#81 Endometrial Ablation

Question 1

Who is a candidate for endometrial ablation?

Answer 1

Premenopausal women with HMB, normal uterine cavity, and no future fertility desired

Question 2

What is the bleeding pattern patients should expect after endometrial ablation?

Answer 2

Range from Normalization of periods to amenorrhea (not achieved in substantial number of cases)

Question 3

Is endometrial ablation a sterilization procedure?

Answer 3

No. Patients should be counseled about effective contraception due to risk of becoming pregnant

Question 4

What pre operative work up needs to be done for endometrial ablation

Answer 4

Endometrial sampling to rule out hyperplasia/malignancy.

Assessment of cavity architecture with TVUS, SIS, and/or HSC.

Question 5

What type of energy is used in the resectoscope?

Answer 5

Radio frequency alternating current

Question 6

Besides energy, what other methods of endometrial ablation are there?

Answer 6

Cryotherapy, heated free fluid, microwave, thermal balloon

Question 7

What type of energy is used in the Novasure system?

Answer 7

Radio frequency electricity

Question 8

For HMB, is medical treatment better/worse/same compared to endometrial ablation?

Answer 8

higher satisfaction with ablation vs oral therapy. No difference in quality of life at 1 yr with Mirena vs ablation although ablation better at controlling bleeding at 1 yr. however no difference in bleeding at yrs 2-3y

Question 9

How does suppression of endometrial proliferation affect resectoscopic ablation of endometrium?

Answer 9

Pre op danazol of GnRH agonist results in shorter procedure, greater ease of surgery, lower rate of post op dysmenorrhea, higher rate of post surgical amenorrhea (short term, unknown about long term effect). No data available to assess use of pre op systemic progesterone or mechanical preparation of lining (D&C)

Question 10

To what depth do non resectoscope systems treat (apart from Novasure)?

Answer 10

About 4-6mm

Question 11

How thick is a typical endometrium during luteal phase? Single layer

Answer 11

6mm. More for women with annovulation

Question 12

Standard radiofrequency electrosurgical operative hysteroscopy or resectoscopy with monopolar instrumentation requires what kind of distention media?

Answer 12

electrolyte-free, low-viscosity solutions, such as 3% sorbitol, 1.5% glycine, 5% mannitol, and combined solutions of sorbitol and mannitol

Question 13

What are risks of electrolyte free distention media during hysteroscopy?

Answer 13

Dilutional hyponatremia And hypoosmolality (except mannitol), which can lead to cerebral edema.

Question 14

Why are premenopausal women more at risk of cerebral edema with absorption of electrolyte free solution during hysteroscopy?

Answer 14

Estrogen and progesterone inhibit the brain’s sodium pump

Question 15

How can you decrease the amount of systemic intravasation of hysteroscopic distention media?

Answer 15

Pre op GnRH analogues or immediate pre op use of intracervical dilute vasopressin. Using lowest effective intrauterine pressure. Avoid pre op overhydration

Question 16

Which method of endoscopic ablation is most associated with cervical lacerations and uterine perforation?

Answer 16

Resectoscopic endometrial ablation

Question 17

If uterus is perforated with active electrode during resectoscope procedure, what is mandatory?

Answer 17

Exploration of peritoneal cavity. Laparotomy vs laparoscopy

Question 18

What is postablation tubal ligation syndrome?

Answer 18

Cyclic pain in a women s/p endometrial ablation who previously had tubal ligation surgery, thought to be due to remaining endometrium in cornua

Question 19

What is the treatment for postablative tubal ligation syndrome?

Answer 19

Hysterectomy appears to be most effective therapy.

Question 20

What are the obstetric risks if a patient get pregnant after endometrial ablation?

Answer 20

high rates of malpresentation, prematurity, placenta accreta, and perinatal mortality.

Question 21

Is there a delay in diagnosis of endometrial cancer after endometrial ablation?

Answer 21

Does not appear to be. It seems that most women retain an intrauterine cavity to allow egress of postmenopausal bleeding.

Question 22

Relative and absolute contraindications to endometrial ablation?

Answer 22

women with endometrial cavities that exceed device limitations. procedure should not be performed with recent pregnancy or in the presence of active or recent uterine infection, endometrial malignancy, or hyperplasia.