AAGL Practice Report: Practice Guidelines for the Management of Hysteroscopic Distending Media: (Replaces Hysteroscopic Fluid Monitoring Guidelines. J Am Assoc Gynecol Laparosc. 2000;7:167-168.).

The objective of this guideline is to provide clinicians with evidence-based information about commonly used and available hysteroscopic distending media to guide them in their performance of both diagnostic and operative hysteroscopy. While necessary for the performance of hysteroscopy and hysteroscopically-directed procedures, distending media, if absorbed systemically in sufficient amounts, can have associated adverse events, including life-threatening complications. Consequently, understanding the physical properties and the potential risks associated with the use of the various distending media is critical for the safe performance of hysteroscopic procedures. This report was developed under the direction of the Practice Committee of the AAGL as a service to their members and other practicing clinicians.

Endometrial ablation in patients with myomas.

PURPOSE OF REVIEW: This review evaluates how the presence of uterine myomas may limit the ability to provide endometrial ablations for patients with menorrhagia, affect subsequent postoperative course and alter long-term outcome. RECENT FINDINGS: New instrumentation and the off-label use of some global ablation techniques allow some selected patients with submucosal myomas to be treated solely by endometrial ablation. The addition of an endometrial ablation in patients undergoing a hysteroscopic myomectomy improves bleeding and their long-term control, but does not decrease the subsequent need for a hysterectomy. Necrosis of intramural myomas is a rare postoperative complication. Untreated myomas may continue to increase in size and lead to a hysterectomy. SUMMARY: The presence of myomas in patients undergoing endometrial ablation may compromise the results and lead to later problems, but most patients can be treated successfully and myomas are not an absolute contraindication.

Hysteroscopic myomectomy in postmenopausal women.

STUDY OBJECTIVE: To review the findings in postmenopausal patients undergoing hysteroscopic myomectomy. DESIGN: Retrospective case-controlled study (Canadian Task Force classification II-2). SETTING: Private practice. PATIENTS: Eighteen women with postmenopausal bleeding and two asymptomatic women with abnormal ultrasounds. INTERVENTIONS: Hysteroscopic myomectomy in 19 patients, with concomitant destruction of the endometrium in 4 patients, and resectoscopic biopsy in 1 patient. MEASUREMENTS AND MAIN RESULTS: Three patients underwent subsequent gynecologic surgery. One had hysteroscopy to evaluate and remove an asymptomatic residual myoma found on ultrasound. A sarcoma was found in two of the symptomatic patients. Two patients underwent hysterectomy-one for a sarcoma and the other for a carcinoma of the cervix. One patient has had further postmenopausal bleeding. CONCLUSION: Women who have a submucosal myoma that becomes symptomatic in the menopausal period may be at increased risk for a sarcoma.

Improving results of hysteroscopic submucosal myomectomy for menorrhagia by concomitant endometrial ablation.

STUDY OBJECTIVE: To evaluate the effect of endometrial ablation on the outcome of premenopausal patients undergoing hysteroscopic myomectomy for menorrhagia or menometrorrhagia DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Private practice. PATIENTS: One hundred seventy-seven women with one or more submucosal myomas experiencing menorrhagia or menometrorrhagia. INTERVENTION: Hysteroscopic myomectomy without endometrial ablation in 104 patients and with concomitant endometrial ablation in 73 patients. MEASUREMENTS AND MAIN RESULTS: Bleeding was controlled in 95.9% of patients with endometrial ablation and in 80.8% of patients without endometrial ablation (p = .003). Complete removal of the myoma led to better results (p = .039), which were further improved by endometrial ablation (p = .022). Endometrial ablation improved bleeding in patients whose myomas could not be completely removed, but the difference was not statistically significant (p = .23). Subsequent hysterectomies were not decreased by endometrial ablation (p = .48) or by complete removal of the myoma (p = .83). Hysterectomies for bleeding problems were decreased by endometrial ablation. Pain and dysmenorrhea were a frequent cause of hysterectomy. CONCLUSION: Endometrial ablation at the time of hysteroscopic myomectomy improves results in the control of bleeding.

Five-year follow-up of patients participating in a randomized trial of uterine balloon therapy versus rollerball ablation for treatment of menorrhagia.

STUDY OBJECTIVE: To collect long-term follow-up information from women who participated in a randomized trial comparing uterine balloon therapy (UBT; Gynecare, Somerville, NJ) with rollerball ablation for treatment of menorrhagia. DESIGN: Five-year contact of participants treated in a 1996 multicenter, randomized trial (Canadian Task Force classification I). SETTING: Twelve North American university and private practice centers. PATIENTS: Women treated with endometrial ablation for menorrhagia who were available for 5-year follow-up. INTERVENTION: Uterine balloon therapy or rollerball ablation. MEASUREMENTS AND MAIN RESULTS: Of 255 women treated under the original protocol, 147 were available to be interviewed 5 years after the procedure. Of these, 25 patients reported hysterectomy, repeat ablation, or dilatation and curettage (D&C) between years 3 and 5, leaving 122 eligible for analysis (61 UBT, 61 rollerball). Of these 122 patients, 58 (95%) having UBT and 59 (97%) having rollerball ablation reported normal or less bleeding. Similarly, 93% and 100%, respectively, were satisfied with the procedure. Among the total population of 255 women, 42 hysterectomies (21 UBT, 21 rollerball), 5 repeat ablations (3 UBT, 2 rollerball), and 1 D&C (rollerball) were reported by year 5. Thirty-five hysterectomies (83%) were performed because of bleeding and/or pelvic pain; one-third of them were associated with myomas. Nearly 7 of 10 women were cured of menorrhagia without additional intervention 5 years after ablation. CONCLUSION: UBT continues to be an effective, simple treatment of menorrhagia, with clinical outcomes similar to those of rollerball ablation at 5-year follow-up.

The incidence of endometrial cancer after endometrial ablation in a low-risk population.

STUDY OBJECTIVE: To assess the incidence of endometrial cancer in 509 women who had undergone hysteroscopic endometrial ablation in two centers between 1978 and 1994. All patients had normal endometrial histology before ablation. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Teaching hospital-affiliated private practices. PATIENTS: Five hundred nine women with perimenopausal bleeding. INTERVENTION: The patients were contacted directly, by mail or phone, and asked if they had had a diagnosis or treatment for cancer or precancer of the endometrium. The list of unreachable patients was submitted to the National Death Index. After this, names and other pertinent data of the remaining patients were submitted to the Cancer Registries of the 50 states and Washington, DC. Forty-two patients were omitted from these searches due to insufficient information or because they were unreachable, and one excluded because of a diagnosis of Bloom's syndrome. The comparative incidence was obtained from the U.S. SEER data of age-specific rates of endometrial cancer published by the National Cancer Institute. MEASUREMENTS AND MAIN RESULTS: Fifty-one percent of the patients were contacted directly yielding one case of endometrial cancer. Eight patients had died, but none from endometrial cancer. One patient was located in the New Jersey Cancer Registry. A total of 5063 woman-years was identified with two cases of endometrial cancer. The expected incidence was 1.66 cases in an age-matched group with known length of follow-up from the U.S. SEER data. There is no significant difference between the two groups. CONCLUSION: The flaws in the databases include the lack of data on subsequent hysterectomy for benign disease in both the treated group and the SEER database. Low risk for endometrial cancer is narrowly defined to normal endometrium preablation. Nevertheless, the data give an approximation of the incidence for endometrial cancer, and should serve as a benchmark for prospective studies in patients undergoing endometrial ablation as well as a resource to counsel patients in the choice between ablation and hysterectomy.