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Case History

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Image not available. A 43-year-old woman comes demanding surgical treatment for her menorrhagia. She has tried mefenamic acid and tranexamic acid and her levonorgestrel-releasing intrauterine device has fallen out with a particularly heavy bleed. Her family is complete. She has already been investigated and has no significant pelvic pathology. She cannot cope with the embarrassing flooding and has already ruined a white sofa.

What endometrial ablative techniques can you offer?

How is hysterectomy performed?

How do the different methods compare?

What is life after hysterectomy?

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Background

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Image not available. Surgery is a more definitive treatment for menorrhagia and is appropriate for those in whom medical therapy has failed and whose families are complete.1,2

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What endometrial ablative techniques can you offer?

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Endometrial ablation (EA) aims to destroy the endometrium along with the superficial myometrium thus reducing endometrial shedding at menstruation and resulting in less bleeding.3 Not all women are amenorrhoeic, with rates varying between 15% and 50%. Directed ablation/resection deals with removal of individual fibroids and polyps. Endometrial ablative techniques are often done as day cases, and a return to normal activities is usually possible within 3–4 days. There are two types of techniques: first generation requiring hysteroscopy, and second generation that do not (Table 2.1). The former are technically more difficult than the latter.

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Table Graphic Jump Location
Table 2.1Methods of endometrial ablation
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Transcervical endometrial resection (TCRE) involves diathermic removal of the endometrium in strips, similar to a transurethral resection of the prostate. It has been exhaustively proven to be effective. It is the only ablative procedure that obtains endometrial material from the whole of the uterine cavity other than the cornual regions. This may suggest TCRE is more appropriate in peri-menopausal women who have a higher risk of endometrial cancer, though no evidence is available at present to substantiate this theory.

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Pre-operative use of endometrial thinning agents, such as danazol or gonadotrophin-releasing hormone analogues, to improve success rates has been recommended for first-generation endometrial ablative techniques where optimum visualization of the cavity is required.

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The complications of TCRE have been well documented. These include haemorrhage (2.38%–3.5%), perforation (1%) and fluid overload (0.5%–4%) similar to other first-generation methods of EA such as laser and rollerball endometrial ablation.

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Second-generation methods require less operating time and bypass well-recognized first-generation complications by not using fluid with cutting apparatus. In some methods endometrial preparation is also not required, reducing costs and side effects. Although the thermal balloon method is reported to have few complications, it is currently restricted to normal uterine cavities. In comparison, ...

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