Ian Chilcott
Excessive menstrual blood loss >80mls - That interferes with physical, emotional, social and material quality of life 1 in 20 women aged 30 to 49 years consult their GP each year with menorrhagia Single leading cause of referral to gynaecologist
Causes Idiopathic. DUB Fibroids Endometrial polyps Endometrial hyperplasia Adenomyosis Thyroid disease Haemostatic disorders
FBC (TFT Clotting disorders Hormonal profile) Ultrasound Uterus palpable abdominably Pelvic mass of uncertain origin Failed pharmaceutical treatment
Endometrial biopsy (persistent IMB >45 with treatment failure to exclude hyperplasia/malignancy) Endometrial sampling Hysteroscopy
27% pts with abnormal uterine bleeding submucosal fibroids
Appropriate if: No structural or histological abnormality abnormality (fibroids <3cm not distorting cavity)
Mirena (levonorgestrel-releasing intrauterine system) 20mcg LNG/24 hrs over 5 years Reduces menstrual loss by up to 96% 20% amenorrheic at 1 year Use also contraception - progestogen component of HRT
Dilatation and curettage Myomectomy Hysterectomy Endometrial ablation TCRE TCRF Myomectomy Hysterectomy - Laparoscopic
Fibroids Symptoms correlated with location as well as size Grade 0 Grade 1 Grade 2
1 st generation Endometrial resection/ablation LEA Rollerball EA TCRE
Resection TCRE Day case Tissue obtained Gold standard Endometrial preparation Complications Training issues
TCRE Gold standard technique 77% success at 5 years Litta et al - Eur J Obstet Gyn Reprod Biol 2006 Various other studies Amenorrhoea rate 30-40% Success 70-90%
TCRE Complications Fluid absorption >2l 1% Uterine perforation 15/1000 Bowel injury 0.7/1000 Emergency hysterectomy 11/1000 Mistletoe study, Overton BJOG 1997
2 nd Generation Endometrial Ablation Non hysteroscopic Easier Quicker Safer 2nd Generation Endometrial Ablation
Balloon ablation Thermachoice Caverterm Thermablate Microwave endometrial ablation MEA Novasure Hydrothermal ablation Endometrial cryo ablation 2nd Generation Endometrial Ablation
Balloon ablation Thermachoice 1 st of the second generation devices 2nd Generation Endometrial Ablation
Balloon ablation Thermachoice 2nd Generation Endometrial Ablation
Balloon ablation Thermachoice 2nd Generation Endometrial Ablation
Thermachoice Vs TCRE Gervaise Hum Reprod 1999;14 RCT N=147 2 years TCRE Thermachoice Low complication rates Satisfaction 76% 83% Amenorrhoea 38.8% 36.4% Hysterectomy 10% 15% 2nd Generation Endometrial Ablation
Thermachoice Vs Rollerball Meyer Obstet Gynecol 1998;92 RCT N=239 Rollerball Thermachoice 2 years Satisfaction 85.6% 86.7% Amenorrhoea 15.2% 27.2% 5 years Overall success 69% 68% 2nd Generation Endometrial Ablation
Thermachoice Vs Rollerball Meyer Obstet Gynecol 1998;92 RCT N=239 Rollerball Thermachoice 2 years Satisfaction 85.6% 86.7% Amenorrhoea 15.2% 27.2% 5 years Overall success 69% 68% 2nd Generation Endometrial Ablation
Balloon ablation Thermachoice Complication rates Gurcheff and Sharp Medline/FDA database Estimated denominator 150000 Overall complication rate 0.59/1000 2nd Generation Endometrial Ablation
2nd Generation Endometrial Ablation
Mean treatment time 3.5 minutes Therapeutic zone 70-80C
MEA VS TCRE Cooper et allancet 1999;354 N=255 12 months MEA TCRE Amenorrhoea 40% 40% Satisfaction 78% 76% 2nd Generation Endometrial Ablation
A randomised comparison of MEA Vs TCRE: F/U at min 5yrs BJOG 2005 Cooper et al N=239 MEA TCRE Satisfaction 86% 74% Acceptability 97% 91% Amenorrhoea 65% 69% Hysterectomy rate 16% 25%
2nd Generation Endometrial Ablation
3-D Bipolar electrode Myometrial Penetration: Cornua - 2-33 mm Mid-Body - 5-77 mm Depth of ablation controlled by impedance of the tissue: 2nd Generation Endometrial Ablation
1. Device insertion and deployment 3. Ablation cycle with bipolar RF energy- 90 seconds. 2. Cavity integrity assessment 8 secs 2nd Generation Endometrial Ablation
Consistent Depths of Tissue Destruction Across Varied Uterine Sizes (post-ablation specimen)
90 secs
Thermachoice Vs Novasure Bongers BJOG 2004;111 RCT N=126 1 year Novasure Thermachoice Satisfaction 90% 79% Amenorrhoea 43% 8% Low complication rates 2nd Generation Endometrial Ablation
No tissue sample Expensive as disposable equipment Treatment outcomes broadly similar to HEA and between 2nd generation techniques Good safety profile User friendly Shorter operating times Out patient treatments possible Effective Likely to increase in popularity 2nd Generation Endometrial Ablation
The aim of UAE for fibroids is to offer a less invasive alternative to hysterectomy or myomectomy with preservation of the uterus Conscious sedation local anaesthesia catheter is inserted into the femoral artery Fluoroscopic guidance,into the uterine artery. Small embolisation particles are injected through the catheter into the arteries supplying the fibroids, with the aim of causing thrombosis and consequent fibroid infarction. 40% reduction in uterine size Patient selection important
Abdominal Laparoscopic Vaginal
The role of laparoscopy Vaginal hysterectomy - advantages over abdominal procedure Laparoscopy - allows conversion of an abdominal procedure to a vaginal one
Classification 1. Diagnostic laparoscopy, vaginal hysterectomy 2. LAVH Adnexae, adhesions, but uterine arteries taken vaginally 3. LH Uterine arteries taken laparoscopically 4. TLH