Endometrial Ablation and AUB-L

Endometrial Ablation and AUB-L

Key Points


  • Endometrial ablation has a place in the management of abnormal uterine bleeding associated with leiomyomas (AUB-L) in women who have completed childbearing or have no desire for future fertility,
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  • Endometrial ablation (EA) techniques comprise those that are based upon treatment with a uterine resectoscope (Resectoscopic Endometrial Ablation or REA), and those non-resectoscopic (Non-Resectoscopic Endometrial Ablation or NREA) devices designed specifically and solely for the procedure.
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  • For women with AUB-Lo, the leiomyomas are unlikely to contribute to the abnormal bleeding; such women may have AUB-C, -A, -O, -E or -M (see classification), and should be evaluated as appropriate for those clinical conditions. Provided that neither malignancy, nor endometrial intraepithelial neoplasia (endometrial hyperplasia with atypia) are present, EA is an appropriate option for therapy.
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  • For women with AUB-Lsm, and for whom hysteroscopic myomectomy is not feasible, endometrial ablation may be considered, generally using REA techniques.
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  • Most (but not all) NREA devices have not been designed for the large and/or irregular endometrial cavities frequently associated with submucous leiomyomas, and, therefore are not appropriate options.
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  • Patients should be counseled that EA can not be guaranteed to prevent pregnancy, and if pregnancy occurs, there are severe risks to fetus and the pregnant woman. Consequently, appropriate contraception should be used until or unless pregnancy is not possible.

ToolBox

Generic

  • Operating or procedure room table that can be tilted, raised, and lowered.
  • Padded stirrups or leg rests that support the feet and calves in the modified Trendlenberg position
  • Open sided vaginal speculum.
  • Tenaculums
  • Dilators with a diameter appropriate to the outside diameter of the ablation system
  • For hysteroscopically directed techniques, a medical grade camera, light source, and television monitor with appropriate light cables and cable connections.
  • Appropriate anesthesia.
  • Appropriate intravenous solutions.

Resectoscopic EA (REA)

  • Uterine resectoscope with a hysteroscope (preferably 12º) with appropriate inner and outer sheaths.
  •  A appropriate "element", the component of the hysteroscope that fits into the inner sheath,  which holds the electrode(s) and attaches to the radiofrequency (RF) electrosurgical generator.
  • An electrosurgical generator that capable of generating output for monopolar or bipolar resectoscopes as appropriate.
  • Dispersive electrode (for monopolar systems)
  • "Active Electrodes" either monopolar, or bipolar as appropriate to the resectoscope. These could be loops, for resection, or bars/barrels for electrosurgical desiccation/coagulation.
  • Distension media: Non-electrolyte (eg Manitol, Sorbitol, Glycine) for monopolar RF systems and 0.9% normal saline for bipolar systems.
  • A fluid management system
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Non-Resectoscopic EA (NREA)

  • For AUB-Lsm cases there are few NREA devices that have been demonstrated effective at treating the symptom of HMB. An exception is the "Mara" vapor ablation device.

  • For cases of AUB-Lo, where the endometrial cavity is normally configured, any of the approved NREA devices are appropriate options.
  • The list of "tools", comprises the procedure specific generator (eg RF, heating of gas or fluid) specific to the device in question.
  • For the hysteroscopically directed free fluid technique (Genesis HTA), a specific sheath is affixed to a 3 mm diameter hysteroscope with a proprietary adaptor, specific to the hysteroscope in question.
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