By Dr. Sushma Chawla

MD.(PGI) Chawla Nursing Home & Maternity Hospital.9, Lajpat Nagar, Link Road, Jalandhar.

TREATMENT OPTIONS FOR D.U.B

ONLY OPTION FOR MENORRHAGIA EARLIER WAS DILATION & CURETTAGE OR HYSTERECTOMY.

FOR GYNAECOLOGIST THE HYSTERECTOMY IS THE OPERATIVE PROCEDURE DEMANDING THE HIGHEST STANDARD OF SKILL AND REPRESENTS THE PINACLE OF HIS SURGICAL DEXTERITY .

FOR THE PATIENT, THE OPERATION SYMBOLIZES THE DISINTEGRATION OF HER WOMANHOOD.

HYSTERECTOMY CREATES

IATROGENIC PSYCHOREACTIVE PROBLEMS.

DISTURBANCES OF BLADDER & RECTUM FUNCTION.

REDUCED SEXUAL FEELING IN VAGINA BECAUSE OF EXCISION OF PARAVAGINAL AND PARACERVICAL NETWORK OF NERVES AND LIGATION OF UTERINE ARTERY.

A BOON FOR FEMINITY

WITH ADVANCEMENT IN TECHNOLOGY, MINIMALLY INVASIVE TECHNIQUES HAS EMERGED AS A BOON WITH 2 FOLD BENEFITS.

GET RID OF EXCESSIVE BLEEDING. UTERUS & OVARIES REMAIN INTACT TO

MAINTAIN FEMINITY.

UNFORTUNATELY, MANY YOUNG WOMEN UNDERGO SURGERY IN THE FORM OF HYSTERECTOMY

WHY NOT MINIMUM INVASIVE TECHNIQUE ?

LACK OF EXPERTISE AT THE CENTRE FOR MIS.LACK OF FACILITIESINADEQUATE COUNSELLING BY DOCTORSMISGUIDANCE BY QUACKS AND FAMILY

MEMBERSREPEATED VISITS TO CLINICSLACK OF KNOWLEDGE,TRANSPORT IN

UNDERDEVELOPED RURAL AREAS

TREATMENT AVAILABLE FOR D.U.B

TECHNIQUE METHOD• D & C• HYSTEROSCOPIC TECHNIQUES ENDOMETRIAL ABLATION ND: YAG LASER

ELECTROSURGICAL BALL

CRYO ABLATION ENDOMETRIAL RESECTION TCRE ENDOMETRIAL VAPORISATION

• NON HYSTEROSCOPIC OR GLOBAL TECHNIQUETHERMAL BALLOON

VESTA SYSTEM HYDROTHERMAL ABLATION

LAPAROSCOPIC HYSTERECTOMY LAVH, TLH, LSH

WITH EXPLOSION OF INFORMATION

WOMEN ARE ASKING “WHY THEIR UTERUS IS BEING REMOVED?”

HYSTERECTOMY is perhaps the EXCESSIVE SURGERY for MENORRHAGIA where ONLY ENDOMETRIUM is the culprit and not the UTERUS.

VARIOUS METHODS OF ENDOMETRIAL DESTRUCTION CAN BE DIVIDED INTO 2 CATEGORIES:

ABLATION TECHNIQUE THOSE DO NOT PROVIDE HISTOLOGICAL SPECIMEN FOR ANALYSIS.

RESECTION TECHNIQUETHAT PROVIDES HISTOLOGICAL SPECIMEN FOR ANALYSIS.

ENDOMETRIAL ABLATION

HYSTEROSCOPICNON – HYSTEROSCOPIC(GLOBEL TECHNIQUE )

Hysteroscopic Methods include:

LASER ENDOMETRIAL ABLATION/N.D YAG LASER, ARGON, KTP & CO2 LASER (EXPENSIVE, WITH HAZARDS).

ELECTRO SURGERY FOR ABLATION (ROLLER BALL).

ENDOMETRIAL ELECTROSURGICAL RESECTION (TCRE)

ENDOMETRIAL ELECTROSURGICAL VAPORIZATION & ELECTRO COAGULATION (VERSAPOINT).

Non-Hysteroscopic (Global Methods) Include:

BALLOON ABLATIONCAVATERM THERMAL BALLOON ABLATIONRADIO FREQUENCY PROBEUNIPOLAR ELECTRODESBIPOLAR ELECTRODESMICROWAVE ENDOMETRIAL ABLATION (MEA). HYDROTHERMAL ABLATION (HTA) MICROSULIS. DIODE LASER PHOTODYNAMIC THERAPY. PHOTODYNAMIC THERAPYCRYO SURGERY

• BOTH THE PROCEDURES ARE USED TO TREAT MENORRHAGIA• BOTH TECHNIQUES ARE QUICK AND LESS TIME CONSUMING WITH SHORT ANAESTHESIA.• PROCEDURAL RISKS ARE MINIMIZED WITH UBT WHEN USED IN PATIENTS WITH SEVERE MEDICAL DISORDERS• HYSTERECTOMY CAN BE AVOIDED WITH HYSTEROSCOPIC ABLATIVE TECHNIQUES• TCRE PROVIDES ENDOMETRIUM SAMPLING FOR HISTOPATHOLOGY WHEREAS UBT DOES NOT• VISUAL TECHNIQUES (TCRE) ARE SUPERIOR TO NON- VISUAL TECHNIQUES (UBT) BUT IT NEEDS SKILL AND TRAINING

Uterine Balloon Therapy Resection of EndometriumOR

TRANSCERVICAL RESECTION

OF THE ENDOMETRIUM

SELECTION CRITERIA FOR TCRE

ABNORMAL OR EXCESSIVE MENSTRUAL BLEEDING JUSTIFYING HYSTERECTOMY.

NO RELIEF FROM MEDICAL THERAPY OR MEDICAL TREATMENT NOT TOLERATED OR REJECTED

BENIGN ENDOMETRIAL HISTOLOGY AND PAP SMEAR. UTERINE SIZE NOT MORE THAN THE EQUIVALENT OF 10WEEKS

PREGNANCY OR UTERINE CAVITY<10 to 12CM. SUB MUCOUS FIBROID OF <6 CM IN SIZE. COMPLETED FAMILY. A THOROUGH COUNSELING IS DONE INFORMED CONSENT FOR

RESULT, COMPLICATION & RISK OF PREGNANCY AND UNCERTAINTY OF LONG TERM EFFECT IS TAKEN.

ANAESTHESIA

SEDATION. LOCAL ANAESTHESIA WITH OR WITHOUT

VASOCONSTRICTING AGENTS. SPINAL OR EPIDURAL ANAESTHESIA: - AS IT GIVES

LESS BLEEDING, PATIENT REMAINS CONSCIOUS AND CAN REPORT OF FLUID OVERLOAD.

SHORT GENERAL ANAESTHESIA.

INSTRUMENTS FOR TCRE

RESECTOSCOPE WITH CUTTING LOOP OR ROLLER BALL.HYSTEROSCOPE.HYSTEROMAT.LIGHT SOURCE CAMERA.TV & VIDEO.ELECTROCAUTERY UNIT.

FLUID USED

I) 1 .5% GLYCINE.II) SALINE.

TECHNIQUE & SURGICAL STEPS

AFTER FULL INVESTIGATIONS, MEDICAL EVALUATION, COUNSELLING AND WITH INFORMED CONSENT, IN EXCELLENT O.T. SETTING, TCRE IS PERFORMED.STEP 1:- UTERINE CAVITY IS VISUALIZED WITH

HYSTEROSCOPE.STEP 2:- DIRECT BIOPSY IS TAKEN.STEP 3:- ANY FIBROID, SEPTUM/ADHESIONS, POLYP ARE

REMOVED AND ADHESIONS ARE RESECTED.STEP 4:- CUTTING LOOP RESECTS THE ENDOMETRIUM

POSTERIORLY, LATERALLY AND THEN ANTERIORLY.STEP 5:- FUNDUS AND CORNUA ARE ABLATED WITH ROLLER BALL.STEP 6:-BLEEDING POINTS ARE CAUTERIZED WITH ROLLER

BALL.

Advantages ENDOMETRIAL SAMPLING FOR H.P.E UNDER VISION LOW RISK OF ENDOMETRIAL HYPERPLASIA OR

CARCINOMA. PRIOR D & C REDUCES NEED OF PREOPERATIVE

HORMONAL PREPARATION OF ENDOMETRIUM. SUPERFICIAL RESECTION OF MYOMETRIUM

REDUCES FAILURE RATES WHEN ADENOMYOSIS IS PRESENT.

RESECTION OF SUB MUCUS POLYP, SEPTUM, ADHESIONS AND MYOMA CAN BE DONE AT THE SAME SITTING.

Disadvantages

REQUIRES GREATER HYSTEROSCOPY SKILL AND EXTENSIVE UNDERSTANDING OF UTERINE ANATOMY.

INTRAOPERATIVE COMPLICATION

UTERINE PERFORATION, CERVICAL TRAUMA. INTRA PERITONEAL HEMORRHAGE. THERMAL INJURY TO ADJACENT

STRUCTURES. INTRA OPERATIVE HEMORRHAGE. FLUID OVERLOAD HYPONATREMIA,

HYPOOSMOLARITY & BRAIN OEDEMA EMBOLISM.

SHORT TERMINFECTIONHAEMATOMETRASECONDARY HAEMORRHAGECYCLICAL PAINTREATMENT FAILURE

LONG TERM

RECURRENCE OF SYMPTOMS.PREGNANCY.CANCER.

STEPS TO AVOID COMPLICATIONS OF TCRE:-

PREOPERATIVE GnRH ANALOGS, PROGESTERONE.INJECTION OF INTRACERVICAL VASOPRESSIN. USE LEAST PRESSURE TO MAINTAIN UTERINE DISTENSION BELOW MEAN ARTERIAL PRESSURE OF PATIENT.STRICT ADHERENCE TO A PROTOCOL FOR MEASUREMENT OF SYSTEMIC ABSORPTION. CONTINUOUS MONITORING OF DISTENSION MEDIA USEDACCURATE MEASUREMENT BY USING CLOSED SYSTEM FROM 3 SOURCES OUT FLOW CHANNEL, PERINEAL COLLECTION DRAPE, FLOOR SUCTION MAT.I/V FUROSEMIDE (10-40MG) IF DEFICIT REACHES 750-1000MLSERUM ELECTROLYTES SHOULD BE MEASURED TERMINATE THE PROCEDURE IF DEFICIT REACHES 1500-2000 OR SERUM SODIUM FALLS BELOW 125MEQ/L.

COMPARISON OF LASER ABLATION AND TCRE

TCRE FASTER, SAFER, LESS COSTLY.LESS FLUID ABSORBED.HIGHER SATISFACTION RATE.ADEQUATE TISSUE AVAILABLE FOR HPE.

Author Cases Amenorrhea improvement Not improvement Repeat TCRE

Mather & Hill (1990) 100 21% 95% 3%3% 0%

Magos et al (1991) 250 27-42% 92% 8%7% 4%

Pyper & Haeri (1991) 80 6-8% 81% 19%19% 5%

Hysteroscopic TCRE – Comparative Results with Different StudiesHysteroscopic TCRE – Comparative Results with Different Studies

CONCLUSION

10YRS OF EVIDENCE BASED STUDIES AND REVIEWS REVEAL THAT: TCRE IS AN EXCELLENT SUCCESSFUL TREATMENT AND A GENUINE ALTERNATIVE TO HYSTERECTOMY.

VISUAL TECHNIQUES ARE DEFINITELY SUPERIOR TO NON VISUAL TECHNIQUES OF ABLATION

SUCCESS RATE REPORTED AS 79 – 95% IT SHOULD BE OFFERED TO WOMEN WISHING

SURGICAL TREATMENT.

WHY TCRE WAS NOT WIDELY ACCEPTED

Extreme enthusiasm, thought hysterectomy was a thing of the past

Untrained people started trying Found it difficult to perform.Had unexpected major complication.Did not find good results claimed by proponent because training programme were not availableGynecologist could not train themselves to the same levelLong term results were not yet available. Patients expectations were too high.

Publication of first randomized trial comparing TCRE to hysterectomy gave credibility to the procedure & substantiated their use evaluation & development.

1st evidence based guidelines on endometrial ablation published & recommended that it is good alternative for hysterectomy and should be offered to all patients of DUB.

There is ongoing search for newer easier (global devices) techniques of endometrial ablation as classical as Hystroscopic method of ablation.Easier to perform With less skill & training With local anaesthesia

Novasure System

Three dimensionalFan shapedexpandableBipolar device Porus metallic membrane draped around metallic skeletonPower used 180wTreatment time (3min)Depth of destruction 4-4.5mm in uterine corpus, at corneal region 2.2 – 2.9 mm Satisfaction rate 83%.

Cavaterm thermal balloon Ablation:-

Introduced in 1996Silicon balloon catheter attached with central unit.1.5% glycine fills the balloonfluid heated for 15 minutes 1-3yrs followup showed 70% amenorrhea or minimum bleeding.Cavaterm Procedure & novasure procedure were found to be safe & effective.

Vasta D.U.B Treatment System

3minutes procedure Ablates 2-4mm with endometriumMulti Electrode balloon with handsetValleylab electro surgical generatorSilicone inflatable electrode carrier has a triangular shape which unfurl when outer sheath is withdrawnThere are 6 ventral and 6 electrode plates on the surface Cornual plate has fixed temperature of 72 C and other at 75 C 8-12ml air inflates the balloon 88% satisfaction

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UTERINE BALLOON THERAPY (UBT)

INDICATION YOUNG WOMEN WITH UTERUS OF NORMAL SIZE AND HEAVY

BLEEDING. COMPLETED CHILD BEARING. PATIENT NOT KEEN FOR HYSTERECTOMY OR NOT FIT FOR

MAJOR SURGERY BECAUSE OF MEDICAL DISORDERS. NOT A STERILIZATION PROCEDURE. ONLY ONE THERAPY CYCLE to BE PERFORMED IN A GIVEN

TREATMENT CYCLE. CAN BE OFFERED TO MENTALLY DISABLED, BED RIDDEN,

PARALYSIS, MEDICALLY UNFIT LIKE TOO OBESE, HYPERTENSIVE, DIABETES, RENAL FAILURE, TERMINAL CANCER PATIENT

CONTRAINDICATIONS

PREGNANCY DESIRED.HISTORY OF LATEX ALLERGY.SUSPECTED ENDOMETRIAL CANCER.EXISTENCE OF WEAK MYOMETRIUM (C.S MYOMECTOMY).ACTIVE GENITAL OR URINARY TRACT INFECTION. IUCD.

PATIENT COUNSELLING

PHYSICIAN NEEDS TO DISCUSS RISKS, BENEFITS & ALTERNATIVES PRIOR TO PROCEDURE.PATIENTS WITH CHILDBEARING CAPACITY SHOULD BE PROVIDED AN APPROPRIATE BIRTH CONTROL METHOD & SHOULD BE CAUTIONED OF THE COMPLICATIONS OF PREGNANCY.VAGINAL DISCHARGE IS EXPERIENCED DURING FIRST FEW DAYS.IT SHOULD ALSO BE EXPLAINED.

PRETREATMENT PREPARATION OF PATIENT

THE LINING OF THE UTERUS SHOULD BE THINNED BY TIMING THE MENSTRUAL CYCLE TO THE EARLY PROLIFERATIVE PHASE WITH DRUGS OR CURETTAGE PRIOR TO PROCEDURE.A NON-STEROIDAL ANTI-INFLAMMATORY DRUG (NSAID) BE GIVEN AT LEAST ONE HOUR PRIOR TO TREATMENT.

PROCEDURETHE PROCEDURE CAN BE DONE UNDER LOCAL ANAESTHESIA Or SEDATION. AS THERE IS NO NECESSITY OF CERVICAL DILATION PRIOR TO INSERTION OF THE CATHETER, SHORT GENERAL ANAESTHESIA CAN BE USED IN APPREHENSIVE PATIENT.STEP 1AN INITIAL PV EXAMINATION REVEALS THE SIZE OF THE UTERUS AND RULES OUT OTHER PATHOLOGIES.STEP 2A SUCTION CURETTAGE IS DONE TO THIN THE ENDOMETRIUM PRIOR TO THE PROCEDURE.

STEP 3AFTER HOLDING THE CERVIX WITH AN ALLIS FORCEPS, THE CATHETER IS PRIMED & INSERTED UPTO THE FUNDUS.

STEP 4STERILE 5 PERCENT DEXTROSE WATER IS INJECTED INTO THE BALLOON SLOWLY UNTIL THE INTRAUTERINE PRESSURE STABILIZES BETWEEN 160 AND 180 MMHG.

STEP 5ENDOMETRIAL TISSUE IS THERMALLY ABLATED BY MAINTAINING TEMPERATURE 87 DEGREE CELCIUS FOR 8 MINUTES.

STEP 6FLUID IS DRAWN OUT AND THE DEFLATED CATHETER IS WITHDRAWN.FOR SAFETY, THE MACHINE AUTOMATICALLY SWITCHES OFF IF THE PRESSURE OR TEMPERATURE FLUCTUATES OR IS ABOVE PRESET VALUES.

DEVICE OF UBT

POST OPERATIVE CARE & FOLLOW UP

CRAMPING / PELVIC PAIN – RANGES FROM MILD TO SEVERE.

NAUSEA & VOMITING. VAGINAL DISCHARGE – MAY BE WATERY FOR 2

– 3 WEEKS. SEXUAL INTERCOURSE TO BE AVOIDED. REGULAR PAP SMEAR TO BE CONTINUED.

COMPLICATIONS

UTERINE PERFORATION.THERMAL INJURY TO ADJACENT STRUCTURES.FALSE PASSAGE CAN OCCUR.HAEMATOMETRA.ENDOMETRITIS.PREGNANCY.

RESULTS

76% EUMENORRHOEA OR HYPOMENORRHOEASUCCESS DEPENDS ON. – AGE OF PATIENT. – DURATION OF MENORRHAGIA. – THICKNESS OF ENDOMETRIUM.IF MORE THAN 4MM, THEN PREOPERATIVE MEDICAL PREPARATION SHOULD BE DONE.

CONCLUSIONUBT IS AN EFFECTIVE METHOD AND CAN REDUCE HYSTERECTOMY RATE THUS REDUCING MORBIDITY IN WOMEN.

WOMEN OF TODAY DISTRESSED WITH DUB IS LOOKING FOR MINIMUM INVASIVE TECHNIQUE WHICH CAN IMPROVE QUALITY OF LIFE WITH MINIMUM TIME, STAY, ANAESTHESIA, COMPLICATION & MINIMUM EXPENDITURE .