Thermal balloon ablation versus endometrial resection for the treatment of abnormal uterine bleeding

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.

Medical therapy versus radiofrequency endometrial ablation in the initial treatment of heavy menstrual bleeding (iTOM Trial): A clinical and economic analysis

BACKGROUND

Radiofrequency endometrial ablation (REA) is currently a second line treatment in women with heavy menstrual bleeding (MHB) if medical therapy (MTP) is contraindicated or unsatisfactory. Our objective is to compare the effectiveness and cost burden of MTP and REA in the initial treatment of HMB.

METHODS

We performed a randomized trial at Mayo Clinic Rochester, Minnesota. The planned sample size was 60 patients per arm. A total of 67 women with HMB were randomly allocated to receive oral contraceptive pills (Nordette ®) or Naproxen (Naprosyn®) (n = 33) or REA (n = 34). Primary 12-month outcome measures included menstrual blood loss using pictorial blood loss assessment chart (PBLAC), patients' satisfaction, and Menorrhagia Multi-Attribute Scale (MMAS). Secondary outcomes were total costs including direct medical and indirect costs associated with healthcare use, patient out-of-pocket costs, and lost work days and activity limitations over 12 months.

RESULTS

Compared to MTP arm, women who received REA had a significantly lower PBLAC score (median [Interquartile range, IQR]: 0 [0-4] vs. 15 [0-131], p = 0.003), higher satisfaction rates (96.8%vs.63.2%, p = 0.003) and higher MMAS (median [IQR]: 100 [100-100] vs. 100 [87-100], p = 0.12) at 12 months. Direct medical costs were higher for REA ($5,331vs.$2,901, 95% confidence interval (CI) of mean difference:$727,$4,852), however, when indirect costs are included, the difference did not reach statistical significance ($5,469 vs. $3,869, 95% CI of mean difference:-$339, $4,089).

CONCLUSION

For women with heavy menstrual bleeding, initial radiofrequency endometrial ablation compared to medical therapy offered superior reduction in menstrual blood loss and improvement in quality of life without significant differences in total costs of care.

CLINICAL TRIAL REGISTRATION

NCT01165307.

Endometrial thermal balloon ablation in women with previous cesarean delivery: pilot study

STUDY OBJECTIVE

To evaluate the safety and efficacy of thermal balloon ablation in the management of menorrhagia in women with history of cesarean delivery.

DESIGN

Descriptive study (Canadian Task Force classification II-2).

SETTING

Tertiary care university hospital.

PATIENTS

One hundred sixteen premenopausal women with dysfunctional uterine bleeding were offered endometrial thermal balloon ablation. This group included 26 women who had previously delivered via cesarean section (CS): 11 women with 1 CS, 8 women with 2 CS, 4 women with 3 CS, 2 women with 4 CS, and 1 woman with 5 CS.

INTERVENTION

Endometrial thermal balloon ablation.

MEASUREMENTS AND MAIN RESULTS

One hundred thirteen procedures were completed successfully; in 3 women, the procedure could not be completed. There were no major immediate operative complications. Sixteen patients (13.8%) required further gynecologic interventions after ablation: hysterectomy in 15, and dilation and curettage in 1. This included 13 women (14.4%) in the group with no previous CS and 3 women (11.5%) in the group with previous CS.

CONCLUSION

Within the limitations of this preliminary study, endometrial thermal balloon ablation seems to be a possible therapeutic option for treatment of dysfunctional uterine bleeding in women with previous cesarean delivery.

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.

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.

Perioperative Predictors of Successful Hysteroscopic Endometrial Ablation

OBJECTIVE

To determine which perioperative factors influence the success of hysteroscopic endometrial ablation in patients with menorrhagia.

STUDY DESIGN

A longitudinal study of 128 women who underwent hysteroscopic endometrial ablation or resection. Clinical data included age, uterine size, the presence of intramural or submucosal myomas and polyps, and length of follow-up from initial hysteroscopic ablation to re-ablation or hysterectomy ('failure'). Kaplan-Meier survival analysis, log-rank tests and Cox proportional hazard regression were used to evaluate the equality of survival distributions and to model the overall effects of the various predictor variables on surgical outcomes.

RESULTS

Patients were followed for a median time of 44 months. Thirteen women (10.2%) underwent a second operative procedure. Multivariate analysis identified submucosal myoma as a statistically significant positive predictor of the risk of failure [hazard ratio (HR) 5.22, 95% confidence interval (CI) = 1.63, 16.73)]. Older age was associated with a marginally lower risk of subsequent surgery (HR 0.90 per additional year of age, 95% CI = 0.81, 1.00).

CONCLUSIONS

The presence of submucosal myoma increases the risk of subsequent surgery in patients undergoing endometrial ablation.

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 occurrence and outcome of 39 pregnancies after 1621 cases of transcervical resection of endometrium

BACKGROUND

To evaluate the outcomes and management of pregnancy after transcervical resection of the endometrium (TCRE).

METHODS

Retrospective study of 39 pregnancies after 1621 procedures of TCRE.

RESULTS

Among 1621 women who were successfully followed up after TCRE, there were 39 pregnancies in 32 women, including five ectopic pregnancies (12.8%) and 34 intrauterine pregnancies (87.2%). The majority of pregnancies (84.6%) occurred within the first 2 years. In the first year after TCRE, the incidence of pregnancy was 1.5%. In women who had amenorrhoea after TCRE, the chances of conception (2/676; 0.3%) were significantly (P < 0.001) lower than for those who continued to have period (30/945; 3.2%). Thirty-two cases with intrauterine pregnancy were terminated under ultrasound guidance with two difficult procedures. Only one pregnancy in our study resulted in spontaneous miscarriage which was managed by suction curettage. One term pregnancy had placenta increta resulting in Caesarean hysterectomy.

CONCLUSIONS

Pregnancies after TCRE are associated with increased risk, and clinicians should be aware of the various complications of pregnancy that may occur after TCRE, including an increased risk of ectopic pregnancy. Surgical termination of pregnancy after TCRE is potentially a difficult procedure and should be carried out under ultrasound guidance.

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.

Pregnancy after endometrial ablation: English literature review and case report

Endometrial ablation is an effective treatment for dysfunctional uterine bleeding. The incidence of pregnancy after endometrial destruction is low and is reported to be 0.7%. We report what is to the best of our knowledge the first case of pregnancy after microwave endometrial ablation and review the outcomes of 74 pregnancies after various methods of endometrial destruction.

Thermal ablation performed in a primary care setting: the South Warwickshire Experience

OBJECTIVE

To assess the feasibility of performing outpatient thermal ablation in a primary care setting.

DESIGN

Prospective study.

SETTING

A small peripheral hospital in the UK used by local general practitioners and visiting hospital practitioners for its outpatient facilities.

POPULATION

The area of South Warwickshire serves a population of 270,000.

METHODS

Two general practitioners were trained to perform outpatient thermal ablation using the Thermachoice thermal ablation system (Thermachoice II). The unit functioned autonomously with support from a local gynaecologist and radiologist, accepting referrals from hospital consultants and general practitioners.

MAIN OUTCOME MEASURES

Severity of menstrual loss, premenstrual symptoms, dysmenorrhoea and quality of life assessed by visual analogue scales before treatment and at one month, two months, one year and two years.

RESULTS

Eighty-seven women were treated. No major complications were encountered from the procedure. Reduction of menstrual loss or cure was reported by over 94% of women. Premenstrual syndrome (PMS) and symptoms of dysmenorrhoea were also improved by treatment. The majority of women were satisfied with the operation at one month (96%), two months (93%), one year (92%) and two years (94%).

CONCLUSIONS

Thermal ablation is a simple procedure well suited to an outpatient setting. There are few complications as a result of the use of the thermal ablation catheters, and this study has shown that the procedure can be undertaken in a primary care setting with excellent results.

Microwave and thermal balloon ablation for heavy menstrual bleeding: a systematic review

OBJECTIVE

To compare the effectiveness of two second generation endometrial ablation techniques (microwave and thermal balloon endometrial ablation) with first generation techniques of endometrial ablation to treat heavy menstrual bleeding in women.

SEARCH STRATEGY

We searched the Cochrane Library (issue 3, 2002), the National Research Register, MEDLINE (1966 to August 2002), Embase (1980 to August 2002) and Web of Science Proceedings (all years). We also searched reference lists and contacted experts and manufacturers in the field.

SELECTION CRITERIA

Randomised controlled trials and controlled trials of microwave endometrial ablation and thermal balloon endometrial ablation versus transcervical resection and rollerball ablation, alone or in combination, to treat heavy menstrual bleeding were included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected studies for inclusion and extracted data. As there was considerable clinical and methodological heterogeneity among the studies, meta-analysis was not undertaken and results are presented descriptively.

RESULTS

Two randomised controlled trials of microwave endometrial ablation and eight trials (six randomised controlled trials) of thermal balloon endometrial ablation were included in the review. No significant differences were found between first and second generation techniques in terms of amenorrhoea, bleeding patterns, pre-menstrual symptoms, patient satisfaction or quality of life. Microwave endometrial ablation and thermal balloon endometrial ablation had significantly shorter operating and theatre times than first generation techniques. Adverse effects were few with all techniques, but there were fewer peri-operative adverse effects with second generation techniques.

CONCLUSION

Microwave endometrial ablation and thermal balloon endometrial ablation are alternatives to first generation techniques for treating heavy menstrual bleeding. No head-to-head trials of microwave endometrial ablation and thermal balloon endometrial ablation have been undertaken and there is not yet enough evidence of differences in clinical effectiveness between these two techniques.

Intrauterine instillation of trichloroacetic acid is effective for the treatment of dysfunctional uterine bleeding

OBJECTIVE

To evaluate the effectiveness of trichloroacetic acid (TCA) instillation into uterine cavity for the treatment of dysfunctional uterine bleeding (DUB).

DESIGN

Prospective clinical study.

SETTING

A university research hospital.

PATIENT(S)

Ninety women participated who had dysfunctional uterine bleeding.

INTERVENTION(S)

Ninety-five percent of TCA was instilled into uterine cavity for endometrial ablation in women with dysfunctional uterine bleeding who want conservative treatment. Participants in group 1 received only TCA; participants in group 2 received a single dose of gonadotropin-releasing hormone analogue 1 month before the procedure.

MAIN OUTCOME MEASURE(S)

All participants underwent an evaluation that included cycle history, body mass index measurement, and transvaginal ultrasonography of pelvis, diagnostic hysteroscopy and endometrial biopsy.

RESULT(S)

At the end of 12 months of the treatment, amenorrhea rates in group 1 and group 2 were 26.7% vs. 31.1%, with pooled amenorrhea, hypomenorrhea, and eumenorrhea rates of 95.6% vs. 97.8%, respectively. There was no significant difference between the groups vis-a-vis postprocedure results. More than 90% of women who have this procedure are satisfied with the results. There were no observed negative effects or related complications with this treatment.

CONCLUSION(S)

An instillation of TCA into uterine cavity produces acceptable results and provides conservative management of DUB.

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.

A cost-utility analysis of microwave and thermal balloon endometrial ablation techniques for the treatment of heavy menstrual bleeding

OBJECTIVE

To assess the cost effectiveness of the second-generation surgical treatments for heavy menstrual bleeding (microwave and thermal balloon endometrial ablation) compared with existing endometrial ablation techniques (transcervical resection and rollerball, alone or in combination) and hysterectomy.

DESIGN

A state transition (Markov) cost-utility economic model.

POPULATION

Women with heavy menstrual bleeding.

METHODS

A Markov model was developed using spreadsheet software. Transition probabilities, costs and quality of life data were obtained from a systematic review of effectiveness undertaken by the authors, from published sources, and expert opinion. Cost data were obtained from the literature and from a NHS trust hospital. Indirect comparison of thermal balloon endometrial ablation versus microwave endometrial ablation or either second-generation endometrial ablation method versus hysterectomy, and comparison of second-generation versus first-generation techniques were carried out from the perspective of health service payers. The effects of uncertainty were explored through extensive one-way sensitivity analyses and Monte Carlo simulation.

MAIN OUTCOME MEASURES

Incremental cost effectiveness ratios based on cost per quality adjusted life year (QALY) gained, and cost effectiveness acceptability curves.

RESULTS

Compared with first-generation techniques, both microwave and thermal balloon endometrial ablation cost less and accrued more QALYs. Hysterectomy was more expensive, but accrued more QALYs than all endometrial ablation methods. Baseline results showed that differences between microwave endometrial ablation and thermal balloon endometrial ablation were slight. Sensitivity analyses showed that small changes in values may have a marked effect on cost effectiveness. Probabilistic simulation highlighted the uncertainty in comparisons between different endometrial ablation options, particularly between second-generation techniques.

CONCLUSIONS

Despite limitations in available data, the analysis suggests that second-generation techniques are likely to be more cost effective than first-generation techniques in most cases. Hysterectomy, where a woman finds this option acceptable, continues to be a very cost effective procedure compared with all endometrial ablation methods.

Randomised controlled trial of bipolar radio-frequency endometrial ablation and balloon endometrial ablation

OBJECTIVE

To compare the effectiveness of two second-generation ablation techniques, bipolar radio-frequency impedance-controlled endometrial ablation (NovaSure) and balloon ablation (ThermaChoice), in the treatment of menorrhagia.

DESIGN

Double-blind, randomised, controlled trial.

SETTING

A large teaching hospital with 500 beds in The Netherlands.

POPULATION

Women suffering from menorrhagia referred by their general practitioner.

METHODS

Women suffering from menorrhagia, without intracavitary abnormalities, were randomly allocated to bipolar radio-frequency ablation (bipolar group) and balloon ablation (balloon group) in a 2:1 ratio. At follow up, both women and observers were unaware of the type of treatment that had been performed.

MAIN OUTCOME MEASURES

The main outcome measure was amenorrhea at 3, 6 and 12 months after randomisation.

RESULTS

One hundred and twenty-six women were included in the study, of which 83 were allocated to the bipolar group, and 43 to the balloon group. No complications occurred in either of the treatment groups. At the one-year follow up stage, amenorrhea rates were 43% (34/83) in the bipolar group and 8% (3/43) in the balloon group (treatment effect in time P < 0.001). At this stage, 90% of the patients in the bipolar group were satisfied with the result of the treatment against 79% in the balloon group (treatment effect in time P= 0.003).

CONCLUSION

The bipolar radio-frequency impedance-controlled endometrial ablation system is more effective than balloon ablation in the treatment of menorrhagia.

Outpatient hysteroscopy and ultrasonography in the management of endometrial disease

PURPOSE OF REVIEW

This review is to inform the ongoing debate about the choice between ultrasound and hysteroscopy in the management of endometrial disease presenting with abnormal uterine bleeding using information provided from recently published literature.

RECENT FINDINGS

Transvaginal ultrasound measurement of endometrial thickness, using 4 or 5 mm cut-offs to define abnormality, is a good test for excluding endometrial cancer in women with postmenopausal bleeding. In contrast, hysteroscopy is a good test for detecting endometrial cancer, but less effective at excluding serious disease. The accuracy of transvaginal ultrasound in diagnosing intracavity pathology such as submucous fibroids and polyps is improved with saline instillation to levels of accuracy comparable to that of outpatient hysteroscopy. Miniaturization of hysteroscopes and ancillary instrumentation (e.g. development of bipolar intrauterine systems) has facilitated 'see and treat' outpatient hysteroscopy, so that it should no longer be considered simply an outpatient diagnostic modality. Preliminary cost-effectiveness studies have supported the use of ultrasound in the diagnosis of endometrial disease, but further, more comprehensive studies are required comparing ultrasound and outpatient hysteroscopy.

SUMMARY

Recently published research has provided the clinician with high-quality data regarding the accuracy of ultrasound and hysteroscopy in the diagnosis of endometrial disease. Despite this, controversy remains regarding the relative roles of these uterine imaging modalities. Future research needs to be directed towards providing effectiveness and cost-effectiveness data in order to resolve the ongoing debate and guide best clinical practice.

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.

Thermal Balloon Ablation in Patients with Multiple Morbidity: 3-Year Follow-up

STUDY OBJECTIVE

To evaluate the effectiveness of a thermal uterine balloon therapy system in a specific group of patients with multiple morbidity.

DESIGN

Retrospective cohort analysis (Canadian Task Force classification II-2).

SETTING

Department of Obstetrics and Gynecology in two university teaching hospitals.

PATIENTS

Seventy women with severe systemic disease (American Association of Anesthesiologists physical status score >/= III) and severe menorrhagia.

INTERVENTION

Uterine balloon therapy under local anesthesia and 3 years of follow-up.

MEASUREMENTS AND MAIN RESULTS

The women had a mean age of 44.3 years (range, 24-76). After treatment, 25.7% of the patients had no bleeding, 45.7% hypomenorrhea, and 21.4% normal menstrual flow. The procedure was repeated successfully for one patient, and five failures (7.1%) were observed. The blood count values differed significantly (p <.001) before and after balloon therapy.

CONCLUSION

Uterine balloon therapy is a suitable and useful option for women with severe uterine bleeding and concomitant severe systemic nongynecologic disease.

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.

Successful Pregnancy After Thermal Balloon Endometrial Ablation

BACKGROUND

Thermal balloon ablation is as effective as other electrosurgical modalities used for endometrial ablation. Pregnancy rate after endometrial ablation is 0.24-0.68%. We report a near-term viable pregnancy after thermal balloon uterine ablation.

CASE

Thermal balloon uterine endometrial ablation was performed on a 38-year-old woman with menorrhagia. She conceived 11 months after the operation and decided to continue the pregnancy. After 35 weeks of uneventful gestation, she spontaneously delivered a liveborn infant.

CONCLUSION

Although rare, pregnancy after endometrial ablation is possible. Obstetric complications, such as pathologic placental adherence and fetal demise due to a small, scarred uterine cavity, have been reported. This pregnancy went to 35 weeks without complication despite a three-chambered appearance of the uterus.

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.

Hysteroscopic appearance of the endometrial cavity following thermal balloon endometrial ablation

OBJECTIVE

To assess the appearance of the endometrial cavity after thermal balloon endometrial ablation.

DESIGN

Observational study.

SETTING

University teaching hospital.

PATIENT(S)

Twenty-two women who had undergone thermal balloon endometrial ablation and who were followed up for at least 6 months.

INTERVENTION(S)

Outpatient diagnostic hysteroscopy.

MAIN OUTCOME MEASURE(S)

Appearance of the endometrial cavity and presence of intrauterine adhesions on hysteroscopy.

RESULT(S)

Postablation intrauterine adhesions were found in eight women (36.4%); six had focal adhesions in the fundal area and two had complete obliteration of the cavity. Of these eight women, three had spotting during menstruation, three had hypomenorrhea, one had eumenorrhea, and one had amenorrhea. The uterine cavity was fibrotic in four (18%) women; all reported spotting during menstruation. Ten women had a normal uterine cavity; eight had hypomenorrhea, one had spotting, and one had eumenorrhea.

CONCLUSION(S)

The hysteroscopic appearance of the uterine cavity after thermal balloon endometrial ablation varies considerably. Menstrual outcome is associated with postablation appearance.

Comparison between the levonorgestrel intrauterine system (LNG-IUS) and thermal balloon ablation in the treatment of menorrhagia

OBJECTIVES

To compare the effectiveness of endometrial thermal ablation and the levonorgestrel intrauterine system (LNG-IUS) in the management of menorrhagia.

STUDY DESIGN

Fifty women attending a gynaecology clinic at a District General Hospital in south-west England were randomised to either surgical treatment using thermal ablation (Thermochoice, Gynecare) or medical treatment using a LNG-IUS (Mirena, Schering Healthcare). A pictorial menstrual chart was completed pre-insertion/operatively and again at 6 months post-insertion/operatively. Non-parametric tests (Mann-Whitney) were used for statistical analysis.

RESULTS

Follow-up analysis was possible in 23 women in the Thermochoice group and 21 women in the Mirena group. The menstrual scores were slightly higher in the Thermochoice group (median 101) than the Mirena group (median 75) (P=0.025) pre-insertion/operatively but this difference was lost post-insertion/operatively (P=0.689) with median menstrual scores of 27 for the Thermochoice group and 19 for the Mirena group, respectively.

CONCLUSION

Both Thermochoice endometrial ablation and a Mirena LNG-IUS are equally effective in the management of menorrhagia. The choice of treatment should be tailored to the woman's needs and preferences.

Severe menorrhagia due to factor VII deficiency successfully treated by thermal balloon endometrial ablation

Factor VII deficiency, a rare inherited bleeding disorder, is often complicated by menorrhagia leading to severe anemia. These women are treated by repeated blood product transfusions, various hormone preparations, and repeated endometrial curettage. Despite the high risks involved, women with refractory disease were usually advised to undergo hysterectomy. A 36-year-old patient was known to suffer from factor VII deficiency and common variable immune deficiency, and had a long history of worsening menorrhagia. As various medical therapies failed to improve her menorrhagia, and she often required curettage and blood transfusions, we offered her more definitive treatment with thermal balloon endometrial ablation. The procedure was uneventful, and during 24 months of follow-up the patient has had several events of spotting but no heavy periods. It is suggested that thermal balloon endometrial ablation is a suitable minimally invasive therapeutic option for menorrhagia in women with factor VII deficiency.

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.