Hydrothermal endometrial ablation can reduce the need for hysterectomy and transfusion.

Abstract

Women seeking emergency care for severe uterine hemorrhage with profound anemia often undergo transfusion dilatation curettage and ultimately hysterectomy. The purpose of this article is to describe a modern conservative approach to treating persistent uterine hemorrhage unresponsive to medical therapy, avoiding transfusion and allowing for nonemergent future therapy without the potential complications of transfusion. Six patients with unremitting uterine bleeding were included in the study performed in the Department of Gynecology at an academically affiliated general hospital. Patients underwent successful hydrothermal endometrial ablation after failed medical therapy. This procedure is effective in controlling severe uterine bleeding in patients with large intrauterine fibroids; thus, the number of women being transfused can be significantly reduced.

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Hydrothermal Endometrial Ablation Can Reduce the
Need for Hysterectomy and Transfusion
Herbert A. Goldfarb, MD, Michelle Hanes, MD, Farzaneh Nabizadeh, MD
ABSTRACT
Women seeking emergency care for severe uterine hem-
orrhage with profound anemia often undergo transfusion
dilatation curettage and ultimately hysterectomy. The pur-
pose of this article is to describe a modern conservative
approach to treating persistent uterine hemorrhage unre-
sponsive to medical therapy, avoiding transfusion and
allowing for nonemergent future therapy without the po-
tential complications of transfusion. Six patients with un-
remitting uterine bleeding were included in the study
performed in the Department of Gynecology at an aca-
demically affiliated general hospital. Patients underwent
successful hydrothermal endometrial ablation after failed
medical therapy. This procedure is effective in controlling
severe uterine bleeding in patients with large intrauterine
fibroids; thus, the number of women being transfused can
be significantly reduced.
Key Words: Hydrothermal endometrial ablation, Fi-
broids, Myoma, Hemorrhage.
INTRODUCTION
Of the 600 000 hysterectomies performed each year,1over
150 000 patients undergoing the procedure have severe
uterine bleeding as a significant diagnosis.2Many patients
have bleeding to the point of severe anemia and often
require emergency transfusion to control anemia and al-
low orderly elective therapy. Many of these hysterecto-
mies and transfusions can be avoided. In the majority of
cases involving severe uterine hemorrhage, we have
found large submucosal and intrauterine fibroids.3Medi-
cal therapy has frequently failed to control hemorrhag-
ing.4–6This case report describes a group of 6 post repro-
ductive patients treated from 2003 through 2005 who
underwent hydrothermal endometrial ablation to control
severe persistent uterine hemorrhage.
In 1997, Milton Goldrath7described a technique for hys-
teroscopic instillation of hot saline solution to treat recur-
rent uterine bleeding. According to the current hydrother-
mal technique (HTA Boston Scientific, Natick, MA), saline
is placed inside the endometrial cavity, and computer
control is used to guard against fluid leakage. The fluid is
then heated to 90°C and monitored for 10 minutes under
direct hysteroscopic control. Blanching of the endome-
trium as well as intrauterine or submucosal myomas can
be visually followed. Because of the emergent nature of
all procedures, no pretreatment is undertaken. A suction
curettage is performed for tissue diagnosis and thinning of
the endometrium. A #5 suction Vacurette is used to avoid
overdilatation.
CASE REPORTS
Patient 1
The patient is a 46-year-old, G0, with a history of primary
infertility and a myomatous uterus. She underwent myo-
mectomy in 1993. Findings at that time included a 12-
week to 14-week size uterus and normal-appearing ova-
ries. Five intramural myomas were removed at that time.
In addition, upon entering the endometrial cavity, we
noted and excised a 4-cm myoma of the endometrium.
Total leiomyoma weight was 200g. The patient then pre-
sented in July 2003 complaining of severe menorrhagia.
Address correspondence to: Herbert A. Goldfarb, MD, E-mail: drhgoldfarb@
gmail.com.
DOI: 10.4293/108680810X12785289143954
© 2010 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
JSLS (2010)14:192–195
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SCIENTIFIC PAPER

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She was noted to have a 24-week size uterus at that time.
Hemoglobin/hematocrit (H/H) was 10.1/31.2. Norethin-
drone acetate 5mg bid was prescribed to control menor-
rhagia. The endometrial biopsy was benign. In August
2003, the patient’s H/H had increased to 12/35. However,
she was still experiencing bleeding and agreed to a su-
pracervical hysterectomy but refused any possibility of
intraoperative nonautologous transfusion because she is a
Jehovah’s Witness.
The decision was then made that preoperative autologous
blood should be available before definitive surgery. The
patient gave written informed consent to undergo hydro-
thermal endometrial ablation to control bleeding and fur-
ther increase hemoglobin before hysterectomy. She un-
derwent suction D&C, hysteroscopy, and hydrothermal
ablation on August 19, 2003. Pathology showed asynchro-
nous secretory endometrium. A hysteroscopic examina-
tion revealed a large 4-cm Type 2 submucosal myoma.
Iron therapy was begun, and improvement was noted.
The patient was therefore able to donate a unit of autol-
ogous blood before definitive surgery. On September 15,
2003, the patient was taken to the OR for a supracervical
hysterectomy with posterior cervical myomectomy. Her
H/H at that time was 13.3/39.6. Findings included a 26-
week size uterus with multiple myomas. The posterior
cervix was noted to have a 20-cm ? 20-cm myoma. Both
ovaries and tubes appeared normal bilaterally. Pathology
noted an endometrium with reactive changes consistent
with the prior ablation. The uterus was also noted to have
cervical, intramural, subserosal, and submucosal leiomyo-
mas with focal hypercellularity and focal infarct. The pa-
tient had an uncomplicated postoperative course.
Patient 2
A 43-year-old, P2002, patient presented with a 2-year
history of menorrhagia and dysmenorrhea. She was noted
to be anemic with a hemoglobin of 7g and hematocrit of
25%. Her local physician had prescribed oral contracep-
tives, but bleeding was not controlled. An MRI showed a
4-cm submucosal fibroid, and a 5-cm subserosal fibroid.
Oral contraceptives were discontinued, and the patient
was given GnRH agonist 3.75mg IM, to control bleeding
during iron therapy.6,7She continued to bleed however
after 6 weeks of agonist therapy, and subsequently under-
went suction D&C with hysteroscopy and hydrothermal
ablation. Intraoperative findings included a large submu-
cous fibroid and an 8-week to 10-week size uterus. Pre-
operative H/H was 9.6/29.1. The patient did well postop-
eratively, and bleeding ceased. The endometrial curettings
were noted to include fragments of an endometrial polyp
on pathology. The patient returned to the OR on Septem-
ber 20, 2004 for a suction D&C with hysteroscopic resec-
tion8–10of the submucosal fibroid and laparoscopic my-
olysis.11The Vaportrode (Wolf Surgical, Gyor, Hungary)
electrode was used during the hysteroscopic portion of
the case to further ablate the endometrium.12Preoperative
H/H was 12.4/37.2. Estimated blood loss during this op-
eration was 50mL. Intraoperative findings included a 4-cm
submucosal fibroid and a 5-cm fundal fibroid. Pathologic
evaluation revealed portions of leiomyomata with exten-
sive coagulation necrosis. The patient did well postoper-
atively with no further complaints. She has been followed
for 14 months and has had no further bleeding. The uterus
has decreased in size with only a 2.5-cm residual myoma
seen on endovaginal ultrasound.
Patient 3
A 49-year-old female presented with menorrhagia and
known fibroid uterus. She reported having a myomec-
tomy in 1997 with 15 fibroids removed. An MRI revealed
an enlarged leiomyomatous uterus 12.2cm ? 8.7cm ?
8.5cm. Multiple intramural, subserosal, and submucosal
myomas were demonstrated. The largest submucosal my-
oma included a left posterior body myoma measuring
2.9cm ? 2.8cm and a right-sided submucosal myoma
measuring 3.3cm ? 2.3cm. Distortion of the endometrial
canal was noted. The patient received GnRH agonist
3.75mg IM. Norethindrone acetate 5mg bid was added to
control bleeding. These interventions were not successful.
Hysteroscopy, suction curettage, and hydrothermal abla-
tion were performed on February 23, 2005. Findings at
that time included a large submucosal fibroid. Bleeding
now stopped; the patient then received a second dose of
agonist on March 22, 2005, followed by a hysteroscopic
resection and laparoscopic myolysis13on April 12, 2005.
Findings included a 12-week size fibroid uterus with mul-
tiple submucosal fibroids. The patient’s preoperative he-
moglobin was increased from 10.3/31.9 on December 12,
2004 to 14.3/44.8. On POD #1, the patient was noted to
have an H/H of 12.7/39.9. She did well postoperatively
with no further complaints at her follow-up visit.
Patient 4
The patient is a 45-year-old female who presented in May
2004 complaining of 3 months of menorrhagia. The pa-
tient underwent a D&C for menorrhagia in March 2004
that was performed by her local physician, but without
relief. A sonogram obtained on POD#6 showed a uterus
measuring 11.7cm ? 6.9cm ? 10.1cm with two 5-cm
subserosal fibroids and one 4-cm intramural fibroid. The
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patient was started on norethindrone acetate 5mg bid. The
patient received GnRH agonist 3.75mg IM on May 25 and
June 22, 2004. The menorrhagia persisted in the face of
medical interventions. The patient then underwent hydro-
thermal ablation on July 12, 2004. She subsequently un-
derwent hysteroscopic resection of submucosal fibroids14
with laparoscopic myolysis.15The patient did well post-
operatively with no further complaints.
Patient 5
This patient is a 45-year-old, G2P2, with a 1-year history of
increasing uterine bleeding. Her last menstrual period
began in May 2005 and continued until the middle of
August. Norethindrone acetate 5mg bid slowed the bleed-
ing. Hysteroscopic examination revealed an intrauterine
mass filling the entire cavity of the uterus.9,13Ultrasound
revealed a 6-cm fibroid mostly intrauterine and an addi-
tional 6-cm to 7-cm subserosal mass. The patient’s hemat-
ocrit was 24%. She refused transfusion and hysterectomy.
Hydrothermal ablation was performed with fluid (normal
saline was heated to 90°C for 10 minutes). The patient
stopped bleeding and is being treated with iron supple-
ments to restore her hemoglobin level.
Patient 6
The patient is a 44-year-old, G3P3, with a 6-month history
of increasing vaginal bleeding. She was treated by her
local medical doctor with progesterone and subsequent
dilatation and curettage. Findings included fibroid uterus
and proliferative endometrium. Because of increasing
bleeding, the patient sought emergent treatment at her
local hospital. Her hemoglobin was found to be 6g. She
was treated with 2 units of packed red blood cells. She
contacted our office and was subsequently started on
norethindrone acetate 5mg bid; however, she continued
bleeding and underwent hysteroscopy, dilatation and cu-
rettage, and hydrothermal ablation. The findings included
a 5-cm submucosal myoma. The bleeding stopped, and
the patient is being treated with hematinics.
DISCUSSION
In this article, we describe 6 post reproductive patients
with severe uterine bleeding and resultant severe anemia
who were unresponsive to GnRH analog therapy and
norethindrone acetate therapy. Each of the patients had
significant ?4-cm intrauterine myomas. It was judged that
attempting hysteroscopic resection or abdominal surgery
without transfusion would be putting the patient at con-
siderable risk. Hydrothermal ablation was successful in all
6 patients. In the first patients, the fibroids were well over
1 kilogram, and myomectomy or myolysis was not appro-
priate. Conservative therapy was appropriate in the other
patients. Hydrothermal ablation should be considered the
first-choice treatment for patients with persistent uterine
bleeding, resistant to medical therapy because it signifi-
cantly reduces the need for transfusion. Glasser15showed
that hydrothermal ablation could be effective in the treat-
ment of submucosal myomas of up to 4cm. In our pa-
tients, all myomas were ?4cm. With the use of hydrother-
mal ablation,transfusion
unnecessary.
inthesepatientswas
The treatment of persistent severe menorrhagia has most
often included transfusion and hysterectomy. Our ap-
proach is to identify the cause of bleeding and bring it
under control with medical therapy until hemoglobin im-
provement allows us to perform desired conservative
therapy. We report here on 6 patients who did not re-
spond to medical therapy but did respond to hydrother-
mal ablation. Please note that subsequent myolysis and
resection of the fibroids were carried out because of
previous findings.16,17The combination of myolysis, en-
dometrial ablation, with or without resection, reduced the
subsequent hysterectomy rates from 35% to 5.7% in that
study. Failure to treat both the external portion of the
fibroid and the internal submucosal portion resulted in a
high recurrence rate of symptoms and subsequent hyster-
ectomy.
CONCLUSION
Severe anemia secondary to uterine fibroids often requires
blood transfusion followed by hysterectomy. Hydrother-
mal ablation can obviate the necessity for transfusion and
play an important role in the treatment of persistent uter-
ine bleeding secondary to large submucosal and intrauter-
ine myomas that are resistant to medical therapy. This
report demonstrates the feasibility of hydrothermal abla-
tion to avoid the need for hysterectomy as an emergency
procedure and to reduce the need for transfusion, thus
significantly reducing the number of women being trans-
fused. This new approach, to our knowledge, has not
been previously reported in the literature.
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