questionnaire. The procedure was well tolerated with good cooperation and no oversedation. Preheating was the most painful, and pain could be alleviated by asking the patient to self-administer a bolus of anesthesia before that phase. The median consumption of propofol was 35 mg (range 0-70 mg) and of alfentanil was 175 microg (range 50-200 microg). There were no intraoperative complications and the overall success rate in treating menorrhagia was 87%. Over 85% of the women did not think that general anesthesia was necessary. They all were highly satisfied and would recommend the procedure to others.

CONCLUSION

Patient-controlled sedation is a safe and effective method of alleviating pain and discomfort during thermal balloon ablation and is well accepted by patients.

Uterine balloon therapy for menorrhagia: A feasibility study of its use in the community setting

OBJECTIVES

To determine whether uterine balloon therapy (UBT) for menorrhagia can be performed safely in the community setting, obviating the need for hospital admission or general anaesthesia.

DESIGN

Prospective case studies of 20 women undergoing Thermachoice endometrial ablation for menorrhagia.

SETTING

Glasgow Centre for Family Planning and Reproductive Health Care, Greater Glasgow Primary Care NHS Trust, Glasgow, UK.

PARTICIPANTS

Twenty women with menorrhagia unresponsive to medical therapy.

MAIN OUTCOME MEASURES

Pain levels experienced by women during the procedure, measured by visual analogue scores and analgesia requirements postoperatively.

RESULTS

Pain scores were in the range 0.1-6.6 (median 1.1) for outpatient hysteroscopy, compared to 0.1-9.8 (median 4.0) for uterine balloon therapy. No procedure was abandoned due to pain.

CONCLUSION

UBT performed under local anaesthetic is tolerated well by patients. It is an effective treatment for menorrhagia, which is safe and easy to perform in the community setting.

Endometrial balloon ablation as a therapy for intractable uterine bleeding in an adolescent

STUDY OBJECTIVE

To evaluate the use of a minimally invasive global endometrial ablation technique in the management of life-threatening bleeding unresponsive to hormonal treatment.

RESULTS

Immediate cessation of bleeding with recovery of normal hematologic profile.

CONCLUSIONS

Endometrial ablation by global balloon ablation may be considered an alternative to hysterectomy in life-threatening hemorrhage in the adolescent patient who is unresponsive to hormonal therapy.

One-year results of the vesta system for endometrial ablation

STUDY OBJECTIVE

To compare a distensible multielectrode balloon for endometrial ablation with electrosurgical ablation performed by a combined resection-coagulation technique.

DESIGN

Randomized, prospective trial (Canadian Task Force classification I). Setting. Eight centers.

PATIENTS

Women with menorrhagia validated with a standardized pictorial blood loss assessment chart (PBAC), without intracavitary organic uterine disease, who failed or poorly tolerated medical therapy. Intervention. Results in 122 patients treated by Vesta and 112 treated surgically, evaluable at 1 year, were compared, with success defined as monthly blood loss of less than 80 ml and avoidance of additional therapy.

MEASUREMENTS AND MAIN RESULTS

Pretreatment PBAC scores for patients treated by Vesta and resection or rollerball were 535+/-612 and 445 +/- 313, respectively; at 1 year they were 18+/-37 and 28+/-60, respectively. With PBAC below 75 as the definition of success, 86.9% of Vesta-treated patients were successful compared with 83.0% treated by rollerball or resection. Total amenorrhea, defined as no visible bleeding and no use of protective products, was 31.1% and 34. 8%, respectively. None of the outcome comparisons between treatments showed statistical difference. Complications in both groups were few and minor. Most (86.6%) Vesta procedures were carried out with paracervical block with or without intravenous sedation in an office or outpatient setting, compared with 79.7% epidural or general anesthesia for rollerball or resection.

CONCLUSION

The Vesta system of endometrial ablation is equally effective and safe as classic resectoscopic methods. Potential advantages include avoidance of fluid and electrolyte disturbance associated with intravasation of distending media, and ability to perform the procedure under local anesthesia in an office setting with less total operating time.

GLOBAL ENDOMETRIAL ABLATION

Hysteroscopic endometrial ablation was introduced in the 1980's as an alternative to hysterectomy in women who failed medical management. Global endometrial ablation was introduced in the 1990's as an easier, safe, and equally effective alternative to hysteroscopic ablation. Several devices have been introduced, some of which are still undergoing feasibility studies or clinical trials. These devices include: three hot water intrauterine balloons, two intrauterine free saline solutions, a multielectrode electrocoagulating balloon, a 3-D bipolar electrocoagulation probe, a microwave, a diode fibre laser, and at least three cryoprobes. These devices require less operator skill and no irrigant or distending solutions. All require either heat or cold to destroy the endometrium. Although all devices are promising and have produced impressive preliminary results, the long-term efficacy, complication rates, and cost effectiveness have not been established. This review describes all devices as they appeared chronologically and presents only peer-reviewed data.

Endometrial thermal balloon ablation with the ThermaChoice system: effect of intrauterine pressure and duration of treatment

STUDY OBJECTIVE

To determine the safety and efficacy of thermal balloon therapy under variable intrauterine pressures and durations of treatment.

DESIGN

Retrospective cohort study. (Canadian Task Force classification II-1).

SETTING

University-affiliated teaching hospital. Patients. Sixty-six women with menorrhagia.

INTERVENTION

Eighteen patients were treated with the ThermaChoice thermal balloon system for 8 minutes at 80 to 150 mm Hg pressure, 15 were treated for 8 minutes at 151 to 180 mm Hg, and 33 were treated for 12 to 16 minutes at 151 to 180 mm Hg.

MEASUREMENTS AND MAIN RESULTS

No intraoperative complications occurred and postoperative morbidity was minimal. At 12 to 24 months follow-up, persistent menorrhagia was reported in 56% of women treated at 80 to 150 mm Hg compared with 20% treated at 151 to 180 mm Hg for 8 minutes (p = 0.01), and in 24% treated for 12 to 16 minutes at 151 to 180 mm Hg (p = 0.1).

CONCLUSION

Thermal balloon endometrial ablation is a safe and effective treatment for menorrhagia. Balloon pressure greater than 150 mm Hg increased the effectiveness of treatment. Success was not affected or influenced by increasing the duration of treatment from 8 to 12 minutes or more.

Thermal balloon endometrial ablation to treat menorrhagia in high-risk surgical candidates

OBJECTIVE

To evaluate the safety and efficacy of thermal balloon therapy in a subset of women with menorrhagia considered to be high-risk surgical candidates for hysteroscopic endometrial ablation or hysterectomy.

DESIGN

Prospective, observational study (Canadian Task Force classification II-2).

SETTING

University-affiliated teaching hospital.

PATIENTS

Women with menorrhagia, at high risk because of bleeding disorders (12), morbid obesity (6), heart-lung transplantation (2), cardiac pacemaker (2), postmenopausal bleeding (8), bowel disease with extensive adhesions and ileostomies (3), cervical stenosis (3), and other medical disorders (9).

INTERVENTION

Treatment consisted of controlled heating to 87 degrees C of 5% dextrose in water within an intrauterine latex balloon pressurized to 170 mm Hg for 8 minutes. General anesthesia was used in 28 patients (60%) and local anesthesia with or without intravenous sedation in 18 (40%).

MEASUREMENTS AND MAIN RESULTS

No intraoperative complication occurred and postoperative morbidity was minimal. Follow-up of 43 women ranged between 6 and 30 months. Overall success of the procedure was 79% (34 patients), with 33% reporting amenorrhea, 19% hypomenorrhea, 28% eumenorrhea, and 21% menorrhagia.

CONCLUSION

Thermal balloon endometrial ablation is safe and effective in treating menorrhagia when other therapies are contraindicated or difficult to perform.

Endometrial laser intrauterine thermo-therapy (ELITT): a revolutionary new approach to the elimination of menorrhagia

Various non-hysteroscopic procedures have been developed in the attempt to treat dysfunctional uterine bleeding that fails to respond to medical treatment efficiently and easily. Among these procedures is low-dose laser radiation of the endometrium with the diode source, which is characterized by the highest incidence of amenorrhea.

Immediate versus delayed treatment of perimenopausal bleeding due to benign causes by balloon thermal ablation

STUDY OBJECTIVE

To compare the effectiveness and safety of thermal balloon ablation without pretreatment with endometrium-thinning agents compared with delayed ablation with pretreatment for women with perimenopausal menorrhagia.

DESIGN

Prospective, randomized, controlled trial (Canadian Task Force classification I).

SETTING

Hospital-based ambulatory medical center.

PATIENTS

Thirty women age 46 to 51 years with severe enough perimenopausal menorrhagia to make them candidates for either hysterectomy or endometrial ablation. Two patients with submucosal myomas and six who had undergone cesarean section were included.

INTERVENTIONS

Thirteen patients were randomly assigned to be treated within 30 days and received a single intramuscular administration of gonadotropin releasing hormone (GnRH) analog; 17 women were allocated to be treated within 3 days of enrollment without uterine preparation. A thermal balloon was inserted transcervically under general anesthesia, and after inflation in the endometrial cavity with 5% dextrose in water, was heated to 87 degrees C for 8 minutes.

MEASUREMENTS AND MAIN RESULTS

Immediate and long-term major and minor complications and success rates were analyzed. Bleeding patterns and mean duration of menstrual flow were compared between groups at 6-month follow-up. No major intraoperative or postoperative complications occurred in either group, including the women who had recently undergone hysteroscopic myomectomy or had a history of cesarean section. Minor side effects were similar in both groups, and did not exceed 5%. Overall, at 6-month follow-up, 7 women were amenorrheic, 20 hypomenorrheic, and 3 eumenorrheic. No significant differences were noted between women treated with immediate or delayed ablation in either the distribution of bleeding patterns or days of flow per cycle (mean +/- SEM 1.8 +/- 0.42 vs 2.1 +/- 0.75 days, respectively).

CONCLUSION

This pilot study suggests that prompt treatment of perimenopausal menorrhagia with thermal balloon endometrial ablation is as effective and safe as deferred therapy combined with GnRH analog as an endometrium-thinning agent. In light of our results, the theory that previous cesarean section and presence of small submucosal myomas constitute relative contraindications for the procedure merits further consideration. (J Am Assoc Gynecol Laparosc 6(2):145-150, 1999)

Laparoscopically assisted vaginal hysterectomy

The LAVH revolution beginning in the late 1980s is far from over. The overwhelming growth and, at times, overuse of the laparoscopic approach have waned somewhat as physicians reevaluate LAVH, adopt new techniques such as arterial embolization and myolysis, and rediscover old techniques such as uterine morcellation at vaginal hysterectomy. In addition, the cost of new procedures and instrumentation has come under intense scrutiny. As analysis of patient care moves from cost containment to improved outcomes, there will be renewed interest in minimally invasive approaches. The challenge to accumulate data, critically analyze each approach, and select the most appropriate procedure for each patient holds the greatest promise for improved patient satisfaction and outcomes.

Modern treatments of menorrhagia attributable to dysfunctional uterine bleeding

Menorrhagia (excessive uterine bleeding) affects some 20 percent of the women of reproductive age worldwide. The following review describes known and theorized etiologies of the disorder, followed by a discussion of treatment options that are currently in use as well as those on the horizon. There is much interest internationally in decreasing hysterectomy rates, particularly for those women with abnormal bleeding and anatomically normal uteri. It is these women who are the focus of this paper. Pharmacotherapy and surgery are the mainstay treatments for such patients with menorrhagia secondary to dysfunctional uterine bleeding. Most commonly, hormonal and nonhormonal medications are followed by dilatation and curettage, and ultimately, in many cases, hysterectomy. Endometrial ablation techniques have been evolving since the 1980s in response to the need for an efficacious, safer, and more cost-effective alternatives to hysterectomy. Hysteroscopic ablation achieves these goals but is difficult technically and requires significant additional training even for otherwise skilled and experienced gynecologists. The current decade has seen the development of many innovative approaches to performing endometrial ablation. These methods are intended to be much simpler to perform with less risk than electrosurgical or laser endometrial ablation. The final section of this article presents the published data to date on these new technologies, which should (in their refined state) revolutionize the treatment of menorrhagia secondary to dysfunctional uterine bleeding.

Thermal balloon endometrial ablation: safety aspects evaluated by serosal temperature, light microscopy and electron microscopy

OBJECTIVES

Thermal balloon endometrial ablation is a new method for treating menorrhagia. The technique appears to be less difficult compared to standard hysteroscopic ablation techniques and to be significantly safer. The influence into the uterine wall of the thermal balloon ablation procedure was investigated with special reference to the ability of total destruction of the endometrium and the thermal action on the myometrium and the serosa.

STUDY DESIGN

Temperatures were measured at the uterine serosal surface during thermal balloon endometrial ablation for 8-16 min in eight patients. After subsequent hysterectomy the extent of thermal damage into the myometrium was assessed by light and electron microscopy.

RESULTS

The highest temperature measured on the uterine serosa was 39.1 degrees C. Coagulation of the myometrium adjacent to the endometrium could be demonstrated by light microscopy in all patients, with a maximum depth of 11.5 mm. By electron microscopy no influence of heat could be demonstrated beyond 15 mm from the endometrial surface.

CONCLUSION

Up to 16 min of thermal balloon endometrial ablation therapy can destroy the endometrium and the submucosal layers. The myometrium is only coagulated to a depth where full thickness necrosis or injury is unlikely.

Uterine thermal balloon therapy for the treatment of menorrhagia: the first 300 patients from a multi-centre study. International Collaborative Uterine Thermal Balloon Working Group

OBJECTIVE

To evaluate the safety and efficacy of thermal balloon therapy for menorrhagia.

DESIGN

Prospective, observational study.

SETTING

Fifteen centres in Canada and Europe.

POPULATION

Two hundred and ninety-six eligible women for whom follow up data were available for three months or more. Eligible women included those for whom further fertility was not a concern, were not postmenopausal, suffered from intractable menorrhagia, had a normal uterine cavity, and who were fully informed regarding the investigational nature of uterine thermal balloon therapy.

METHODS

Three hundred and twenty-one procedures of balloon endometrial ablation were performed using the same protocol between June 1994 and August 1996. Exclusion criteria included structural uterine abnormality or (pre) malignant lesions. Treatment entailed controlled heating of fluid in an intrauterine balloon. General anaesthesia was employed in the 61% of procedures while local anaesthesia with or without sedation was used in 39% of cases.

ANALYSIS

Follow up data at 3 and/or 6, and/or 12 months were required for inclusion in the analysis. A paired t test, Wilcoxon signed-ranks test, and multiple and logistic regression analyses were used to evaluate the changes in bleeding and dysmenorrhoea patterns, and possible confounding variables, respectively. Success was defined as the subjective reduction of menses to eumenorrhoea or less.

RESULTS

No intra-operative complications occurred, and post-operative morbidity was minimal. Success of the procedure was constant over the year (range 88%-91%). Treatment led to a significant decrease in the duration of menstrual flow and severity of pain (P < 0.0001). Increasing age, higher balloon pressure, smaller uterine cavity, and a lesser degree of pre-procedure menorrhagia were associated with significantly improved results. Pre-treatment with gonadotrophin releasing hormone agonists increased amenorrhoea and spotting rates (P = 0.03), but was only used in 5% of cases.

CONCLUSION

Thermal balloon endometrial ablation appears to be safe, as well as effective in properly selected women with menorrhagia and is potentially an outpatient procedure.