Hysteroscopic endometrial ablation using free heated saline for the treatment of menorrhagia

STUDY OBJECTIVE

To assess the safety and efficacy of hysteroscopic endometrial ablation using controlled intrauterine instillation and circulation of heated (90 degrees C) saline.

DESIGN

Phase II clinical study (Canadian Task Force classification II-2).

SETTING

Preliminary study performed in an outpatient ambulatory surgery center of a university hospital.

PATIENTS

Twenty women with menorrhagia of benign causes.

INTERVENTION

Hysteroscopic endometrial ablation.

MEASUREMENTS AND MAIN RESULTS

There were no complications. At no time did fluid leak from the fallopian tubes or cervix during treatment. Six patients had concurrent laparoscopy to measure serosal temperatures and to observe fimbriae directly during the 10-minute treatment. Serosal and endocervical temperatures were not elevated. Eighteen women kept evaluable menstrual diaries for 2 months before and 12 months after surgery. Ten women (55.6%) became amenorrheic, four (22.1%) hypomenorrheic, and three (16.7%) returned to normal periods after 12 months of follow-up. One woman (5.6%) reported a 75% decrease in menstrual flow but continued to be menorrhagic by definition. One patient subsequently underwent hysterectomy for simple endometrial hyperplasia.

CONCLUSION

This procedure appears to be a safe method of globally ablating the endometrium, resulting in effective treatment of menorrhagia.

Endometrial ablation by hysteroscopic instillation of hot saline solution

Current methods of endometrial ablation to treat excessive uterine bleeding use laser or electrosurgical energy sources. These procedures are highly skill dependent, and numerous cases of fluid overload as well as other complications have been reported. A new method of endometrial ablation instills heated 0.9% normal saline at 80 to 90 degrees C. The fluid is recirculated and therefore, it is possible to measure accurately and predetermine the maximum amount of allowable absorption that occurs. Animal data indicate that the procedure is effective and may be safer than current methods of endometrial ablation. Standardization of this new method will require clinical trials, initially with women undergoing hysterectomy, for proper evaluation of the extent of thermal damage in relation to the time and intensity of heat exposure.

The hysteroscopic management of endometrial leiomyomatosis

Uterine myomata are frequently the cause of abnormal uterine bleeding. They may be removed successfully by hysteroscopy. As a rule, the myomata are single, although on occasion several pedunculated myomas may be present. Three women were diagnosed with extremely large numbers of submucous leiomyomata. Many of the lesions were removed by hysteroscopic resection and many were destroyed with the neodymium:yttrium-aluminum-garnet laser.

A method of closing laparoscopy port incisions using a modified Veress needle

A new method of closing laparoscopy port incisions uses a modified Veress needle. The device easily closes the fascia and peritoneum, which should prevent incisional hernias at these sites. It adds little if any cost to laparoscopic procedures. It has been used in 28 patients with satisfactory results.

Hysteroscopic endometrial ablation

The addition of endometrial ablation to gynecologic surgical procedures has had a significant impact on the management of intractable menorrhagia. It is an outpatient procedure that causes limited disability to the patient. Although long-term data regarding this procedure are not available, the laser ablation series dates back to 1979 and there have been no delayed sequelae.

Vaginal removal of the pedunculated submucous myoma. Historical observations and development of a new procedure

A new method of vaginal removal of submucous fibroids was attempted on 151 patients. The procedure involves dilation of the cervix with Laminaria tents and removal of the submucous fibroid by grasping with appropriate instruments. Myomas were removed successfully in 92% of the patients; hysterectomy and abdominal myomectomy were avoided in all but four of them. Perforation occurred in two patients. Morbidity was minimal. The four patients who desired pregnancy conceived.

Use of danazol in hysteroscopic surgery for menorrhagia

The advent of hysteroscopic laser surgery has provided an alternative to hysterectomy in women with menorrhagia refractory to other forms of treatment. This procedure has been used with considerable success to reproduce the signs and symptoms of Asherman's syndrome when combined with pretreatment using the synthetic steroid Danocrine (danazol). Experience with 335 patients treated with danazol, 800 mg/d, for 25 days before undergoing hysteroscopy with a neodymium:yttrium-aluminum-garnet laser demonstrated that excellent results (amenorrhea or limited spotting) were achieved in 97% of cases. All 46 patients with clotting disorders did well after surgery. The major complications associated with this procedure were fluid overload, profuse bleeding, postoperative urinary tract infections and postoperative hematometra, all of which were controlled successfully. Only one patient had to discontinue danazol treatment because of an adverse reaction.

Vaginal removal of the pedunculated submucous myoma: the use of laminaria

Vaginal removal of submucous fibroids was attempted in 92 patients. The procedure, successful in 83 cases, involved dilation of the cervix with laminaria tents and removal of the submucous fibroid by grasping with appropriate instruments. Myomas were successfully removed in 90% of the patients, and hysterectomy or myomectomy were avoided in 88%. Morbidity was minimal.

Office hysteroscopy and suction curettage: can we eliminate the hospital diagnostic dilatation and curettage?

The hospital diagnostic dilatation and curettage is the most widely used method in investigating abnormal uterine bleeding. This procedure is expensive and inconvenient and poses some surgical and anesthetic risks. As an alternative to hospital dilatation and curettage, the procedure of office hysteroscopy and suction curettage was evaluated in 406 patients. The indications for the procedure are similar to the classic indications for a diagnostic dilatation and curettage. The method is convenient, safe, and relatively inexpensive. The diagnostic accuracy of office hysteroscopy and suction curettage surpasses prior reports of the accuracy of diagnostic dilatation and curettage. Office hysteroscopy and suction curettage should be the method of choice in the evaluation of abnormal uterine bleeding.

Uterine tamponade for the control of acute uterine bleeding

In the field of obstetrics, uterine packing has been used for many years to control postpartum hemorrhage. The control of acute hemorrhage from the nonpuerperal uterus is more difficult. Historically, curettage has been used, but when this fails, hysterectomy has often been a last resort. We have used a Foley catheter inserted into the uterine cavity in 20 patients for the control of acute, profuse uterine hemorrhage. The procedure was completely successful in 17 patients and partially successful in two patients. Failure to control bleeding occurred in one patient. The procedure requires no special expertise or extraordinary equipment. Anesthesia is not required. The procedure involves filling the uterine cavity and the cervical canal with enough pressure to cause immediate tamponade between the Foley catheter balloon and the semirigid uterine wall. The catheter is left in place from several hours to 2 days, depending on the etiology of the hemorrhage. There were no complications attributable to this form of uterine tamponade.

Laser photovaporization of endometrium for the treatment of menorrhagia

As an alternative to hysterectomy in patients with excessive bleeding, the endometrium was destroyed by means of the neodymium-YAG laser. The photovaporization was done under direct vision through a hysteroscope. Twenty-two patients have been treated, all but one successfully, i.e., little or no menstrual flow. The human uterus having a thick myometrium was found to be ideal for this modality. To suppress endometrial regeneration further, each patient was placed on a regimen of danazol for 2 to 3 weeks prior to and after the procedure. Hysterograms after laser photovaporization showed variable degrees of uterine contraction, scarring, and adhesion formation. Biopsies of the endometrial surface up to 20 months following the procedure showed no evidence of inflammation other than foreign body giant cell reaction around carbon particles. Minimal endometrial regeneration occurred.