Endometrial ablation

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The endometrial ablation (from Greek ἔνδον = endos (inside), old Greek μέτρα = metra (uterus) and Latin ablatio - removal, detachment) is a medical measure to remove and / or destroy the uterine lining in the event of dysfunctional bleeding ( hypermenorrhea , menorrhagia ) . It is used to avoid a hysterectomy when hormonal treatments are not possible or have been unsuccessful. The procedure is usually performed on an outpatient basis.

Indications

An endometrial ablation is medically indicated if the menstrual period is too heavy, too frequent and irregular, which cannot be treated hormonally and is not caused by submucosal fibroids or polyps of the uterine lining. Family planning should be completed, a malignant disease of the uterine lining ( endometrial cancer ) and its precursors must be excluded. This requires a tissue examination of the uterine lining by scraping , if possible combined with a uterine specimen . The method is a way of avoiding the removal of the uterus in patients with a high risk of surgery and anesthesia , or if a hysterectomy is rejected .

Procedure

There are different methods, but the basic principle is the same. The mucous membrane of the uterus is obliterated or removed down to the muscles. This means that no new mucous membrane can build up in the uterus in the monthly cycle . As a result, the menstrual period stops or is reduced to a normal level again. The procedures are also divided into 1st and 2nd generation methods.

1st generation methods 2nd generation methods
Snare resection Balloon catheter (Thermachoice®, Cavaterm®)
Rollerball cryosurgical procedures
Nd: YAG laser Hydrothermal ablation
Microwave coagulation bipolar three-dimensional mesh (NovaSure®)

The methods of the 1st generation differ in principle from those of the 2nd generation in that in the latter, the entire mucous membrane is treated simultaneously and homogeneously. In addition, these are easier to learn and require less experience.

1st generation methods

In the first generation procedures, instruments are inserted during an endoscopy and the lining of the uterus is removed with an electric loop, ablated by laser, or obliterated using electric current or microwaves.

  • Endometrial ablation through removal and sclerotherapy (coagulation):

  • normal endometrium

  • electric coagulation roller

  • worn and deserted endometrium

During hysteroscopic resection, large areas of the mucous membrane are removed layer by layer with an electric loop, including the superficial myometrium layer. The endometrium alone or in addition is thermally obliterated using a rollerball or a similar electrode. This means that areas of the mucous membrane close to the entrance to the fallopian tubes can also be safely reached. According to the recommendations of the Gynecological Endoscopy Working Group of the German Society for Gynecology and Obstetrics , however, hysteroscopic removal of the mucous membrane with an electric loop in combination with sclerotherapy using a rollerball or roller is currently standard. Another advantage of this method is that intrauterine septa, fibroids and polyps can be removed in the same session.

  • Nd: YAG laser: Hysteroscopic ablation of the endometrium of the endometrium with the laser is not very common. With this method, the mucous membrane is also thermally obliterated.
  • Microwave coagulation: The thermal obliteration of the endometrium through the use of microwaves is mainly used in the countries of the Commonwealth where it was developed.

2nd generation methods

  • Uterine balloon method: In this procedure, a balloon catheter is inserted into the uterus and the balloon is filled with hot water. Depending on the method, the uterine cavity is heated for 8 to 15 minutes, thereby destroying the uterine lining.
  • Hydrothermal ablation: With hydrothermal ablation, 90 ° C hot saline solution circulates through the uterine cavity, which leads to sclerotherapy of the mucous membrane.
  • Cryotherapy: The sclerosing of the mucous membrane is achieved by applying cold via a probe.
  • Bipolar three-dimensional mesh: The procedure, also known as the gold mesh method, uses a three-dimensional mesh that is expanded in the uterine cavity. The obliteration of the endometrium takes place here via electrical heat energy.

Success rate

The convalescence after endometrial ablation is between one day and two weeks. The endometrium heals scarring, causing amenorrhea (in around 40% of patients) or a decrease in the amount of bleeding. The hormonal cycle is not influenced by this, and menstrual pain is usually favorable.

A complete failure of the method, the lack of any improvement in the symptoms, is rare and is only reported in 5%. However, about 20% of the women treated require a second operation or a hysterectomy. To improve the success rate, drug pretreatment with progestins or GnRH analogues can be useful.

Endometrial ablation is not a suitable form of contraception . Since the mucous membrane can never be completely removed or destroyed, endometrial cancer can develop in rare cases .

Alternatives

Various hormonal treatment measures , in particular the hormone IUD, are available as possible alternatives to endometrial ablation . If the woman wants 100% freedom from bleeding, a hysterectomy is preferable.

Risks

Complications with endometrial ablation are rare but can be very serious:

history

Endometrial ablation was developed in 1979 by the American gynecologist Milton H. Goldrath, who first performed it with a Nd: YAG laser .

See also

literature

Web links

Individual evidence

  1. ^ Diethelm Wallwiener , J. Rimbach, Manfred Kaufmann , B. Audeniz, C. Sohn, Gunther Bastert , R. Conradi: Hysteroscopic endometrial ablation to avoid a hysterectomy in "high-risk" patients. Birth Frauenheilk 54 (1994), 498-501
  2. ↑ Lethaby A, Hickey M, Garry R, ​​Penninx J: Endometrial resection / ablation techniques for heavy menstrual bleeding . In: Cochrane Database Syst Rev . No. 4, 2009, p. CD001501. doi : 10.1002 / 14651858.CD001501.pub3 . PMID 19821278 .
  3. ↑ a b c d e f C. Altgassen, B. Bojahr, K. Diedrich , A. Gallinat, R. Kreienberg , G. Kreuz, T. Römer, R. Söder, D. Wallwiener : Endometrium ablation - operative, organ-preserving treatment of dysfunctional uterine bleeding. Frauenarzt 51 (2010), 218-22
  4. ↑ A. Niesel, A. Gallinat, U. Neeb: Endometrial carcinomas after endometrial ablation - a literature review. Natal Frauenheilk 63 (2003), 31-36, doi : 10.1055 / s-2003-37095
  5. ↑ Thomas Römer: Long-term results after endometrial ablation. In: Hans Georg Bender , Peter Dall: 54th Congress of the German Society for Gynecology and Obstetrics. Springer Verlag, 2003, ISBN 3540011064 , pp. 158-162 in the Google Book Search
  6. ↑ Thomas Römer, D. Grabow, J. Müller: Conservative management of a post-ablation syndrome after transcervical endometrial ablation. Natal Frauenheilk 57 (1997), 43-45
  7. ↑ Milton H. Goldrath: Hysteroscopic endometrial ablation. Obstet Gynecol Clin North Am. 22: 559-72 (1995), PMID 8524537