TEALE FENNING

bronwyn · Posted: Mon Jul 24, 2006 5:29 pm Post subject: Partial endometrial resection

Another little GOPD scenario Mad

Nick Raine-Fenning · Posted: Mon Jul 24, 2006 11:00 pm Post subject:

I like these GOPD and real life scenarios as they seem to reflect the type of question that you get asked!

That is a good thing right Confused

I think this is a question that, once you have symphasised and apologised, you approach as if you are advising (aka counselling = managing) a 49-year old woman with heavy periods.

Discuss all options including no treatment and hysterectomy (all types) but do not forget to stress she may only have 2-3 years of menstruastion to tolerate.

Also ensure adequate contraception and remind her of the need for smears (typical RCOG marks).

I would be interested to see your bubbles"
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"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

bronwyn · Posted: Wed Jul 26, 2006 5:53 pm Post subject:

What is the role of having another go at a resection? Is the risk of perforation higher? Can't seem to find this anywhere.
Would you repeat a scan before deciding management to check if the fibroid is still present (suitability for other forms of ablative procedures/ IUCD)?
Important too to check histology prior to previous resection to ensure no hyperplasia etc
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Bronwyn Bell
SpR
Portsmouth

Nick Raine-Fenning · Posted: Thu Jul 27, 2006 11:58 am Post subject:

Those are all valid points.

Yes the risks are higher as she is likely to have intrauterine adhesions and instrumentation may be difficult.

Histology would definitely get you a point as would pregancy!

All treatment options are open but you would have to say she is unlikely to consider the same, or an alternative conservative, procedure again and that the most likely option would be hysterectoym (vagina/ sub-total / total).

You must also address the fact she will be upset this has failed so quickly.
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"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

Xerxes I · Posted: Sat Apr 05, 2008 8:03 am Post subject:

I think as a rule (which I just made up) endometrial resection or ablation deserves only one go. In some cases like Novasure, the manufacturer advises against it if somebody has been in the cavity before. In other cases it's left to common sense.

Nick Raine-Fenning · Posted: Sat Apr 05, 2008 8:36 am Post subject:

No so sure about the newer devices but you can certainly repeat a formal resection / ablation and often have to in practice. They seem to have a 3-8 year efficacy and often require further therapy (whatever that may be) around the 5 year mark which is why it is more suited to women in their mid-late(r) 40s.

Note to self (and all of you) "must read the MISTLETOE study properly one day"!

Here are a few related articles in the meantime:

TOG Review by David Parkin

NICE Appraisal Consultation Document: Fluid-filled thermal balloon and microwave endometrial ablation techniques for heavy menstrual bleeding

A national survey of the complications of endometrial destruction for menstrual disorders: the MISTLETOE study. Minimally Invasive Surgical Techniques--Laser, EndoThermal or Endorescetion

The latter contains the following useful links (abstracts only I'm afraid):

Endometrial destruction techniques for heavy menstrual bleeding. [Cochrane Database Syst Rev. 2005]

A randomised controlled trial comparing the Cavaterm endometrial ablation system with the Nd:YAG laser for the treatment of dysfunctional uterine bleeding. [BJOG. 2003]

The VALUE national hysterectomy study: description of the patients and their surgery. [BJOG. 2002]

Severe complications of hysterectomy: the VALUE study. [BJOG. 2004]

Endometrial ablation by rollerball electrocoagulation compared to uterine balloon thermal ablation. Technical and safety aspects. [Eur J Obstet Gynecol Reprod Biol. 2003]

Xerxes I · Posted: Sat Apr 05, 2008 10:08 am Post subject:

thanks Nick, wonderful links.

NICE reckons 10% of abltion/resections will need further surgery. Of these, 40% will have repeat ablation/resection and 60% hysterectomy. Of the 40% that had repeat ablation, 10% will need repeat surgery! and this tme 90% will have hysterectomy.

What I said was far from evidence-based, it was evidence level 18, (personal opinion of one fairly junior registrar).

salihabduallah · Joined: 04 Sep 2007 Posts: 88

Can Uterine artery embolization be an option ?
is there certain measurment of fibroid to get benefit from Ut,art. embolisation ?