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Samala M, Pasupula SS, Mudigonda S, Tadikonda RR. Endometrial ablation techniques in treating menorrhagia. Minerva Obstet Gynecol 2023; 75:279-287. [PMID: 35912462 DOI: 10.23736/s2724-606x.22.05101-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Menorrhagia is a frequent gynecological problem that is clinically described as excessive blood loss of 80 mL per menstrual cycle. It has the potential to lower their quality of life and to induce anemia. Medical therapy has typically been the first line of treatment; however, it is frequently ineffectual. Hysterectomy, on the other hand, is clearly 100 percent effective in stopping bleeding, but it is more expensive and can cause serious problems. So, the endometrial ablation is preferred when the endometrial layer is destroyed or removed during the procedure. To "ablate" (remove) the endometrial lining, a variety of procedures has been devised. The gold standard resectoscopic procedures (laser, transcervical endometrial resection, and rollerball) require hysteroscopic visualization of the uterus and while safe, necessitate expert surgeons. Several innovative procedures have lately been developed, the majority of which may be conducted blindly and take less time. Many nonresectoscopic procedures are still in the process of being developed, refined, and investigated. This article discusses the various techniques and procedures used in endometrial ablation, the importance of the physician using endometrial thinning agents because success rates are higher when thinning agents are used, and the importance of women understanding the complications mainly related to pregnancy. Women should be helped to make informed management decisions by discussing the risks and benefits of each treatment with their consultant. Since there are many treatment options available, with no one option being superior in all respects, patient preference and treatment preferences should be considered when deciding on management.
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Vitale SG, Riemma G, Mikuš M, Carugno J, Torella M, Reyes-Muñoz E, Cela V, Perez Medina T, Della Corte L, Pacheco LA, Haimovich S, De Franciscis P, Angioni S. Quality of Life, Anxiety and Depression in Women Treated with Hysteroscopic Endometrial Resection or Ablation for Heavy Menstrual Bleeding: Systematic Review and Meta-Analysis of Randomized Controlled Trials. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1664. [PMID: 36422203 PMCID: PMC9695759 DOI: 10.3390/medicina58111664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/12/2022] [Accepted: 11/15/2022] [Indexed: 10/10/2023]
Abstract
Background and Objectives: Hysteroscopic endometrial resection (ER) or global endometrial ablation (GEA) are feasible methods to treat heavy menstrual bleeding (HMB). The aim of this systematic review and meta-analysis of randomized controlled trials (RCTs) was to assess patient's quality of life (QoL) in women treated with ER/GEA compared to hysterectomy. Materials and Methods: Electronic searches in MEDLINE Scopus, ClinicalTrials.gov, EMBASE, PROSPERO and Cochrane CENTRAL were conducted from their inception to July 2022. Inclusion criteria were RCTs of premenopausal women with HMB randomized to conservative surgical treatment (ER/GEA) or hysterectomy. The primary outcome was the evaluation of QoL using the SF-36 score. Results: Twelve RCTs (2773 women) were included in the analysis. Women treated with hysteroscopic ER/GEA showed significantly lower scores for the SF-36 general health perception (mean difference (MD) -8.56 [95% CI -11.75 to -5.36]; I2 = 0%), social function (MD -12.90 [95% CI -23.90 to -1.68]; I2 = 91%), emotional role limitation (MD -4.64 [95% CI -8.43 to -0.85]; I2 = 0%) and vitality (MD -8.01 [95% CI -14.73 to -1.30]; I2 = 74%) domains relative to hysterectomy. Anxiety, depression scores and complication rates were similar between treatments. Relative to uterine balloon therapy, amenorrhea was more common with EA/GER (relative risk 1.51 [95% CI 1.03 to 1.20] I2 = 28%), but posttreatment satisfaction was similar. Conclusions: Women's perception of QoL might be seen to be less improved after hysteroscopic ER/GEA rather than hysterectomy. However, such findings need to be confirmed by additional trials due to the high number of outdated studies and recent improvements in hysteroscopic instrumentation and techniques.
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Affiliation(s)
- Salvatore Giovanni Vitale
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy
| | - Gaetano Riemma
- Obstetrics and Gynecology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80128 Naples, Italy
| | - Mislav Mikuš
- Department of Obstetrics and Gynecology, University Hospital Center Zagreb, 10000 Zagreb, Croatia
| | - Jose Carugno
- Obstetrics, Gynecology and Reproductive Sciences Department, Minimally Invasive Gynecology Unit, University of Miami, Miller School of Medicine, Miami, FL 33124, USA
| | - Marco Torella
- Obstetrics and Gynecology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80128 Naples, Italy
| | - Enrique Reyes-Muñoz
- Department of Gynecological and Perinatal Endocrinology, Instituto Nacional de Perinatología, Mexico City 11000, Mexico
| | - Vito Cela
- Division of Gynecology and Obstetrics, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Tirso Perez Medina
- Department of Obstetrics and Gynecology, University Hospital Puerta de Hierro Majadahonda, Autonoma University of Madrid, 28001 Madrid, Spain
| | - Luigi Della Corte
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, 80131 Naples, Italy
| | | | - Sergio Haimovich
- Department of Obstetrics and Gynecology, Laniado University Hospital, Netanya, Israel and Adelson School of Medicine, Ariel University, Ariel 98603, Israel
| | - Pasquale De Franciscis
- Obstetrics and Gynecology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80128 Naples, Italy
| | - Stefano Angioni
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy
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Paul TD, Readman E, Mooney S. Tubal interruption and subsequent surgery for pain after endometrial ablation: A retrospective cohort study. Aust N Z J Obstet Gynaecol 2021; 61:934-940. [PMID: 34491577 DOI: 10.1111/ajo.13425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 08/08/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Endometrial ablation (EA) is an alternative to hysterectomy for abnormal uterine bleeding (AUB), with reduced recovery time and fewer operative risks. However, post-ablation pain may be associated with subsequent surgery, including hysterectomy. It is uncertain what factors affect surgery rates for post-ablation pain, particularly with respect to timing and technique of tubal interruption. AIM To evaluate the relationship between tubal interruption and post-ablation pain and subsequent surgery. MATERIALS AND METHODS We conducted a retrospective cohort study involving 324 patients at a Melbourne tertiary hospital from 2009 to 2020. The primary outcome was subsequent pelvic surgery for pain following EA. RESULTS Pain following EA was reported by 29.7% of patients, with 10.5% of patients undergoing subsequent surgery for pain. Patients with tubal interruption were more likely to undergo subsequent surgery for pain than those with no tubal interruption (odds ratio (OR): 3.49, 95% CI: 1.59-7.66; P = 0.002). Tubal ligation was strongly associated with subsequent surgery for pain (OR: 3.12, 95% CI: 1.48-6.57; P = 0.003). In contrast, those with salpingectomy did not have an increased risk of subsequent surgery for pain, compared to those with no tubal interruption (OR: 1.5; 95% CI 0.32-7.13). Pre-ablation pain (adjusted OR: 2.98, 95% CI: 1.37-6.48; P = 0.006) and previous caesarean section (OR: 2.66; 95% CI: 1.13-6.25; P = 0.025) were also associated with subsequent surgery for pain. CONCLUSION Our results suggest that tubal interruption, pre-ablation pain and previous caesarean section are associated with subsequent surgery for pain. These results can better inform preoperative counselling regarding the risk of subsequent surgery after EA.
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Affiliation(s)
- Tarini D Paul
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Melbourne, Victoria, Australia
| | - Emma Readman
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Melbourne, Victoria, Australia
| | - Samantha Mooney
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Melbourne, Victoria, Australia
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Nakayama K, Razia S, Ishibashi T, Ishikawa M, Yamashita H, Nakamura K, Sawada K, Yoshimura Y, Tatsumi N, Kurose S, Minamoto T, Iida K, Ishikawa N, Kyo S. Pathological findings in the endometrium after microwave endometrial ablation. Sci Rep 2020; 10:20766. [PMID: 33247224 PMCID: PMC7695731 DOI: 10.1038/s41598-020-77594-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 10/12/2020] [Indexed: 01/04/2023] Open
Abstract
The acceptance of MEA in Japan is well demand due to its outstanding effectiveness and safety. Infrequently, a repeat MEA or hysterectomy is needed for recurrent menorrhagia in case of failure ablation. The reasons of recurrent menorrhagia subsequent MEA treatment are unclear. The objective of current study is to identify the possible causes of menorrhagia repetition following MEA, together with the observation of histological changes in the endometrium due to this treatment compared with normal cycling endometrial tissue. A total of 170 patients, 8 (4.7%) of them carried out hysterectomy after 16.8 months (range, 2-29 months) of MEA treatment. Normal (n = 47) and MEA (n = 8) treated paraffin embedded endometrial tissue were prepared for hematoxylin and eosin (H&E) and immunostaining study to recognize the histological changes in the endometrium as a result of MEA treatment. The histological features observed increased tubal metaplasia (TM) including negative expression of the estrogen receptor (ER) and progesterone receptor (PR) in the endometrium subsequent MEA treatment. Increased TM together with the absence of ER and PR expression might be a reasonable explanation for repetition menorrhagia in cases of failure ablation. Further study is required to clarify the molecular mechanisms of tubal metaplasia and the expression loss of hormone receptor in the endometrium as a result of MEA treatment. Current studies propose that low dose estrogen-progestin may not be effective with recurrent menorrhagia patient's due to the inadequacy of hormone receptor expression in the endometrium following MEA.
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Affiliation(s)
- Kentaro Nakayama
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, Enyacho 89-1, Izumo, Shimane, 6938501, Japan.
| | - Sultana Razia
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, Enyacho 89-1, Izumo, Shimane, 6938501, Japan
| | - Tomoka Ishibashi
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, Enyacho 89-1, Izumo, Shimane, 6938501, Japan
| | - Masako Ishikawa
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, Enyacho 89-1, Izumo, Shimane, 6938501, Japan
| | - Hitomi Yamashita
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, Enyacho 89-1, Izumo, Shimane, 6938501, Japan
| | - Kohei Nakamura
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, Enyacho 89-1, Izumo, Shimane, 6938501, Japan
| | - Kiyoka Sawada
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, Enyacho 89-1, Izumo, Shimane, 6938501, Japan
| | - Yuki Yoshimura
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, Enyacho 89-1, Izumo, Shimane, 6938501, Japan
| | - Nagisa Tatsumi
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, Enyacho 89-1, Izumo, Shimane, 6938501, Japan
| | - Sonomi Kurose
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, Enyacho 89-1, Izumo, Shimane, 6938501, Japan
| | - Toshiko Minamoto
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, Enyacho 89-1, Izumo, Shimane, 6938501, Japan
| | - Kouji Iida
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, Enyacho 89-1, Izumo, Shimane, 6938501, Japan
| | - Noriyoshi Ishikawa
- Department of Organ Pathology, Shimane University School of Medicine, Izumo, 6938501, Japan
| | - Satoru Kyo
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, Enyacho 89-1, Izumo, Shimane, 6938501, Japan
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Wang C, Yang X, Fan Q, Yuan J, Li Y, Wang Y. Feasibility and safety of cryoablation on the porcine ureter using a new balloon cryoprobe. Cryobiology 2020; 96:130-136. [PMID: 32707123 DOI: 10.1016/j.cryobiol.2020.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/16/2020] [Accepted: 07/16/2020] [Indexed: 11/30/2022]
Abstract
Cryoablation, as a well-characterized technology, has multifarious clinical applications. But few are reported on ureteral endometriosis. Thus, we examined the feasibility and safety of cryotherapy with a novel balloon cryoprobe on ureter in a live porcine model. During the freezing and thawing cycle, temperature was recorded in different parts of the ureter in real-time. Two-minute cryoablation could induce necrosis within range in 1 cm diameter on serosa layer. The temperature respectively dropped to -136.5 °C, -96.1 °C and -17.5 °C at the cryotherapy center, 1 cm and 1.5 cm from center on serosal side. The ureters were harvested immediately, 2 weeks or 3 months after cryotherapy. No perforation, stricture, adhesions, or hydronephrosis was observed. Histopathologic representations of ureters after cryoablation indicated that full thickness necroses of ureters were seen in all samples. The results demonstrated ureteral cryoablation using a novel balloon probe was feasible, safe, and effective. These findings provided us reference before cryoablation could be applied in clinical practice in treating ureteral endometriosis.
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Affiliation(s)
- Chao Wang
- Department of Gynecologic Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030, China; Shanghai Municipal Key Clinical Specialty of Gynecologic Oncology, Shanghai, 200030, China; Shanghai Key Laboratory of Embryo Original Diseases Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China
| | - Xiaoming Yang
- Department of Gynecologic Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030, China; Shanghai Municipal Key Clinical Specialty of Gynecologic Oncology, Shanghai, 200030, China; Shanghai Key Laboratory of Embryo Original Diseases Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China
| | - Qiong Fan
- Department of Gynecologic Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030, China; Shanghai Municipal Key Clinical Specialty of Gynecologic Oncology, Shanghai, 200030, China; Shanghai Key Laboratory of Embryo Original Diseases Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China
| | - Jiangjing Yuan
- Department of Gynecologic Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030, China; Shanghai Municipal Key Clinical Specialty of Gynecologic Oncology, Shanghai, 200030, China; Shanghai Key Laboratory of Embryo Original Diseases Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China
| | - Yuhong Li
- Department of Gynecologic Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030, China; Shanghai Municipal Key Clinical Specialty of Gynecologic Oncology, Shanghai, 200030, China; Shanghai Key Laboratory of Embryo Original Diseases Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China
| | - Yudong Wang
- Department of Gynecologic Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030, China; Shanghai Municipal Key Clinical Specialty of Gynecologic Oncology, Shanghai, 200030, China; Shanghai Key Laboratory of Embryo Original Diseases Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China.
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Yang X, Wang C, Sun X, Fan Q, Yuan J, Li Y, Wang Y. Cryoablation used in fertility-sparing treatment for early endometrial cancer: A pig model experiment using a new designed balloon cryoprobe. Cryobiology 2020; 94:89-94. [PMID: 32305255 DOI: 10.1016/j.cryobiol.2020.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 04/12/2020] [Accepted: 04/12/2020] [Indexed: 11/25/2022]
Abstract
Young patients with early endometrial cancer have a strong desire to retain reproductive function, which require us to develop a therapeutic method that can not only assure the complete resection of tumor but also retain the uterine integrity. In the present study, we proposed a fertility-sparing surgery option that combined hysteroscopic resection with cryoablation to achieve this goal. To verify the safety and effectiveness of cryoablation for local uterine wall, we designed the experiment in pig model using a novel cryoablation balloon probe. In the process of freezing and thawing, the temperature of different parts of the uterus was measured in real time. The uterus was harvested immediately, three weeks after cryotherapy for histological evaluation. The results demonstrated cryoablation using the new cryoprobe is safe and effective. The effective freezing range can cover a range of 2 cm in diameter at least. This study provided us evidence before cryoablation could be applied in clinical practice of fertility-sparing treatment for young women with early endometrial cancer.
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Affiliation(s)
- Xiaoming Yang
- Department of Gynecologic Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030, China; Shanghai Municipal Key Clinical Specialty of Gynecologic Oncology, Shanghai, 200030, China; Shanghai Key Laboratory of Embryo Original Diseases Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China.
| | - Chao Wang
- Department of Gynecologic Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030, China; Shanghai Municipal Key Clinical Specialty of Gynecologic Oncology, Shanghai, 200030, China; Shanghai Key Laboratory of Embryo Original Diseases Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China.
| | - Xiao Sun
- Shanghai Municipal Key Clinical Specialty of Gynecologic Oncology, Shanghai, 200030, China; Shanghai Key Laboratory of Embryo Original Diseases Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China.
| | - Qiong Fan
- Department of Gynecologic Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030, China; Shanghai Municipal Key Clinical Specialty of Gynecologic Oncology, Shanghai, 200030, China; Shanghai Key Laboratory of Embryo Original Diseases Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China.
| | - Jiangjing Yuan
- Department of Gynecologic Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030, China; Shanghai Municipal Key Clinical Specialty of Gynecologic Oncology, Shanghai, 200030, China; Shanghai Key Laboratory of Embryo Original Diseases Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China.
| | - Yuhong Li
- Department of Gynecologic Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030, China; Shanghai Municipal Key Clinical Specialty of Gynecologic Oncology, Shanghai, 200030, China; Shanghai Key Laboratory of Embryo Original Diseases Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China.
| | - Yudong Wang
- Department of Gynecologic Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030, China; Shanghai Municipal Key Clinical Specialty of Gynecologic Oncology, Shanghai, 200030, China; Shanghai Key Laboratory of Embryo Original Diseases Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China.
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Bofill Rodriguez M, Dias S, Brown J, Wilkinson J, Lethaby A, Lensen SF, Jordan V, Wise MR, Farquhar C. Interventions for the treatment of heavy menstrual bleeding. Hippokratia 2018. [DOI: 10.1002/14651858.cd013180] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Magdalena Bofill Rodriguez
- University of Auckland; Department of Obstetrics and Gynaecology; Park Rd Grafton Auckland New Zealand 1142
| | - Sofia Dias
- University of York; Centre for Reviews and Dissemination; Heslington York UK YO10 5DD
| | | | - Jack Wilkinson
- Manchester Academic Health Science Centre (MAHSC), University of Manchester; Centre for Biostatistics, School of Health Sciences, Faculty of Biology, Medicine and Health; Clinical Sciences Building Salford Royal NHS Foundation Trust Hospital Room 1.315, Jean McFarlane Building University Place Oxford Road Manchester UK M13 9PL
| | - Anne Lethaby
- University of Auckland; Department of Obstetrics and Gynaecology; Park Rd Grafton Auckland New Zealand 1142
| | - Sarah F Lensen
- University of Auckland; Department of Obstetrics and Gynaecology; Park Rd Grafton Auckland New Zealand 1142
| | - Vanessa Jordan
- University of Auckland; Department of Obstetrics and Gynaecology; Park Rd Grafton Auckland New Zealand 1142
| | - Michelle R Wise
- The University of Auckland; Department of Obstetrics and Gynaecology; Private Bag 92019 Auckland New Zealand 1003
| | - Cindy Farquhar
- University of Auckland; Department of Obstetrics and Gynaecology; Park Rd Grafton Auckland New Zealand 1142
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Knuttinen MG, Stark G, Hohenwalter EJ, Bradley LD, Braun AR, Gipson MG, Kim CY, Pinchot JW, Scheidt MJ, Sella DM, Weiss CR, Lorenz JM. ACR Appropriateness Criteria ® Radiologic Management of Uterine Leiomyomas. J Am Coll Radiol 2018; 15:S160-S170. [PMID: 29724419 DOI: 10.1016/j.jacr.2018.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 03/04/2018] [Indexed: 10/17/2022]
Abstract
Uterine fibroids, also known as leiomyomas, are the most common benign tumor in women of reproductive age. When symptomatic, these patients can present with bleeding and/or bulk-related symptoms. Treatment options for symptomatic uterine leiomyomas include medical management, minimally invasive treatment such as uterine artery embolization, and surgical options, such as myomectomy. It is important to understand the role of these treatment options in various clinical scenarios so that appropriate consultation is performed. Furthermore, patients should be presented with the outcomes and complications of each of these treatment options. A summary of the data and clinical trials of the treatment options for symptomatic uterine leiomyomas is outlined in this article. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | - Gregory Stark
- Research Author, University of Illinois at Chicago, Chicago, Illinois
| | - Eric J Hohenwalter
- Panel Chair, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Linda D Bradley
- Cleveland Clinic, Cleveland, Ohio; American Congress of Obstetricians and Gynecologists
| | - Aaron R Braun
- St. Elizabeth Regional Medical Center, Lincoln, Nebraska
| | | | - Charles Y Kim
- Duke University Medical Center, Durham, North Carolina
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Laberge P, Leyland N, Murji A, Fortin C, Martyn P, Vilos G. Ablation de l'endomètre dans la prise en charge des saignements utérins anormaux. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 38:S609-S628. [PMID: 28063570 DOI: 10.1016/j.jogc.2016.09.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Jain P, Rajaram S, Gupta B, Goel N, Srivastava H. Randomized controlled trial of thermal balloon ablation versus vaginal hysterectomy for leiomyoma-induced heavy menstrual bleeding. Int J Gynaecol Obstet 2016; 135:140-144. [PMID: 27575538 DOI: 10.1016/j.ijgo.2016.04.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 04/15/2016] [Accepted: 07/27/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare the efficacy of thermal balloon ablation (TBA) with that of vaginal hysterectomy in the treatment of leiomyoma-induced heavy menstrual bleeding (HMB). METHODS An open-label randomized controlled trial was conducted between November 1, 2012, and October 31, 2014, in a tertiary care hospital in Delhi, India. Eligible women with HMB (aged ≥40 years, uterus size ≤14 weeks of pregnancy, leiomyoma ≤5 cm, uterocervical length ≤12 cm) were randomly assigned (1:1) to undergo TBA or vaginal hysterectomy using computer-generated random number tables. The primary outcome was the number of women in the TBA group with HMB 6 months after surgery. Analyses were by intention to treat. RESULTS Each group contained 20 women. No women in the TBA group had HMB at 6 months. Nineteen women were amenorrheic by 6 months and one was hypomenorrheic. CONCLUSION TBA can replace vaginal hysterectomy in some perimenopausal women with uterine leiomyomas. Clinical Trials Registry India: CTRI/2016/07/007119.
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Affiliation(s)
- Prachi Jain
- Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India.
| | - Shalini Rajaram
- Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
| | - Bindiya Gupta
- Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
| | - Neerja Goel
- Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
| | - Himsweta Srivastava
- Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
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11
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Kumar V, Chodankar R, Gupta JK. Endometrial ablation for heavy menstrual bleeding. ACTA ACUST UNITED AC 2016; 12:45-52. [PMID: 26756668 DOI: 10.2217/whe.15.86] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Endometrial ablation can be described as one of the great gynecological success stories. It has changed the management of heavy menstrual bleeding dramatically. The development of newer (second generation) endometrial ablative techniques has enabled clinicians to set up comprehensive 'one stop clinics' based on an outpatient service to treat heavy menstrual bleeding effectively without the need for general anesthetic or conscious sedation. This article describes the rationale and evidence for use of different endometrial auto-ablative systems along with relevant technical and clinical aspects. It also addresses the essentials of a successful approach to outpatient endometrial ablation along with discussion on risks, complications and contraindications of the procedure.
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Affiliation(s)
- Vinod Kumar
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Rohan Chodankar
- Heatherwood & Wexham Park Hospitals NHS Foundation Trust, Slough, UK
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12
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Endometrial Ablation: Normal Imaging Appearance and Delayed Complications. AJR Am J Roentgenol 2015; 205:W451-60. [DOI: 10.2214/ajr.14.13960] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Laberge P, Leyland N, Murji A, Fortin C, Martyn P, Vilos G, Leyland N, Wolfman W, Allaire C, Awadalla A, Dunn S, Heywood M, Lemyre M, Marcoux V, Potestio F, Rittenberg D, Singh S, Yeung G. Endometrial Ablation in the Management of Abnormal Uterine Bleeding. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2015; 37:362-79. [DOI: 10.1016/s1701-2163(15)30288-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Morelli M, Rocca ML, Mocciaro R, Di Cello A, Sacchinelli A, De Trana E, Cariati F, Venturella R, Zullo F. Sonographic findings in postmenopausal women with a prior endometrial ablation: interpretation and management of women with endometrial thickening and bleeding. J Minim Invasive Gynecol 2015; 22:489-94. [PMID: 25573186 DOI: 10.1016/j.jmig.2014.12.164] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 12/03/2014] [Accepted: 12/23/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To understand the meaning of endometrial thickening and bleeding in postmenopausal women who had previously undergone endometrial ablation (EA). DESIGN Retrospective observational study. Canadian Task Force III. SETTING Obstetrics and Gynecology Unit, Magna Graecia University, Catanzaro, Italy. PATIENTS Sixty-three postmenopausal women who had previously undergone EA. INTERVENTIONS A retrospective evaluation of clinical charts of postmenopausal women who had a follow-up visit after EA between January 2000 and August 2014. MEASUREMENTS AND MAIN RESULTS The rates of endometrial thickening (with or without bleeding), endometrial atrophy, and cancer were determined. Postmenopausal bleeding was reported in 9 patients (14.3%). Endometrial thickening was observed in 51 patients (80.9%; mean ± SD endometrial thickness, 7.7 ± 3.0 mm). A significantly (p < .05) greater number of patients with an endometrial thickness of 5 to 10 mm was observed compared with those with an endometrial thickness of <5 mm or >10 mm. A significant (p = .001) difference in increase in endometrial thickness was observed between patients with and without bleeding. Overall, hysteroscopy plus endometrial biopsy was scheduled in 24 patients. In all bleeding women, a histological diagnosis of endometrial atrophy was demonstrated. Concerning bleeding-free women, in 14 patients with endometrial thickening of >10 mm, mucosal atrophy was detected. The only bleeding-free patient in whom an endometrial echogenic fluid collection was detected had a histological diagnosis of endometrioid endometrial cancer. Thus, patients who underwent hysteroscopy had a 95.8% rate of mucosal atrophy and a 4.2% rate of endometrial cancer. The overall cancer rate in our global population (menopause with previous EA) was 1.6%. CONCLUSION Postmenopausal bleeding and sonographic detection of endometrial thickening in patients with previous EA are not necessarily related to a malignant disease. Nonetheless, ultrasound visualization of endometrial thickening plus an echogenic endometrial fluid collection in these patients always warrants an invasive diagnostic procedure regardless of whether or not bleeding is reported.
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Affiliation(s)
- Michele Morelli
- Obstetrics and Gynecology Unit, Department of Experimental and Clinical Medicine, Magna Graecia University and Gynecologic Oncology Unit, Tommaso Campanella Cancer Center of Germaneto, Catanzaro, Italy
| | - Morena Luigia Rocca
- Obstetrics and Gynecology Unit, Department of Experimental and Clinical Medicine, Magna Graecia University and Gynecologic Oncology Unit, Tommaso Campanella Cancer Center of Germaneto, Catanzaro, Italy.
| | - Rita Mocciaro
- Obstetrics and Gynecology Unit, Department of Experimental and Clinical Medicine, Magna Graecia University and Gynecologic Oncology Unit, Tommaso Campanella Cancer Center of Germaneto, Catanzaro, Italy
| | - Annalisa Di Cello
- Obstetrics and Gynecology Unit, Department of Experimental and Clinical Medicine, Magna Graecia University and Gynecologic Oncology Unit, Tommaso Campanella Cancer Center of Germaneto, Catanzaro, Italy
| | - Angela Sacchinelli
- Obstetrics and Gynecology Unit, Department of Experimental and Clinical Medicine, Magna Graecia University and Gynecologic Oncology Unit, Tommaso Campanella Cancer Center of Germaneto, Catanzaro, Italy
| | - Enrico De Trana
- Obstetrics and Gynecology Unit, Department of Experimental and Clinical Medicine, Magna Graecia University and Gynecologic Oncology Unit, Tommaso Campanella Cancer Center of Germaneto, Catanzaro, Italy
| | - Francesco Cariati
- Obstetrics and Gynecology Unit, Department of Experimental and Clinical Medicine, Magna Graecia University and Gynecologic Oncology Unit, Tommaso Campanella Cancer Center of Germaneto, Catanzaro, Italy
| | - Roberta Venturella
- Obstetrics and Gynecology Unit, Department of Experimental and Clinical Medicine, Magna Graecia University and Gynecologic Oncology Unit, Tommaso Campanella Cancer Center of Germaneto, Catanzaro, Italy
| | - Fulvio Zullo
- Obstetrics and Gynecology Unit, Department of Experimental and Clinical Medicine, Magna Graecia University and Gynecologic Oncology Unit, Tommaso Campanella Cancer Center of Germaneto, Catanzaro, Italy
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Nonresectoscopic endometrial ablation in high-risk surgical patients: a cohort study. J Minim Invasive Gynecol 2014; 20:487-91. [PMID: 23870238 DOI: 10.1016/j.jmig.2013.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 02/05/2013] [Accepted: 02/06/2013] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To evaluate the use of nonresectoscopic endometrial ablation in women with high anesthetic and surgical risk compared with low-risk women based on the American Society of Anesthesia (ASA) physical status stratification. DESIGN This is a cohort study of women who were classified as high-risk (HR) or low-risk (LR) cohorts based on ASA physical status stratification. The ASA classification includes 6 grades: ASAP1, a normal healthy person; ASAP2, mild systemic disease; ASAP3, severe systemic disease; ASAP4, severe systemic disease that is a constant threat to life; ASAP5, a critically ill patient who is not expected to survive without the operation; and ASAP6, declared brain-dead patient whose organs are being removed for donor purposes. Baseline characteristics including comorbidities were obtained. Outcome measures included amenorrhea, treatment failure, and operative complications. The time to treatment failure was compared using Kaplan-Meier analysis. Risk adjustments were performed using regression models. SETTING Academic medical center in the Upper Midwest. PATIENTS Seven-hundred eleven women underwent nonresectoscopic endometrial ablation at our institution between January 1998 and December 2005. INTERVENTIONS Bipolar radiofrequency was used in 448 women and thermal balloon ablation in 263 women. MEASUREMENTS AND MAIN RESULTS The HR cohort had a higher proportion of women with cardiac disease (27.1% vs. 6.7%, p < .001) and more women with nongynecologic cancer (12.3% vs. 2.9%, Fisher exact test, p < .001). Nonetheless, endometrial ablation had comparable efficacy in both the HR and LR cohorts with 5-year failure rates of 11.7% and 14.8% (p = .659), respectively. Amenorrhea rates were also similar in both cohorts (29.7% vs. 27.2%, p = .645). After adjusting for known confounders including age, parity, dysmenorrhea, previous tubal ligation, uterine length, and the type of the procedure, the calculated hazard ratio for failure in the HR cohort was 0.80 (95% confidence interval; 0.31-1.74, p = .607), and the adjusted odds ratio for amenorrhea was 1.27 (95% confidence interval, 0.71-2.20; p = .411). Complications were rare in both groups. The mortality rate in the HR cohort was significantly higher compared with the LR cohort (7.9% vs. <1%, p < .001), but this was not related to the ablation procedures. CONCLUSION For women who are high anesthetic and surgical risks because of serious underlying comorbidities, nonresectoscopic endometrial ablation can provide minimally invasive, safe, and effective therapy for menorrhagia.
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Abstract
Global endometrial ablation techniques are a relatively new surgical technology for the treatment of heavy menstrual bleeding that can now be used even in an outpatient clinic setting. A comparison of global ablation versus earlier ablation technologies notes no significant differences in success rates and some improvement in patient satisfaction. The advantages of the newer global endometrial ablation systems include less operative time, improved recovery time, and decreased anesthetic risk. Ablation procedures performed in an outpatient surgical or clinic setting provide advantages both of potential cost savings for patients and the health care system and improved patient convenience.
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Affiliation(s)
- Sarah Woods
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, 853 Jefferson Avenue, Rm E102, Memphis, TN 38163, USA
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Fonseca-Moutinho JA, Barbosa LS, Torres DG, Nunes SM. Abnormal uterine bleeding as a presenting symptom is related to multiple uterine leiomyoma: an ultrasound-based study. Int J Womens Health 2013; 5:689-94. [PMID: 24194648 PMCID: PMC3814927 DOI: 10.2147/ijwh.s50786] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose To determine the prevalence of uterine leiomyomas, diagnosed by ultrasound, in a private health care setting located in the central eastern region of Portugal, and to explore the demographic and clinical factors related to diagnosis and symptomatology. Patients and methods The files of 624 patients attending a private clinic in Covilhã, Portugal, from January 2 to December 31, 2010 were retrieved for evaluation. Pelvic ultrasound record, age, weight, height, age at menarche, number of pregnancies and deliveries, marital status, menstrual cycles characteristic, and contraceptive method at consultation were included in the analysis. Results Uterine leiomyoma (UL) was diagnosed by ultrasonography in 161 (25.8%) patients. A single UL was diagnosed in 80 (49.7%) patients. In 79 (49.1%) patients, the largest leiomyoma had a dimension <20 mm. Prevalence of UL was age dependent: at 11.0% for women 20–39 years old; 45.4% for those aged 40–59 years; and 19.5% for women 60 years or older. Metrorrhagia was the most distressing presenting symptom. When menorrhagia was the presenting symptom, the probability of having an ultrasound diagnosis of UL was 73.3%. Metrorrhagia or menorrhagia, as presenting symptom, was significantly related to the ultrasound diagnosis of multiple ULs. Conclusion UL was especially prevalent in women aged between 40 and 59 years. Patients with multiple ULs had significantly more abnormal uterine bleeding. In patients with menorrhagia or metrorrhagia, special attention should be taken in searching for the presence of multiple ULs during ultrasound.
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Affiliation(s)
- José Alberto Fonseca-Moutinho
- Faculty of Health Sciences, School of Medicine, Beira Interior University, Covilhã, Portugal ; Child and Women Department, Cova da Beira Academic Medical Center, Covilhã, Portugal
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Tal R, Segars JH. The role of angiogenic factors in fibroid pathogenesis: potential implications for future therapy. Hum Reprod Update 2013; 20:194-216. [PMID: 24077979 DOI: 10.1093/humupd/dmt042] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND It is well established that tumors are dependent on angiogenesis for their growth and survival. Although uterine fibroids are known to be benign tumors with reduced vascularization, recent work demonstrates that the vasculature of fibroids is grossly and microscopically abnormal. Accumulating evidence suggests that angiogenic growth factor dysregulation may be implicated in these vascular and other features of fibroid pathophysiology. METHODS Literature searches were performed in PubMed and Google Scholar for articles with content related to angiogenic growth factors and myometrium/leiomyoma. The findings are hereby reviewed and discussed. RESULTS Multiple growth factors involved in angiogenesis are differentially expressed in leiomyoma compared with myometrium. These include epidermal growth factor (EGF), heparin-binding-EGF, vascular endothelial growth factor, basic fibroblast growth factor, platelet-derived growth factor, transforming growth factor-β and adrenomedullin. An important paradox is that although leiomyoma tissues are hypoxic, leiomyoma feature down-regulation of key molecular regulators of the hypoxia response. Furthermore, the hypoxic milieu of leiomyoma may contribute to fibroid development and growth. Notably, common treatments for fibroids such as GnRH agonists and uterine artery embolization (UAE) are shown to work at least partly via anti-angiogenic mechanisms. CONCLUSIONS Angiogenic growth factors play an important role in mechanisms of fibroid pathophysiology, including abnormal vasculature and fibroid growth and survival. Moreover, the fibroid's abnormal vasculature together with its aberrant hypoxic and angiogenic response may make it especially vulnerable to disruption of its vascular supply, a feature which could be exploited for treatment. Further experimental studies are required in order to gain a better understanding of the growth factors that are involved in normal and pathological myometrial angiogenesis, and to assess the potential of anti-angiogenic treatment strategies for uterine fibroids.
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Affiliation(s)
- Reshef Tal
- Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY 11219, USA
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Sharp HT. Endometrial ablation: postoperative complications. Am J Obstet Gynecol 2012; 207:242-7. [PMID: 22541856 DOI: 10.1016/j.ajog.2012.04.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Revised: 03/19/2012] [Accepted: 04/03/2012] [Indexed: 10/28/2022]
Abstract
Endometrial ablation as a treatment for abnormal uterine bleeding has evolved considerably over the past several decades. Postoperative complications include the following: (1) pregnancy after endometrial ablation; (2) pain-related obstructed menses (hematometra, postablation tubal sterilization syndrome); (3) failure to control menses (repeat ablation, hysterectomy); (4) risk from preexisting conditions (endometrial neoplasia, cesarean section); and (5) infection. Physicians performing endometrial ablation should be aware of postoperative complications and be able to diagnose and provide treatment for these conditions.
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20
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Hysterectomy Subsequent to Endometrial Ablation. J Minim Invasive Gynecol 2012; 19:459-64. [DOI: 10.1016/j.jmig.2012.03.013] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Revised: 03/06/2012] [Accepted: 03/08/2012] [Indexed: 11/18/2022]
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Stovall DW. Alternatives to hysterectomy: focus on global endometrial ablation, uterine fibroid embolization, and magnetic resonance-guided focused ultrasound. Menopause 2011; 18:437-44. [PMID: 21701430 DOI: 10.1097/gme.0b013e318207fe15] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The aim of this study was to inform the clinician of alternatives to hysterectomy through a critical evaluation of three treatment options: global endometrial ablation, uterine fibroid embolization, and magnetic resonance-guided focused ultrasound. Studies published in English-language, peer-reviewed journals were systematically searched using Cochrane and Medline. Keywords used included "alternatives to hysterectomy," "endometrial ablation," "uterine fibroid embolization," "uterine artery embolization," and "focused ultrasound." Articles meeting the inclusion criteria were reviewed and analyzed for themes and similarities. All three alternative methods of treatment reviewed are currently approved for use in the United States and abroad. In fact, five different global endometrial ablation devices are approved by the Food and Drug Administration for treatment of menorrhagia. Patient satisfaction scores after endometrial ablation are high (90%-95%), but amenorrhea rates are much lower (15%-60%). Data from randomized trials demonstrate that uterine fibroid embolization results in a shorter hospital stay and quicker return to work as compared with abdominal hysterectomy for leiomyomas, but after embolization, up to 20% of women need a second procedure. Ex-ablative therapy of leiomyomas with focused ultrasound is the newest of the three methods. It has a special set of patient selection criteria and is only available at less than 20 medical centers in the United States. Leiomyoma symptom relief after focused ultrasound therapy at 1 year post-procedure is high (85%-95%). There are many effective alternatives to hysterectomy in women with menorrhagia and/or symptomatic leiomyomas. However, because these procedures are performed by individuals from different subspecialists, primarily gynecologists and interventional radiologists, clinicians must consider using a multidisciplinary approach to find the best procedure for a given patient. There are no randomized trials comparing uterine fibroid embolization to vaginal hysterectomy, laparoscopic hysterectomy, or laparoscopic myomectomy.
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Affiliation(s)
- Dale W Stovall
- Department of Obstetrics, University of Virginia School of Medicine, Charlottesville, VA 22903, USA.
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22
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Ciarmela P, Islam MS, Reis FM, Gray PC, Bloise E, Petraglia F, Vale W, Castellucci M. Growth factors and myometrium: biological effects in uterine fibroid and possible clinical implications. Hum Reprod Update 2011; 17:772-90. [PMID: 21788281 DOI: 10.1093/humupd/dmr031] [Citation(s) in RCA: 137] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Growth factors are proteins secreted by a number of cell types that are capable of modulating cellular growth, proliferation and cellular differentiation. It is well accepted that uterine cellular events such as proliferation and differentiation are regulated by sex steroids and their actions in target tissues are mediated by local production of growth factors acting through paracrine and/or autocrine mechanisms. Myometrial mass is ultimately modified in pregnancy as well as in tumour conditions such as leiomyoma and leiomyosarcoma. Leiomyomas, also known as fibroids, are benign tumours of the uterus, considered to be one of the most frequent causes of infertility in reproductive years in women. METHODS For this review, we searched the database MEDLINE and Google Scholar for articles with content related to growth factors acting on myometrium; the findings are hereby reviewed and discussed. RESULTS Different growth factors such as epidermal growth factor (EGF), transforming growth factor-α (TGF-α), heparin-binding EGF (HB-EGF), acidic fibroblast growth factor (aFGF), basic fibroblast growth factor (bFGF), vascular endothelial growth factor (VEGF), insulin-like growth factor (IGF), platelet-derived growth factor (PDGF) and TGF-β perform actions in myometrium and in leiomyomas. In addition to these growth factors, activin and myostatin have been recently identified in myometrium and leiomyoma. CONCLUSIONS Growth factors play an important role in the mechanisms involved in myometrial patho-physiology.
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Affiliation(s)
- Pasquapina Ciarmela
- Department of Experimental and Clinical Medicine, Faculty of Medicine, Polytechnic University of Marche, via Tronto 10/a, 60020 Ancona, Italy.
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Garza Leal JG, Hernandez Leon I, Castillo Saenz L, Lee BB. Laparoscopic Ultrasound-Guided Radiofrequency Volumetric Thermal Ablation of Symptomatic Uterine Leiomyomas: Feasibility Study Using the Halt 2000 Ablation System. J Minim Invasive Gynecol 2011; 18:364-71. [DOI: 10.1016/j.jmig.2011.02.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2010] [Revised: 02/11/2011] [Accepted: 02/19/2011] [Indexed: 10/18/2022]
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Tuohy E, Litt E, Alikhan R. Treatment of patients with von Willebrand disease. J Blood Med 2011; 2:49-57. [PMID: 22287863 PMCID: PMC3262353 DOI: 10.2147/jbm.s9890] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Indexed: 11/23/2022] Open
Abstract
Von Willebrand disease (vWD) is the most common hereditary bleeding disorder. The aim of therapy is to correct the dual hemostatic defect, due to defective platelet adhesion-aggregation and abnormal coagulation due to Factor VIII (FVIII) deficiency. The choice of treatment depends on a number of factors, including the severity of the bleed, the procedure planned, the subtype and severity of the disease and the age and morbidity of the patient. Desmopressin (DDAVP) is the treatment of choice for type 1 vWD as it increases endogenous release of FVIII and von Willebrand factor (vWF) and is also used in some subtypes of type 2 vWD. In those patients in whom DDAVP is ineffective or contraindicated, levels can be restored by infusing vWF:FVIII concentrates. The role of antifibrinolytic treatment is an important adjunct to replacement therapy during minor or major surgery involving mucosal surfaces. The dosing and timing of vWF:FVIII concentrates is important depending on the nature of the surgical procedure. The role of secondary prophylaxis needs to be further defined.
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Affiliation(s)
- Emma Tuohy
- Department of Haematology, University Hospital of Wales, Cardiff, UK
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Burke CT, Funaki BS, Ray CE, Kinney TB, Kostelic JK, Loesberg A, Lorenz JM, Millward SF, Nemcek AA, Owens CA, Shaw H, Silberzweig JE, Vatakencherry G. ACR Appropriateness Criteria ® on Treatment of Uterine Leiomyomas. J Am Coll Radiol 2011; 8:228-34. [DOI: 10.1016/j.jacr.2010.12.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Accepted: 12/21/2010] [Indexed: 11/25/2022]
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Combining NovaSure® endometrial ablation and Essure® hysteroscopic sterilization: a feasibility study to evaluate the confirmation tests. ACTA ACUST UNITED AC 2010. [DOI: 10.1007/s10397-010-0625-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Roy S, Saroha V, Jain D. Highly Cellular Leiomyoma Mimics A Malignant Small Round-Cell Tumor: A Diagnostic Dilemma On Frozen Sections. Taiwan J Obstet Gynecol 2010; 49:203-5. [DOI: 10.1016/s1028-4559(10)60043-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2009] [Indexed: 11/28/2022] Open
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El-Nashar SA, Hopkins MR, Creedon DJ, Cliby WA, Famuyide AO. Efficacy of bipolar radiofrequency endometrial ablation vs thermal balloon ablation for management of menorrhagia: A population-based cohort. J Minim Invasive Gynecol 2010; 16:692-9. [PMID: 19896595 DOI: 10.1016/j.jmig.2009.06.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2009] [Revised: 06/17/2009] [Accepted: 06/25/2009] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVE To compare the efficacy of bipolar radiofrequency ablation (RFA) and thermal balloon ablation (TBA) using treatment failure and postprocedure amenorrhea as outcome measures. DESIGN Population-based cohort study (Canadian Task Force classification II-2). SETTING Two medical centers in the upper Midwest. PATIENTS Using the medical records linkage system of the Rochester Epidemiology Project, we identified 455 residents of Olmsted County, Minnesota, who underwent global endometrial ablation because of menorrhagia from January 1, 1998, through December 31, 2005. Amenorrhea was defined as complete cessation of menstruation that started immediately after ablation and lasted at least 12 months. Treatment failure was defined as necessity of repeat ablation or hysterectomy because of persistent bleeding or pain. Time to treatment failure for each procedure was compared using Kaplan-Meier plots. Relevant clinical data and complications were abstracted from medical records. Risk adjustments were performed using Cox and logistic regression models. INTERVENTIONS Radiofrequency ablation (n=255) and thermal balloon ablation (n=200). MEASUREMENTS AND MAIN RESULTS Mean (SD) patient age was 43.3 (5.5) years, and median follow-up was 2.2 years. The 3-year cumulative failure rate was 9% (95% confidence interval [CI], 5%-16%) for RFA and 12% (95% CI, 7%-16%) for TBA (p=.26). The difference remained nonsignificant after adjusting for known predictors of treatment failure such as age, parity, pretreatment dysmenorrhea, and tubal ligation (adjusted HR, 0.7; 95% CI, 0.4-1.4; p=.31). However, women had significantly higher rates of amenorrhea after RFA compared with TBA (32% vs 14%; p <.001). This difference remained significant after adjusting for known predictors of amenorrhea such as age, uterine length, and endometrial thickness (adjusted odds ratio, 2.9; 95% CI, 1.7-4.8; p <.001). Complications were infrequent and similar in the 2 groups. CONCLUSION Both RFA and TBA were equally effective treatments for menorrhagia in a population-based cohort. However, women who underwent RFA were 3 times more likely to have postprocedure amenorrhea.
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Affiliation(s)
- Sherif A El-Nashar
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota 55905, USA
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Garza-Leal J, Pena A, Donovan A, Cash C, Romanowski C, Ilie B, Lin L. Clinical Evaluation of a Third-Generation Thermal Uterine Balloon Therapy System for Menorrhagia Coupled with Curettage. J Minim Invasive Gynecol 2010; 17:82-90. [DOI: 10.1016/j.jmig.2009.10.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2009] [Revised: 10/25/2009] [Accepted: 10/29/2009] [Indexed: 10/20/2022]
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Goel R, Anderson K, Slaton J, Schmidlin F, Vercellotti G, Belcher J, Bischof JC. Adjuvant approaches to enhance cryosurgery. J Biomech Eng 2009; 131:074003. [PMID: 19640135 DOI: 10.1115/1.3156804] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Molecular adjuvants can be used to enhance the natural destructive mechanisms of freezing within tissue. This review discusses their use in the growing field of combinatorial or adjuvant enhanced cryosurgery for a variety of disease conditions. Two important motivations for adjuvant use are: (1) increased control of the local disease in the area of freezing (i.e., reduced local recurrence of disease) and (2) reduced complications due to over-freezing into adjacent tissues (i.e., reduced normal functional tissue destruction near the treatment site). This review starts with a brief overview of cryosurgical technology including probes and cryogens and major mechanisms of cellular, vascular injury and possible immunological effects due to freeze-thaw treatment in vivo. The review then focuses on adjuvants to each of these mechanisms that make the tissue more sensitive to freeze-thaw injury. Four broad classes of adjuvants are discussed including: thermophysical agents (eutectic forming salts and amino acids), chemotherapuetics, vascular agents and immunomodulators. The key issues of selection, timing, dose and delivery of these adjuvants are then elaborated. Finally, work with a particularly promising vascular adjuvant, TNF-alpha, that shows the ability to destroy all cancer within a cryosurgical iceball is highlighted.
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Affiliation(s)
- Raghav Goel
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN 55455, USA
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MANNUCCI PM, FEDERICI AB, JAMES AH, KESSLER CM. von Willebrand disease in the 21st century: current approaches and new challenges. Haemophilia 2009; 15:1154-8. [DOI: 10.1111/j.1365-2516.2008.01932.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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van Riemsdijk V, Graziosi G, Veersema S, Bongers M. Vaginal Myoma Expulsion after NovaSure Endometrial Ablation. J Minim Invasive Gynecol 2009; 16:496-7. [DOI: 10.1016/j.jmig.2009.03.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2008] [Revised: 03/19/2009] [Accepted: 03/27/2009] [Indexed: 11/25/2022]
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Miller CE. Unmet therapeutic needs for uterine myomas. J Minim Invasive Gynecol 2009; 16:11-21. [PMID: 19110181 DOI: 10.1016/j.jmig.2008.08.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2008] [Revised: 08/20/2008] [Accepted: 08/23/2008] [Indexed: 11/25/2022]
Abstract
Uterine myomas may develop in many women, but only become clinically significant in about one third of the affected population. Although uterine myomas are most often benign, they are associated with debilitating symptoms and commonly result in hysterectomy. Current treatments for uterine myomas include pharmacologic therapies, delivery of focused energy, alteration of uterine vascular supply, or surgical procedures. Factors such as the woman's desire for future pregnancy, the importance of uterine preservation, symptom severity, and tumor characteristics direct the choice of therapeutic approach. The ideal treatment will have the following characteristics: easy to perform, minimally invasive, cost effective, preserves fertility, preserves the uterus, efficacious, acceptable tolerability and durability, and low incidence of myoma recurrence.
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Affiliation(s)
- Charles E Miller
- Departments of Obstetrics and Gynecology at University of Chicago and University of Illinois at Chicago, Illinois, USA.
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Abstract
OBJECTIVE To report rates of amenorrhea and treatment failure after global endometrial ablation and to estimate the association between patient factors and these outcomes by developing and validating prediction models. METHODS From January 1998 through December 2005, 816 women underwent global endometrial ablation with either a thermal balloon ablation or radio frequency ablation device; 455 were included in a population-derived cohort (for model development), and 361 were included in a referral-derived cohort (for model validation). Amenorrhea was defined as cessation of bleeding from immediately after ablation through at least 12 months after the procedure. Treatment failure was defined as hysterectomy or reablation for patients with bleeding or pain. Logistic and Cox proportional hazard regression models were used in model development and validation of potential predictors of outcomes. RESULTS The amenorrhea rate was 23% (95% confidence interval [CI] 19-28%) and the 5-year cumulative failure rate was 16% (95% CI 10-20%). Predictors of amenorrhea were age 45 years or older (adjusted odds ratio [aOR] 2.6, 95% CI 1.6-4.3); uterine length less than 9 cm (aOR 1.8, 95% CI 1.1-3.1); endometrial thickness less than 4 mm (aOR 2.7, 95% CI 1.2-6.3); and use of radio-frequency ablation instead of thermal balloon ablation (aOR 2.8, 95% CI 1.7-4.9). Predictors of treatment failure included age younger than 45 years (adjusted hazard ratio [aHR] 2.6, 95% CI 1.3-5.1); parity of 5 or greater (aHR 6.0, 95% CI 2.5-14.8); prior tubal ligation (aHR 2.2, 95% CI 1.2-4.0); and history of dysmenorrhea (aHR 3.7, 95% CI 1.6-8.5). After global endometrial ablation, 23 women (5.1%, 95% CI 3.2-7.5%) had pelvic pain, three (0.7%, 95% CI 0.1-1.9%) were pregnant, and none (95% CI 0-0.8%) had endometrial cancer. CONCLUSION Population-derived rates and predictors of treatment outcomes after global endometrial ablation may help physicians offer optimal preprocedural patient counseling. LEVEL OF EVIDENCE II.
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Treatment of fibroids via uterine artery occlusion (uterine artery embolization and Doppler-guided uterine artery occlusion): potential role in today's armamentarium. Arch Gynecol Obstet 2009; 280:513-20. [PMID: 19205712 DOI: 10.1007/s00404-009-0952-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2008] [Accepted: 01/14/2009] [Indexed: 10/21/2022]
Abstract
Uterine fibroids, the most common benign tumors of the female reproductive system, are the most common indication for hysterectomy. However, this procedure is not the ideal treatment for many women including those who desire to preserve their fertility or simply do not want to undergo surgery. New technologies and surgical innovation provide treatments that are less associated with morbidity such as uterine artery embolization, magnetic resonance imaging-guided focused ultrasound, and laparoscopic uterine artery occlusion. This manuscript will discuss the putative mechanism of action and clinical application of uterine artery occlusion using Doppler-guided Uterine Artery Occlusion, a new investigational treatment modality for uterine fibroids.
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Kim N, Donohue T, Sloand E, Stratton P. Successful use of balloon ablation to treat menorrhagia complicating aplastic anemia. Gynecol Obstet Invest 2008; 66:123-6. [PMID: 18446042 DOI: 10.1159/000128601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2007] [Accepted: 01/28/2008] [Indexed: 11/19/2022]
Abstract
BACKGROUND Aplastic anemia (AA) complicated by menorrhagia is treated with transfusion and hormonal therapy. When bleeding is life-threatening, balloon endometrial ablation can safely be used to treat menorrhagia in selected patients. CASE A 56-year-old postmenopausal woman was diagnosed with AA after several weeks of menorrhagia and pancytopenia. She became heavily alloimmunized after extensive platelet transfusion. During treatment with antithymocyte globulin, vaginal bleeding increased and the platelet count fell to 1,000/microl on supportive measures. After bleeding stopped with use of intravenous Premarin, she was examined in the operating room. There, a clot was removed and appeared to be a uterine caste; hemostasis continued. Transvaginal ultrasound revealed a normal endometrial contour and thin endometrium; endometrial histology was benign. After she completed antithymocyte globulin and her platelet count could be maintained over 30,000/microl with matched platelets, endometrial ablation was performed without any complications. CONCLUSION Thermal balloon endometrial ablation is an effective alternative to hysterectomy for women with persistent menorrhagia and AA when supportive measures fail. Prior to endometrial ablation, evaluation should ensure normal endometrial contour and histology, and that sufficient blood products are available to maintain platelet counts above 30,000/microl during the healing process.
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Affiliation(s)
- Nancy Kim
- Reproductive Biology and Medicine Branch, NHLBI, NIH, Bethesda, MD 20982-1109, USA
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Tunitsky E, Dardano K, Harmanli OH. New-onset pelvic organ prolapse after Novasure endometrial ablation. Arch Gynecol Obstet 2008; 278:187-9. [PMID: 18196256 DOI: 10.1007/s00404-007-0546-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2007] [Accepted: 12/13/2007] [Indexed: 11/28/2022]
Abstract
BACKGROUND Endometrial ablation with bipolar radiofrequency energy (NovaSure) for dysfunctional uterine bleeding has gained wide acceptance due to its ease and efficacy. CASE A 45-year-old, gravida three, para two, female developed symptomatic Stage 3 pelvic organ prolapse (POP) 1 month after endometrial ablation using NovaSure. CONCLUSION To our knowledge, this is the first published case of new-onset POP briefly after an endometrial ablation. It is not clear whether there is a causal association between the ablation procedure and de novo POP. Should there be any additional cases of de novo POP post endometrial ablation, further investigation would be warranted.
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Affiliation(s)
- Elena Tunitsky
- Department of Obstetrics and Gynecology, Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199, USA
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Jacobson GF, Shaber RE, Armstrong MA, Hung YY. Changes in rates of hysterectomy and uterine conserving procedures for treatment of uterine leiomyoma. Am J Obstet Gynecol 2007; 196:601.e1-5; discussion 601.e5-6. [PMID: 17547914 DOI: 10.1016/j.ajog.2007.03.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2006] [Revised: 11/08/2006] [Accepted: 03/02/2007] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to investigate treatment of uterine leiomyoma by hysterectomy and uterine conserving procedures (UCPs). STUDY DESIGN Data from Kaiser Permanente Northern California members undergoing hysterectomy, myomectomy, uterine artery embolization (UAE) and endometrial ablation (EA) for uterine leiomyoma from 1997-2003 were collected. Statistical analysis included trend tests and survival analysis. RESULTS Hysterectomy rates for leiomyoma decreased significantly from 2.13 per 1000 to 1.91 (P < .0001). Rates for myomectomy (.4-.37) and EA (.26-.27) remained stable (P = .17 and .26, respectively), whereas rates for UAE increased significantly from < .01-.24 (P < .0001). The combined rates for hysterectomy and UCPs remained stable at 2.79 (P = .95). Rate of hysterectomy after UCP increased over time, and at 6 years reached 11.5%, 17.7%, and 7.9% for EA, UAE, and myomectomy, respectively. CONCLUSION Whereas rate of hysterectomy for leiomyoma decreased, total rate of invasive treatment remained stable. Increase in rate of UAE had the greatest impact on treatment, possibly replacing hysterectomy.
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Affiliation(s)
- Gavin F Jacobson
- Department of Obstetrics and Gynecology, Kaiser Permanente Northern California, San Francisco, CA, USA
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