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Conservative SurgicalConservative SurgicalModalities in theModalities in theManagement of Management of

Menorrhagia EvolvingMenorrhagia EvolvingTrendsTrends

DR. ULLAS PRASANNAN

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Dysfunctional Uterine bleeding affects 20-30% of women.

Within 5 years 60 % of patients with DUB

undergo hysterectomy.20-30 % all hysterectomies are performedfor DUB.

50 % of all hysterectomy specimens showno abnormalities in the uterus

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Medical Therapy for DUB

Traditionally the first line of management for DUB is D&C followedby medical treatment.

D&C as a therapy for DUB is only

effective in decreasing blood lossduring the first few cycles.

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Medical Therapy for DUB

Generally the preferred first line therapyfor DUB.

Variety of drugs are used

Overall medical management is effectivein only around 50% of women.

Many of the drugs have troublesome sideeffects.Benefit generally lasts only for theduration of treatment.

Cost is another factor

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Medical Management of DUB

Effectiveness SideEffects Cost

OC Pills 50% +

Progestrones 20% + +

Danazol 90-100 % + + + +GnRHa 100 % + + + +

NSAID 30 % +Antifibrinolytic agents

50 % + + +

LNG-IUD 65-97 % + + +www.similima.com

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When medical management fails thetraditional treatment has beenhysterectomy.

Major procedure with sig. morbidity andmortality rates.

Mortality rate -- 0.38/1000

Serious morbidity rate 3%

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During the past 20 years minimalaccess techniques for DUB haveevolved to control menorrhagia.

These techniques perform globalendometrial ablation in a short day-

case operation.

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First generation Endometrial Ablationtechniques (FEAT) werehysteroscopic controlled.

1. Nd:Yag Laser

2. Endometrial Resection(TCRE)

3. Rollerball ablation

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These techniques TCRE and RA extensivelyevaluated in randomized trials.

Success rates 85%

Amenorrhoea rates 20-40%

DisadvantagesRequire considerable surgical skill and a longlearning curve

Complications: 2-6% serious comp. RateMortality: 2/10000

GA is necessarywww.similima.com

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Second generation ablative devices havebeen devised in the past 10 years.

Several devices developed to treat DUB

safely, effectively, quickly and easily andpreferably as an OP procedure.

These FEAT Gold standard for EA.

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1. Microwave Endometrial Ablation

2. Thermal Balloon Ablation

3. Endometrial Laser IntrauterineThermo Therapy (ELITT)

4. Intrauterine surgery using Co-axial Bipolar electrode

5. Hydrothermal Ablation of Endometrium (HTA)

6. Cryoablation of endometrium

TYPES OF PROCEDURES AVALABLE

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Of these, the Microwave Device and theBalloon Catheter have been extensivelyresearched and tested & cleared for clinicaluse.Advantages of SEAT

-- Effective-- Safe-- Easy to learn-- Quick

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Thermal Balloon Ablation (TBA) of Endometrium

Of all the SEAT, TBA has been the most widelyused and accepted procedure

Principle: Involves inserting a balloon-tippedcatheter into the uterine cavity, inflating theballoon so that it conforms to the uterine cavityand heating the fluid to 87 o C, destroying the

whole endometrium.

The two devices in current use are theThermachoice system and the Cavaterm system.

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Indications and inclusion criteria1. Dysfunctional Uterine Bleeding

2. Completed child bearing3. Uterine cavity length < 12 cms.

(Uterus < 12 weeks size)

4. Anatomically normal and regular cavity.5. Pelvic pathology excluded.6. Normal PAP smear.

7. Endometrial atypia excluded by endometrialsampling.

8. Not expecting amenorrhoea

9. Failed medical therapy.www.similima.com

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Pre-OP CounsellingPre-OP Counselling

. All important. Initially, EA was envisaged asan alternative to hysterectomy undertaken for DUB in pts who failed medical therapy.

. Patient should be counselled with regard torealistic expectations for amenorrhoea.

. She should be counselled to expect onlylighter periods

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Pre-op EvaluationRoutine blood, coagulation profile and TFT in

selected cases.PAP smear TVS and saline infusion sonography in selectedcases.Hysteroscopy and endometrial sampling.Fractional curettage .

The aim is to rule out pre-malignant or malignant lesions

of the endometrium .Atypical hyperplasia : 1.3 %Co-existent carcinoma : 20-25 %Risk of progression to cancer : 25-50 %

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EquipmentEq uipment

TBA utilizes a 16cm long 4.5mm diametrecatheter with a heating element housed in alatex balloon on the treatment end.

This apparatus is connected to a control unitwhich can monitor, display and adjust

balloon pressure, temperature and durationof treatment.

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Pre-op endometrial thinning .

EA most effective when done at endo.thickness < 4 mm in the immediate post-menstrual phase.

Endo. thinning pre-op GnRHa or Danazol.

Surgery may be done in the imm. postmenstrual period or after thoroughcurettage(3-min of 5mm suctioncurettage)

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Anaesthesia

Upto 50% can be done under LA

-- paracervical block + IV sedation

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Procedure

Deflated balloon and 5 mm catheter areintroduced transcervically into the cavity andonce in place 5% D is used to inflate theballoon.

Once balloon pressure stabilizes at 160-180mmHg pr., fluid is heated to 87 oC and maintained for 8 min.

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PRE ABLATION

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POST ABLATION

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Predictive factors for adverse outcome

Endometrial thickness > 4mm

Younger ageProlonged duration of bleeding > 9daysRetroverted Uterus

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On the other hand,

Increasing age of the patient

Higher balloon pressures

Small, regular uterine cavity

Lesser degrees of pre-op menorrhagia areall associated with sig. improved results

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TBA produces destruction of the entire

endometrial lining including the basal layer

and superficial myometrial destructionupto a depth of 3.5mm

Mean peak serosal temp: 36 oC

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Results and OutcomePrimary treatment objectives

Decrease in MBLin 80- 90%Avoiding hysterectomy - in 3-5 years, 85 % of patients avoid hysterecomy.

Decreasing dysmenorrhoea- 70%Amenorrhoea rates : 20-40 %Patient satisfaction with regard to improved qualityof life

Sig. Improvement in premenstrualsymptoms .

1 yr, 3yr, 5yr results of TBA are exactly comparable to

TCRE or RA . www.similima.com

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Medical TherapyMedical Therap y vs EAEAControl of menorrhagia and rise in Hb levels sig.

better with EA comp. to medical therapy. Patient satisfaction rates and quality of life are

also much better with EA .With medical therapy about 60% ultimately end in

hysterectomy. With EA only 15% requirehysterectomy.

On the basis of these findings it is nowrecommended that EA be offered as first linetreatment option to all women who have completedtheir family and who have DUB.

This leads to sig. redn in hysterectomy rates..www.similima.com

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Complications

No intra- operative complications.

3% minor post-op complications. Infection (endometritis) Rarely haematometra Post-op pain.

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Advantages--Safe--Effective--Easy to learn--Quick--Ideal method for high-risk

patients.--Can be done under LA.--Day-case surgery .

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Mi E d t i l Abl ti

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Microwave Endometrial Ablation

Microwaves are electromagnetic waves with a wavelength of 1mm-30cm and freq. of 300-300000 MHz

A freq of 9.2 GHz is ideal to destroy the endometrium to adepth of 6mm.

A microwave generator (magnetron) supplies microwaveenergy to a handheld applicator.

Procedure can be done under LA/GA.

The probe is inserted into the cavity, the generator is activated.

At a temperature of 70-80 oC the probe is moved laterally in thecavity.

The whole cavity is painted with a broad brush of destructivemicrowave energy. Treatment time 3-3.5min.

Compares favourably with TCRE. SERNIP B Gradewww.similima.com

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Endometrial Laser Intrauterine Thermo Therapy(ELITT)

Original Laser EA was done using the Nd:Yag Laser which is cumbersome, expensive and requires fluiddistension.

The new ELITT procedure uses 830nm diode Laser with adisposable handset.

Laser is emitted from 3 integrated optical light diffusers6mm in dia. designed to conform to the uterine cavity.This produces a uniform distribution of Laser beam.

No fluid distension needed. Handset is directly inserted.Treatment- 7 min.70% amenorrhoea and > 90% hypomenorrhoea at 1 year.

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Intrauterine surgery using Co-axialBipolar electrode

Versapoint- a new co-axial bipolar system1.6 mm dia inserted into the operatingchannel of a 5 mm hysteroscope.

The system requires fluid distension withnormal saline

Cutting occurs when the activated electrodecomes in contact with the endometrium.

Data on safety and efficacy scarce.

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Hydrothermal Ablation of Endometrium (HTA)

HTA involves instilling heated N.saline intothe uterine cavity to achieve thermal coag.necrosis of the whole endometrium.

Two devices- HTA and EnablHTA is a 7.8mm continuous flowhysteroscope

N.saline at 90 oC is circulated around theuterine cavity for 10 minutes at 50mm Hgpr.

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Cryoablation of endometrium

Destruction of endometrium using freezingtemperatures

Cryoprobes using CO as cryogen with

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Photodynamic endometrial

ablationBased on the activation of a

photosensitizing agent which generateshighly reactive oxygen molecules whichare toxic.

A no. of chemicals exhibitphotosensitizing effect. Eg. 5-ALA5-ALA has been evaluated for EA

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Radiofrequency induced

Thermal Endometrial AblationInvolves generation of electromagnetic

radiation which causes irreversible tissuedamage.

RTA is asso: with a high complicationrate and has been discredited

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Summary

DUB affects a large no: of women.Medical therapy is often an undertreatment for DUB.Hysterectomy, on the other hand is usuallyan overtreatment.

EA appears to be an ideal treatment for menorrhagia where there is no uterine or pelvicpathology & where cytological atypia or malignancy are excluded.

Second generation EA techniques like TBA aresafe, effective, easy to learn and can be doneunder LA.In the future, they may be the therapy of choice for most cases of DUB.

l