OBGYN.net Conference CoverageFrom the 31st Annual Meeting of the American Association of Gynecological Laparoscopists (AAGL)
Prof. Stephen Corson, MD: Hello, I’m Stephen Corson, Professor of Obstetrics and Gynecology at Thomas Jefferson University, Philadelphia, and I’m interviewing this morning a very good friend and colleague, Philip Brooks, who is Clinical Professor at UCLA and practices at Cedars Sinai in Los Angeles. We’re going to talk a little about office endometrial ablation and Philip, you’ve had a vast experience in this. Is this something which the mainstream gynecologist could do?
Philip Brooks, MD: Well, I think that with a little bit of experience and the right equipment, anybody can do office endometrial ablation now with the technologies that are available that have such low pain involvement during the procedure and are really wonderfully adapted to office use.
Prof. Stephen Corson, MD: What are the technologies currently available, those that have been FDA approved?
Philip Brooks, MD: Well, there are four devices approved by FDA currently. There is the Thermachoice balloon, the cryogenic corruption probe, there is the HTA, which is the hot saline free circulating in the uterus, and there is the Novasure/Novacept, which is a bipolar wand.
Prof. Stephen Corson, MD: So all of these are potentially applicable in an office setting?
Philip Brooks, MD: They are all potentially applicable. The problem with some of the balloons, we’ve had experience doing this, is that when you need to distend the uterus, that causes more pain, so that the things that have high-pressure distension systems, the balloons primarily, will result in more discomfort making it less optimal for an office procedure.
Prof. Stephen Corson, MD: Well, then, how do you manage, tell us how you manage the discomfort? What do you give a patient before she comes in, what do you in terms of paracervical blocking, what happens there?
Philip Brooks, MD: Well, let me back up a little and tell you how I came to developing my protocol. To begin with, I try to assess all of the things that happen during an office procedure and I’ve been doing this for probably well over ten years now in developing the protocol. Obviously, the anxiety of the unknown is very important and will enhance pain, so you need to counsel patients well and tell them step-by-step what’s going to happen and what you’re going to do. There is the pain of the manipulation, there is the pain of the procedure itself and you need to block that and so we use local anesthetic in the tip of the cervix, we use paracervical block. You need to block the spasm and I’ve tried to find the best drugs, as prostaglandin antagonists, to be able to interfere with the spasm and the contractions, both inter-operative and post-op, and we use a non-sterile anti-inflammatory or a coxtu inhibitor for those primarily and then, of course, if you want, you’ve got other drugs. My preference is not to use systemic sedation with any great degree because A), it’s more dangerous, I don’t like the concept of turning my office into an operating room and then pretending it’s an office procedure so we use . . .
Prof. Stephen Corson, MD: So you use no intravenous agents?
Philip Brooks, MD: We use virtually no intravenous agents. I have used it when the patient is either too uncomfortable or when the patient has had cramps post-op, but that is so rare. We’ve had 45 cases now where we have not failed once and only in three of those have we used any systemic medication.
Prof. Stephen Corson, MD: Now, when people come in with menorrhagia, in some percentage of the cases, maybe 20%, 30%, they also have some pathology of the uterus, polyps or myomas, can all of these techniques apply to these patients or is there, is that a limiting feature?
Philip Brooks, MD: That is a limiting feature to some of the modalities. First of all, it has been our experience in the early years of the resectoscopic surgery that well over 20% of patients with menorrhagia, cyclic menorrhagia progressively worsening, do have some kind of intrauterine pathology, either myomas or giant polyps or something that may be some abnormality. There are 3% to 5% listed in the literature of uterine anomalies that may or may not impact on bleeding but certainly may or may not impact on reproduction, but they exist. The balloons don’t work with intracavitary abnormalities or big blood clots.
Prof. Stephen Corson, MD: Because there’s no contact.
Philip Brooks, MD: Because you can’t apply the heat directly to the surface adjacent to the myoma or the polyp. The rigid devices, such as the Novasure, the wand, may not be able to be used over a bulging myoma because it’s flat and it can’t be put over the surface. You may only use for an arcuate uterus or a septum or a submucous myoma the hot water that freely circulates around all of the crevices, that works well. The cryo does not seem to be bothered too much by a septum because you have to insert the cryo, albeit blindly, into the different cornu, and so it might be but if there is a myoma, that would interfere.
Prof. Stephen Corson, MD: So the hydrathermic agent system is the only one done under hysteroscopic visualization?
Philip Brooks, MD: That’s correct, it’s done under hysteroscopic visualization but it will conform to all configurations of the uterus, whether it’s arcuate or submucous myoma or polyp.
Prof. Stephen Corson, MD: Now, let me ask you a somewhat different question. If you do an ablation, what should the patient expect downstream? What, let’s say that someone is having menses and you do this operation, one year after, two years after, three years after, is she likely to come back into, essentially slide back into her menorrhagia and eventually have a hysterectomy or is this a procedure that has some longevity? What are the longitudinal studies showing?
Philip Brooks, MD: Most of the data that is reliable and if followed carefully are only out for now we have three years on the HTA, there are five years out on the balloons, there are a lot more years on the resectoscope, but that’s not office procedures, and the information is amazingly reliable. That is, each of those modalities have a different success rate if you gauge a success rate on amenorrhea or by reduction of menses, and it seems to hold up reasonably well. We’re getting actually a little bit improvement. The latest data on the HTA, which I was a primary investigator for which you’re familiar with as well, our latest data out is 36 months show even a slight improvement in amenorrhea rates. Our success rates stay pretty much the same over time. The data and the literature seem to show that if the patient is really young, she has longer to regenerate those vessels and to make the adenomyosis worse and maybe will start bleeding again later on, but if they’re done 42 / 45 years old, the average age in my practice is 42.5, then they’re getting close to menopause, those results hold up.
Prof. Stephen Corson, MD: So we should expect fewer rates, if I can use that term, 90% plus that is, that will stand up over time amenorrhea rates that then are approaching 50%?
Philip Brooks, MD: I would think that in reviewing all of the data and looking for a device that you want to adopt for your practice, you should expect about a 50% amenorrhea rate for it to be successful because now we’re getting that from the better technologies and you should expect 85% to 95% success rate; that is, where the patients are relieved of the symptoms that they came to you for and that is a debilitating bleeding every month, the anemia, the inability to function, either with exercise or business, their professional life, which is so badly altered.
Prof. Stephen Corson, MD: Dr Brooks, thank you.
Philip Brooks, MD: Thank you.