Hysterectomy and it’s alternatives in DUB

1
Hysterectomy and its alternatives in DUB

• Reducing hysterectomy rates

2

• Madhu RajpalMBBS.MS.DGO,MAMS,DSc,FICMCH(KOLKATA
  ),FICMU(MUMBAI),FIAJGO,FACTM (MICHIGUN) US
• LIFE MEMBER AOGS,FOGSI,AOFOG,FIGO,IMA,IMAAMS,NARAC
  HI,ICMCH,IFUMB
• SECRETARY AOGS AGRAJT ORGANISING SECRETARY
  NATIONAL CONFERENCE FOGSI ORGANISING SECRETARY
  NATIONAL ISCCP 2008 AGRAGUEST SPEAKER NATIONAL
  FOGSI CONFERENCE AURANGABADFACULTY IN NATIONAL
  AND INTERNATIONAL CONFERENCES HELD IN INDIA AND
  ABROADHON SECRETARY 2007 AOGS AGRA INDIAHON
  PROFESSOR OF OBS. AND GYNAE ICMCH SENIOR
  CONSULTANT ,OBSTETRICIAN GYNAECOLOGIST
  ,LAPROSCOPIC SURGEON AND INFERTILITY SPECIALIST

3
What is DUB

• Abnormal uterine bleeding in the absence of
  organic disease is called dysfunctional uterine
  bleeding.
• Diagnosis needs exclusion of following
  conditions-
• Pregnancy
• Coagulopathy
• Pelvic disease-fibroid,adenomyosis,endometrial
  polyp,ovarian tumour

4
contd

• Malignancy
• Hypothyroidism
• Drug therapy-IUCD,HRT,anticoagulants.
• .INVESTIGATIONS are directed to exclude the above
  conditions.
• Pregnancy test,CBC,serum progestrone, coagulation
  studies,diabetic screening, endometrial
  sampling,endometrial aspiration,ultrasonography,sa
  line infusion sonography,hysteroscopy.

5
Treatment of DUB

• Individualized considering age,need for
  contraception,desire to retain uterus,Nature and
  severity of complaints,presence of any pelvic
  pathology,outcome of previous treatment,cost of
  treatment,bed occupancy,time away from work

6
What are the treatment options

• Medical treatment-Non hormonal,Hormonal
• Surgical-Minimal invasive surgery, hysterectomy

7
Non hormonal treatment

• These are haemostatic agents used to decrease
  blood loss during menstruation.
• Anti fibrinolytics-Tranexamic acid First line
  therapy for DUB.It decreases plasminogen activity
  by blocking the lysine binding sites. Decrease in
  menstrual blood loss by 50-60
• Cyclo-oxygenase inhibitor

8
Nonhormonal treatment (contd)

• Ethamsylate-decreases capillary fragility, it
  increases platelet adhesiveness also.
• Mifipristone-an antiprogesterone agent that
  competitively binds and inhibits progesterone
  receptors.It causes atrophy of spiral arteries
  and inhibition of angiogenesis.It causes
  amenorrhoea in 60-70 cases.Shrinkage of
  leiomyoma by 40-50

9
Hormonal treatment

• Progestin therapy
• Oral cyclic administration
• Local administration-by progestin impregnated
  intra uterine device levonorgestrel intra
  uterine system(LNG-IUS) marketed as Mirena is
  used for the treatment of DUB.It contains 52mg of
  levonorgestrel and causes atrophy of endometrial
  glands.Effect lasts for 5yrs.

10
Mirena (contd)

• Reduction of menstrual blood loss of 86 in
  menorrhgic women in only 3 months and a further
  reduction to 97 in 12 months after insertion of
  the device.
• Estrogen-high dose estrogen therapy is useful in
  controlling acute episode,by promoting rapid
  endometrial growth.
• COC pills
• Danazol-acts by suppressing ovulation, decreasing
  ovarian prodn of 17b estradiol and direct
  endometrial atrophy.

11
GnRH Analogue

• GnRH analogues suppresses pitutary secretion of
  gonadotrophins and thereby creates hypo
  estrogenic state.these are highly effective and
  cause amenorrhoea in most of the cases.Specific
  indications of GnRH therapy in DUB
  includeendometrial suppression prior to
  endometrial ablation, short term for pt awaiting
  surgery
• Ormiloxifene-is aSERM and has high affinity with
  estrogen receptor, antagonizing the effect of
  estrogen on uterine and breast tissue. There is
  85.7 improvement in heavy bleeding.

12
Minimally invasive surgery

• Endometrial destruction can be done
• By applying various forms of energy to cause
  damage to the basalis layer of the endometrium
  and prevent regrowth.
• Endometrial ablation should include .5 to 3 mm of
  myometrium for complete destruction of the
  endometrial glands.

13
Contraindication of endometrial ablation

• Pregnancy or desire to be pregnant in future.
• Known or suspected endometrial carcinoma
• Pre malignant change in endometrium
• Active PID or hydrosalpinx
• Prior classical cesarean delivery or trans mural
  uterus
• Intrauterine device in place
• Active urinary tract infection at the time of
  treatment

14
Preoperative endometrial suppression

• The surgery will be most effective if under
  taken when endometrial thickness is less than 3
  mm and in the immediate post menstrual phase so
  suppression prior to ablation is a important
  denominator of the treatment success.
• GnRH analogue (most preferred) is given during
  the 3rd week of the cycle followed by 2nd dose 4
  wks after the last injection.

15
Prerequisites for the endometrial resection are

• Menorrhagia resistant to medical therapy.
• Uterus lt_ 12 weeks or uterine cavity less than 10
  cm.
• Endometrial histology-normal or low risk
• Completed family

16
Contd.

• Danazol-is given in the dose of 200-600 mg per
  day for three months
• Both OCP,s and progestins can be used
• Mechanical preparation of endometrium by
  curettage
• Performing ablation in immediate post menstrual
  phase.

17
Ideal ablation technique

• Short learning curve
• No operating hysteroscopy technique required
• Effective and versatile
• Safe
• Anesthetic consideration-under LA/sedation,
  minimal cervical dilatation
• Economic consideration

18
Various types of ablative techniques
19
Comparison between 1st and 2nd generation
technique
20
1st generation ablation techniques

• These techniques were introduced in 1980
• High success rate of 80-90
• Require hysteroscopy and advanced operator skill
• Laser endometrial ablation-Energy from NdYAG
  laser is transmitted to the endomerial cavity
  hysteroscopically and directed to the endometrium
  resulting in a zone of self limited necrosis that
  is 4-5mm deep.

21
Contd.

• throughout the cavity to produce ablation
  effects.It feature a hand held catheter,16
• Cm long and 4-5 mm in diameter with a silicone
  balloon.
• OPERATING PRINCIPAL
• Balloon filled with (5 dextrose with water)
• AT 87 degree centigrade
• Average time for treatment 8 min
• Average procedure time 20 min
• Depth of destruction3.4 /- 1.8mm
• Direct visualization -None

22
Exclusion criteria

• Cavity size gt10 cm,
• Sub mucosal fibroid
• Polyps
• Septate Uterus
• Previous endometrial ablation procedure
• Previous classical cesarean section

23
Laser endometrial ablation (contd)

• gt90 patients experience a significant reduction
  in uterine blood flow
• TRANS CERVICAL RESECTION OF ENDOMETRIUM-diathermy
  loop is used to shave off endometrium in strips
  up to 7mm wide and 3-4mm deep. preoperative
  endometrial suppression is associated with
  success rate of 85-90.tissue can be obtained for
  histopathological examination.

24
Roller ball endometrium ablation

• It was introduced as a simpler alternative to the
  TCRE.
• Energy is delivered through a ball electrode over
  a wider area. The ball is drawn over the entire
  endometrium causing destruction up to 4-5 mm
• The ball is good fit for the uterine fundus and
  coruna.

25
Versa Point-This uses Bipolar Electrodes. Saline
is used as distending Medium

• COMLICATIONS WITH FIRST GENERATION TECHNIQUE
• Early complications-
• 1 25Problems with distending media14-4
• A Fluid over load causing CHF
• B water intoxication
• Hemorrhage 2.4
• Perforation 1.5
• Cervical lacerations
• Visceral and Bowel burn 0.6

26
LATE COMLICATIONS

• 1 Hematometra 1.2
• 2 Perforation0.2 -1.6
• 3 Tubal -occlusion syndrome 6-8
• SECOND GENERATION ABLATION TECHNIQUES
• These global endometrium ablation techniques have
  been engineered to minimize complications

27
Advantages

• A-Do not require hysteroscopy Less skill is
  required
• Lesser complications (e.g. fluid overload
• ,hemorrhage.
• DISADVANTAGES
• A Blind Procedure
• B Direct visualization of endometrium and
  detection of abnormal pathology is not possible
  

28
Thermal balloon ablation

• In 1997,the gynecare Thermachoice uterine balloon
  therapy(UBT) system became the first global
  ablation technology to receive FDA approval.The
  device consists of a balloon that is filled with
  fluid (5dextrose and water) and inflated to a
  pressure of 180mm Hg.A central heating element
  warms the fluid,which is then circulated
  throughout the cavity to produce ablation effects.

29
Cavaterm-is the other system which is available.

• It is made up of a flexible silicone balloon
• And heat is produced by a self redgulating
  element which is set to 80C.A continuous flow of
  heated glycine produces a temperature of 75C for
  treatment time of 15 min.

30
Comparison between thermachoice and caveterm
31
Microwave Endometrial Ablation

• Microsulis is FDA approved for use in fibroid
  associated cavity distortions and uterine
  cavities up to 14cm. It utilizes direct tissue
  heating to a depth of 3mm by microwave energy and
  also provide conductive heating to a further
  depth of 2-3mm. At therapeutic temperature ,the
  total depth of penetration coagulates and
  destroys the basal layer.

32
Operating principle of microwave EA

• Average treatment time-3.5 min
• Average procedure time -11min
• Advantage-ut. Size 6-14cm,presence of polyps,s/m
  fibroids can be tried
• Exclusion criteria-pr ut surgery
• Success rate -90

33
Hydrothermal ablation

• The HTA is FDA approved ablation of endometrial
  lining which is achieved by re circulating saline
  heated to a temperature of 90C
• Op principle-HT circulation of saline at 90C
• Average tt time-10min
• Average procedure time-30min
• Exclusion criteria-I M fibroidgt4cms,ut anatomical
  anomaly ,classical c/s

34
Endometrial laser I U Thermo therapy(ELITT)

• It consists of three laser fibres connected by
  Teflon bridge in an inverted triangular
  configuration,without causing cavity distention.
• CRYOABLATION-it is FDA approved system which uses
  cryoprobe cooled by compressed gas mixture to
  freeze the endometrium through Joule Thompson
  effect.

35
Conclusion

• DUB-affects 20-30 women in repro. Age group and
  25 of all gynecological Surgeries
• Diagnosis of exclusion
• Endometrial aspiration-pipelle canula -95
  sensitive
• SIS
• Nonhormonal tt
• LNG-IUS
• 1st gen. ablation technique-success rate of
  80-90
• 2nd gen. ab. Tech.have been engineered to
  minimize complications