women : need relief from heavy bleeding? endometrial ablation to the rescue!
DESCRIPTION
Overly heavy bleeding is more than just an inconvenience – it can affect your day to day life. Some women deal with prolonged and excessive bleeding with each period, but aren’t ready for or do not want a hysterectomy. Dr. Richard Eden discusses this procedure that can lighten up your month.TRANSCRIPT
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Abnormal Uterine BleedingWhat to do about it?Richard Eden, M.D.
www.SpringfieldClinic.comwww.SpringfieldClinic.com
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Abnormal Uterine Bleeding Affects…
• Adolescents
• Women of reproductive age
• Perimenopausal and postmenopausal women
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Abnormal Uterine BleedingDefinitions
• Menorrhagia-heavy or prolonged uterine bleeding that occurs at regular intervals. Usually >7d or >80 ml blood loss.
• Oligomenorrhea-cycle length >35 days• Polymenorrhea-cycle length < 21days• Amenorrhea-absence of menstruation for at least 6 months.• Metrorrhagia-irregular menstrual bleeding or bleeding
between periods. Usually normal or reduced flow.• Menometrorrhagia-irregular menstrual bleeding with
excessive volume and duration of flow.
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EndometriumEndometrium
MyometriumMyometrium
MenorrhagiaExcessive Menstrual Bleeding
CervixCervix Abnormal bleeding is defined by: Length of cycle (days)
Duration of menses (days)
Amount of blood loss (ml)
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Normal Menses
Normal Abnormal
Duration of flow 4-6 days >7days
Volume of flow 35 ml >80 ml
Length of cycle 21-35 days
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Uterus
• Hollow, pear-shaped muscular organ, which lies in the pelvic cavity, between the urinary bladder and the rectum
• Functions to prepare for and maintain pregnancy
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Laparoscopy-Normal Uterus
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Normal Uterus & Right Ovary/Tube
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Normal Uterus & Left Ovary/Tube
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Abnormal Uterine Bleeding
• Affects >10 million women in the U.S.
• Impacts daily activities and quality of life
• May cause anxiety
• May lead to iron-deficiency anemia/fatigue
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Normal Menstrual Cycle
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Abnormal Uterine BleedingDifferential Diagnosis
• Structural-Cervical or vaginal
laceration-Uterine or cervical
polyp-Uterine leiomyoma
(fibroids)-Adenomyosis-Cervical
stenosis/Asherman’s (hypomenorrhea)
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Abnormal Uterine Bleeding Differential Diagnosis
• Hormonal -Anovulatory bleeding (lack of ovulation-decreased
progesterone) -Hypogonadotropic hypogonadism -Pregnancy -Hormonal contraception (BCP’s, Depo-Provera)• Malignancy -Uterine or Cervical cancer -Endometrial hyperplasia (potentially pre-malignant) -Chemotherapy or radiation• Bleeding Disorders -VonWillebrand’s Disease, Hemophilia, ITP, Factor deficiencies, platelet disorders.
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Abnormal Uterine Bleeding Workup
• History -Timing of bleeding, quantity of bleeding, menstrual history, associated symptoms. Family history of bleeding disorders. Excessive psychological stress, exercise, or weight loss.• Physical Exam -pap smear (rule out cervical cancer) -endometrial biopsy (rule out uterine cancer) -excessive facial hair growth, obesity (BMI>25) (polycystic ovarian disease 6-10% of women) -abnormal breast discharge (prolactin disorders) -anorexia signs (hypothalamic dysfunction) -goiter, weight loss or gain (thyroid disease) -other disease states (leukemia, hypersplenism, chemo, radiation)• Labs -Pregnancy test -FSH, LH, Estradiol -TSH, Prolactin, DHEA-S, Testosterone• Imaging -Pelvic ultrasound (transvaginal) -Sonohystogram (saline infusion ultrasound) or hysterosalpingogram (x-ray) -MRI (better for adenomyosis dx than U/S)• Surgical -Hysteroscopy -D&C
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Medical Treatment of Abnormal Uterine Bleeding
• Iron• NSAID’s• Combined Contraceptives (estrogen and
progesterone)• Progesterone only methods• IV Estrogen• GnRH agonists• Androgens• Antiprogestational agents
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Iron
• Menstrual volume > 60 ml- iron deficiency anemia
• Primary symptom is fatigue• Daily doses of 60-180 mg of iron needed for
anemia Rx• May be the only treatment necessary
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NSAID’s
• Nonsteroidal Anti-inflammatory Drugs
• Can decrease bleeding by 30-40%
• Motrin (ibuprofen) 400mg every 4 hrs
• Anaprox (Naproxen) 550 mg every 12 hrs
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Combined Contraceptives
• Contain both estrogen & progesterone
• Birth control pills (daily)
• Birth control patch Ortho Evra (weekly)
• Contraceptive ring Nuvaring (monthly)
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NuvaRing
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Progesterone only Methods
• Mini-pill-often used in breastfeeding moms, useful in patients who cannot take estrogen containing pills (Hx of strokes, DVT’s, breast cancer).
• Depo-Provera-3 month birth control, high amenorrhea rate, causes weight gain, causes increased bone loss.
• Progesterone sub dermal implants (Implanon)-3 year birth control. High irregular bleeding rates during the first few months.
• Progesterone IUD (Mirena)-5 year birth control, 70-80% reduction in blood loss, 99.8% effective contraception, 3-5 minute office procedure. Same bleeding rate control as ablations after 2-3 years of use.
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Implanon
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Mirena IUD
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Other treatments
• IV Estrogen—stops bleeding acutely (71% bleeding cessation vs. 38% placebo), usually within 24-48 hrs, given in hospital setting. Premarin 25 mg IV q 4 hrs x 24 hrs.
• Lupron (GnRH agonist)—induces amenorrhea in 40-60% of patients by shrinking total uterine volume. Limited use due to cost and “menopause-like” side effects. Mostly used for fibroid related bleeding prior to surgery.
• Androgens (Danazol)—synthetic testosterone derivative, reduces bleeding volume 50% in women with ovulatory bleeding. Side effects make long term treatment undesirable.
• Antiprogestational Agents (Mifepristone 50 mg/day)—reduces the number of progesterone receptors in the uterus. Reported to induce amenorrhea in women with fibroids.
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Endometrial Ablation
• Surgical procedure-outpatient surgical setting, usually general anesthesia.
• Indicated for the treatment of menorrhagia or perceived heavy menstrual bleeding in premenopausal women (usually< age 50).
• Presence of anemia or failed medical therapy are other indications for endometrial ablations.
• Goal is to normalize menstrual blood flow.• Contraindicated in postmenopausal bleeding patients.• Not a contraceptive method.• Must be done with childbearing (previous tubal or
vasectomy).• Tubal ligation can be done the same day as the ablation
surgery.
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Ablation Preoperative Evaluation
• Pap smear-used to exclude cervical cancer• Endometrial biopsy-used to exclude uterine cancer
or uterine hyperplasia.• Transvaginal U/S-used to look for anatomic causes
of bleeding such as uterine fibroids, uterine polyps, cervical polyps, or congenital malformations of the uterus (septate uterus). Often combined with saline infusion sonography (SIS).
• Hysteroscopy-using a camera to look “inside” the uterine cavity.
• D&C –dilation & curettage-scrapping uterine lining.
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Endometrial Biopsy
• Safe, relatively simple procedure useful in perimenopausal or high risk women
• Not sensitive for detecting structural abnormalities (eg, polyps or fibroids)
• Office-based techniques (gold standard replacing D&C)– Disposable devices (eg, Pipelle, Tis-u-Trap,
Accurette, Z-sampler)– Reusable instruments (eg, Novak Curette,
Randall Curette, Vabra Aspirator)
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Transvaginal Ultrasonography (TVS)
– Inexpensive, noninvasive, and convenient • Indirect visualization of the endometrial
cavity, myometrium, and adnexa • Measurement of endometrial thickness
(<5 mm vs. >5 mm)• May be used to increase index of
suspicion for endometrial atrophy, hyperplasia, cancer, leiomyomas, and polyps
• May not always distinguish among submucosal fibroid, polyp, or adenomyosis
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Posterior Fibroid
Slide courtesy of Linda Bradley,MD.
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Saline Infusion Sonography (SIS)
• Relatively new technique• Very useful for evaluation of AUB in pre-, peri-, and
postmenopausal women• May be superior to TVS alone (94.1% vs. 23.5% for
detection of focal intrauterine pathology)• SIS + biopsy: 96.2% sensitivity and 98% specificity • Disadvantage: small irregularities may be
misinterpreted as polyps • Able to determine penetration depth of uterine
fibroids
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Saline Infusion Sonography
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Posterior Fibroid
Slide courtesy of Linda Darlene Bradley, MD.
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Submucosal Fibroid
Slide courtesy of Linda Darlene Bradley, M.D.
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Endometrial Polyps
Slide courtesy of Linda Darlene Bradley, MD.
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Hysteroscopy
• Hysteroscopy + biopsy = “gold standard” • Most are performed to evaluate AUB • Diagnostic hysteroscopy easily performed in
the office setting—although it requires skill • Particularly useful in the diagnosis of
intrauterine lesions in women of reproductive age with ovulatory AUB
• Complications (<1%) may include uterine perforation, infections, excessive bleeding, and those related to distending medium
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Hysteroscopy = Uterine Camera
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Flexible hysteroscope
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Normal Uterine Cavity
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Uterine septum
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Endometrial Polyps
Slide courtesy of Linda Darlene Bradley, MD.
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Vascular endometrial polyp
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Uterine Polyp
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Uterine Polyp
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Large Uterine Polyp
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Uterine Cavity Post Resection of Polyp
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Uterine Polyps
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Endometrial Hyperplasia
rSSlide Courtesy of Linda Darlene Bradley, MD.
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Uterine Submucosal Fibroid
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Resection of uterine fibroid
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Ablation Devices
• Novasure—uses radiofrequency electricity with a bipolar gold mesh electrode. The device is passed through the cervix and into the uterine cavity.
• Ablation cycle takes 80-90 seconds. Very fast.
• 78% Success rate• 35-41% amenorrhea rate• 92% patient satisfaction rate at 1 year
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Step 1
After slightly dilating your cervix and inserting a slender wand, your doctor will extend a triangular mesh device into your uterus.
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Step 2
The mesh device gently expands, conforming to the dimensions of your uterine cavity.
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Step 3
Electrical energy is delivered through the mesh for approximately 90 seconds.
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Step 4
The mesh device is retracted back into the wand and both are removed from your uterus.
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Novasure Endometrial Ablation
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Thermachoice Endometrial Balloon
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ThermaChoice Balloon
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Ablation Devices
• Thermachoice—balloon tipped catheter is positioned into the uterine cavity and filled with fluid that is heated to 87 degrees centigrade.
• Ablation cycle takes 8 minutes.• May be better suited for fibroid uterus.• Reported to decrease menstrual cramps
better.• 80 % success rate• 37% amenorrhea rate at one year• 96% patient satisfaction rate
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Ablation Complications
• UTI 0.8-3 %• Vaginal infection 0.6-2.3%• Fever 1.4%• Endometritis 1-2.8 %• Abdominal pain/cramps 0.6-3.2%• Hematometra 0.6 %• Bacteremia 0.5%• Uterine perforations 1.4%• Fluid overload 0.2%• Postablation tubal ligation syndrome 1-10%• Electrolyte imbalance• Cervical laceration
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Contraindicatons to Ablation
• Large uterus > 12 wks size• Uterine fibroids > 3 cm• Uterine cancer or uterine hyperplasia• Postmenopausal females• Recent pregnancy (must be at least 6 wks
postpartum)• Desire for future pregnancy• Active or recent uterine infection (PID)• Previous uterine surgery (C/S or myomectomy)• Anatomic distortion (congenital uterine
malformations—bicornuate uterus, etc.)
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Effectiveness of Ablation
• >90 % patient satisfaction at 1 year• 37-41% amenorrhea rate• About 10% dissatisfaction rate at one year• 2-3 % have repeat ablations after one year• 6-10% will have subsequent hysterectomy
after one year• Some studies report 8% to 24% subsequent
hysterectomy rates at 7 years post ablation
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Endometrial Ablation Summary
• Endometrial ablations are effective treatment for abnormal uterine bleeding
• Outpatient procedure• >90% patient satisfaction rate• High amenorrhea rate• Estimated that endometrial ablations
will replace 30% of all hysterectomies done in U.S.
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Hysterectomy Facts
• Most common female surgery• Definitive solution for many uterine
conditions• 650,000 procedures annually
Most performed through abdominal (open) incision
• Advances in minimally invasive surgery (MIS) for hysterectomyMore GYN surgeons performing MIS for
hysterectomy
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Hysterectomy
• Total abdominal hysterectomy (TAH)
• Vaginal hysterectomy
• Laparoscopic assisted vaginal hysterectomy (LAVH)
• Laparoscopic supracervical hysterectomy (LSH)
• Total laparoscopic hysterectomy (TLH)
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• Open (abdominal) surgery
• Minimally invasive surgery (MIS)Vaginal surgeryConventional laparoscopic surgeryda Vinci® Hysterectomy (robot-assisted
surgery)
Surgical Approaches to Hysterectomy
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Minimally Invasive Surgery (MIS)
• Reduced blood loss• Fewer complications• Shorter Hospital stay• Faster recovery• Less scarring
Circa. 1991
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Vaginal Surgery
Pros• Minimally invasive
Minimal scarring Short hospital stay Less pain compared to abdominal hysterectomy
Cons• Difficult to perform• Reduced visualization• Not indicated for many patients
Nulliparious (women who have not given birth) Multiple fibroids (or large masses) Cancer Adhesions, e.g., endometriosis, prior pelvic surgery
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Minimally invasive Ability to operate through small, keyhole incisions
Better visualization than open surgery
Open Vertical Incision Open Transverse Incision Laparoscopic or
da Vinci® Incision
Laparoscopic Surgery
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Drawbacks with Conventional Laparoscopic Surgery
• Surgeon operates from a 2D image
• Rigid instruments
• Instruments controlled at a distance
• Reduced dexterity, precision & control
• Greater surgeon fatigue
• Surgical assistance is limited
• Makes complex operations more difficult to perform
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How can we overcome these drawbacks?
da Vinci® Surgical System
• State-of-the-art robotic technology
• Surgeon in control• Assistant has direct
access
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Vision System
Surgeon immersed in 3D image of the surgical field
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Surgeon directs precise movements of the instruments using Console controls
The Surgeon Directs the Instruments
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• Conventional minimally invasive instruments are rigid with no wrists
• EndoWrist® Instrument tips move like a human wrist
• Allows surgeon to operate with increased dexterity & precision
Wrist and Finger Movement
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• EndoWrist® Instruments fit through dime-sized incisions
• A wide range of instruments are available
Small Instruments, Small Incisions
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Surgeon has… Improved visualization Better instrumentation,
surgical control & precision Better surgical dexterity for
complex aspects of procedure
Easier & faster suturing Better ergonomics
Double-click to view video
da Vinci® Surgery
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Open Vertical Incision Open Transverse Incision da Vinci® Surgical Incision
Robot-Assisted Surgery Access
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da Vinci® Gynecologic Surgery Indications
• da Vinci® Surgery appropriate for a broader range of gynecologic conditions & patient situations compared to conventional laparoscopy• Cervical cancer
Conventional laparoscopy not widely accepted• Endometrial cancer
Conventional laparoscopy accepted, but technically difficult to perform
• Vaginal or uterine prolapse Conventional laparoscopic suturing not reliable
• Endometriosis• Uterine fibroids• Obese patients
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Enable minimally invasive surgery (MIS) approach– Easier to learn & perform compared to conventional
laparoscopic surgery– da Vinci (robotic-assisted) Surgery will enable:
More Gynecologists to perform minimally invasive surgery
Gynecologists to perform more advanced operations & more types of procedures using a minimally invasive approach
Provide benefits of MIS to hysterectomy candidates– Short hospital stay– Minimal pain & scarring– Quick recovery & return to normal activities
Goals of da Vinci® Hysterectomy
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daVinci Robotic Platform
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My Girls
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My Girls