HYSTEROSCOPY
TREATMENT of ABNORMAL UTERINE BLEEDING
Diagnostic Considerations
Irregular bleeding : usually annovulatory, hormones often successful (?)
Heavy periods-menorrhagia: often fibroids or polyps Always sample endometrium prior to ablation
Non Surgical Treatment Abnormal Uterine Bleeding
Levonorgestrel Intra Uterine Device – Same success rate (70%) as ablation at 3 years (27% surgery)
Hormonal Therapy – Only 10% success at 3 years (77% surgery)
Hysteroscopic Treatment AUB
Future pregnancy desired
• Resect fibroids or polyps
Loop Resection
Smith & Nephew Rotary Extractor
Hysteroscopic Treatment No Future Pregnacy
Endometrial Ablation
freeze, fry, roast, boil, broil, vaporize
Destruction of Endometrium
Indications for Ablation
Does not want more children and will use future contraception Patient perceived heavy bleeding
Not required, but usually failed medical treatment
Pre-Op Laboratory Studies
Electrolytes if patient on diuretics or cardiac meds Complete blood count Coag. Panel if history of bleeding tendencies Document normal Pap smear and normal endometrial sample within 6 months
Pre-Op Considerations
Misoprostol 200mcg intravaginal or laminaria night before Antibiotics (?) e.g. doxycyclene 100mg twice daily x 3d
Pre-Op Preparation
GnRh agonist (Lupron,etc.)
• Induce amenorrhea to treat anemia if present
Suction currettage or do immediately after period
• Purpose – decrease endometrial thickness & more uniform cavity for deeper destruction • Ablation is technically easier
COMPLICATIONS
Perforation Distention media related Mechanical or energy injury to bowel or bladder Bleeding Infection Anesthesthetic Spread endometrial cancer
Therapeutic Hysteroscopy Anesthesia
Local - Paracervical block plus fentanyl 100 mcg IV or ibuprofen 600 mg with diazepam 5mg po 1hr before Spinal – allows monitoring sensorium with respect to hyponatremia General or deep conscious sedation with paracervical block
Vasopressin in Paracervical Block
Less force (about ½) needed for dilation Less fluid absorbed (about 1/3) Ed’s solution= 5U (1/4 ml) vasopressin in 30ml 1% chloroprocaine or lidocaine (+3ml NaCO3). Inject 6-10ml ea. side
WAIT
– more than 5 min (by the clock) if procedure being done by local anesth.
Alternative “Paracervical Block”
Resectoscopic Ablation Roller “Ball”/Wire Loop
Advantages
• Readily available standard equipment • Inexpensive materials • Highest success rates*
Disadvantages
• Skill development • Usually at surgery center or hospital setting
Operating Room Setup Resection
At least 18 liters mannitol, sorbitol or glycine available if fibroids present Hysteroscopy pouch to suction or graduated bucket 1 Person assigned to calculate intake & output every 5 min (timer) Vasopressin available for paracervical block
Equipment Resection/Ablation
Resectoscope: 27 or 24 Fr. dual channel (or else over dilate cervix) Extra wire loops & grooved rollerbarrels Extra connecting wire Electrosurgical unit: 100-200 watt cutting & 90–120 watt coag.
Ablation Technique Roast -”Rollerball”
Start at 140 watts cut &/or 100 watts coag. current (setting will vary on make of equipt. & size/type roller ball) Always keep the ball/loop in motion, slowly, towards you Apply current only when certain of ball/loop location
Hydro Thermal Ablation Boil - (hot water)
Bipolar Cautery Roast - “Novasure”
Cryoablation Freeze - “Her Option”