Endometrial Bleeding

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Hugo Verhoeven, MD: Good afternoon, my name is Hugo Verhoeven from the Centre for Reproductive Medicine in Dusseldorf, Germany, reporting from the AAGL meeting in Miami, Florida. I’m sitting here together with Professor Bruno Van Herendael at the ACMI booth and it is a real pleasure talking to Bruno because we’ve known each other since . . . twenty-five, thirty years, actually. He’s head of the department and Professor of the Department of Gynecologic Surgery at the Antwerp University Hospital. Bruno, thank you very much for the pleasure. We are going to talk today of hysteroscopy and especially of hysteroscopic ablations of the endometrium, one of your hobbies. So, let’s first start with what is hysteroscopy, what is an endometrium and what is ablation?

Prof. Bruno Van Herendael, MD: That’s right. Well, to try to explain it simply, hysteroscopy is looking inside the womb, so what we normally do is on an outpatient base using a very small scope, we pass through the cervical canal that has been anaesthetized or even we can do it with a small scope without any anesthesia at all, and we just look inside that canal and inside the uterine cavity. The reason why we do this is mostly that people come, or women come, and complain about abnormal uterine bleeding and between 63% and 68% of all women will experience in one moment or another of the last time some abnormal uterine bleeding, it could be before the menopause or after the menopause.

Hugo Verhoeven, MD: What are the reasons for those kinds of irregular bleeding?

Prof. Bruno Van Herendael, MD: Well, mostly it’s, there are mechanical factors and there are dysfunctional factors, so to say. Dysfunctional factors, that is referring to what you asked before about the endometrium and the endometrium is the lining of the uterine cavity and sometimes, due to hormonal changes or to the intake of exapaporial hormones like the pill, sometimes that endometrium is built up a little bit different and then shedding starts and so you get inter-menstrual bleeding. That endometrium is the lining and that is actually of that cavity, sorry, and that is actually what comes out during the menstrual period. But sometimes we’ve got mechanical factors, being polyps or myomas that stick out into that cavity and so that’s what we then have to remove. The removal of that is operative hysteroscopy and operative hysteroscopy, of course, requires most of the time, a general anesthesia because we have to open up the cervical canal up to a certain diameter, 1.5cm to 2cm to let the operative scope into the cavity so that we can work there.

Hugo Verhoeven, MD: And for distension, you use CO2 or you use fluid?

Prof. Bruno Van Herendael, MD: Well, we started off with carbon dioxide, CO2, but that was a little bit cumbersome sometimes and people, actually it’s a little bit more difficult, and we have experienced when we train the young registrars is that time when we see that they are more comfortable with fluid, and so nowadays, most of the diagnostic hysteroscopy is done with fluids and the operative hysteroscopy is done with a special fluid so that we can use electricity because we have to take care that the electricity remains within the uterus and doesn’t flow to other organs, but that is very easily feasible in using non-ionic solutions and that’s what we do.

Hugo Verhoeven, MD: Okay. If you want to remove the inner layer of the uterine cavity, the endometrium, different techniques are available.

Prof. Bruno Van Herendael, MD: That’s right.

Hugo Verhoeven, MD: So maybe you can comment on the different techniques and then maybe tell us about your choice, your preference.

Prof. Bruno Van Herendael, MD: Right. So there are, of course, different techniques and the different techniques, well they started to be used and they’re called global endometrial ablation techniques, and they start to be used because people, hysteroscopy is a little bit of technique that one has to be taught and you have to learn it, you have a learning curve and in global ablation techniques, so called, people thought that there was no necessity of a learning curve, but I think there is where things went a little bit wrong and so what we use in global ablation and we use them all, first we had the balloons so it’s hot water balloons maybe that expand the cavity and at the same time the hot water actually coagulates the endometrium, burns the endometrium up to the muscle and so there’s no endometrium growing back. 

And then we have cryo, which means we freeze the endometrium up into the muscle, we’ve got ultrasound that actually destroys again, we’ve got laser techniques that actually destroys the endometrium from the inside out, meaning we start at the level of the myometrium and then come into the cavity and we have now bipolar devices and they are like the Novasure and that’s, I think, the most applicable of global techniques because here we actually don’t have to dilate, with all the others we still have to dilate and for the patients that are not under general anesthesia sometimes it causes some pain. 

The problem why we actually are not continuing this direction except with the Novasure is that most of these techniques did not really go into the cornice of the uterus and so not always, but sometimes, some endometrium remained and so we got back in menstruation that remained inside the uterus because the lower part was closed and that could cause pain. I forgot another technique where we use warm water that is actually circulated inside the cavity and again that destroys the endometrium up to the muscle.

Hugo Verhoeven, MD: So the two techniques that you prefer are the bipolar technique, the coagulation, and then the resectoscope technique with Hobbs-Byer. Okay. What are the complications of those procedures?

Prof. Bruno Van Herendael, MD: Well, the, let’s just talk about advantages first. Well, the advantages of the bipolar is that you’re going to use very small unit that is brought into the cavity and you can do that in most women without dilating the cervix so it can be done in an outpatient procedure. It takes about a few seconds, it takes about sixty to ninety seconds and that’s it, but it’s expensive, that’s our problem, especially in the Western Europe, it’s really expensive because it’s not in the national health insurance and so people have to pay for it.

Hugo Verhoeven, MD: It’s disposable.

Prof. Bruno Van Herendael, MD: And it’s disposable and that’s the reason why. On the other hand, you’ve got the hysteroscopic technique. We have to dilate the cervix up to 1cm to 1.5cm so that we can pass the operative scopes inside the cavity and this technique is especially valuable when we have to cut off some polyps or myomas because we really can do that, like the urologists did that for years, when they even used that for prostatectomy. But inside this cavity, with the distension fluids, we can easily do that. The disadvantages, of course, that the patient has to sleep, so it’s the same as a dilation and curettage, more or less, but the advantage of hysteroscopy when cutting the tissues, the tissues can be brought for pathology and so that we can always have a biological report which, of course, in the global techniques, we first have to do a diagnostic hysteroscopy, take a sample and then bring that to the pathologist then afterwards, so we have to work more or less in two stages.

Hugo Verhoeven, MD: That’s always better than opening the abdomen and removing the uterus or doing a laparoscopic hysterectomy, so it even, certainly for the patient, is much better.

Prof. Bruno Van Herendael, MD: Oh, yes. The global technique with Novasure is really an outpatient procedure. The patient will leave the office in thirty minutes. The hysteroscopic surgery is a day surgery and, of course, hysteroscopy carried a little bit more risk because we have to dilate, but we’ve seen it yesterday here in different speeches. Most of the perforations, and that is actually when we go through the walls of the uterus into the abdominal cavity which is a serious complication, they are made by dilating, by the specific instruments we need to dilate the cervical canal, not by the hysteroscope as such because the hysteroscopy is under direct view. We put a camera on the scope and we see on the screen and so that’s easy in that way. Other complications are distension fluid. If you use too much distension fluid and it gets into the circulation of the patient, of course, you have to be careful, you have to monitor that carefully and so these techniques maybe are better done in centers that are well-equipped to deal with both the control and the endoscopic surgery and, on the other hand, also if complications arise which are seen during the operation, to deal with them.

Hugo Verhoeven, MD: That’s right. Bruno, you wrote also a book on outpatient hysteroscopy.

Prof. Bruno Van Herendael, MD: Yes.

Hugo Verhoeven, MD: Can you give me some information about that book?

Prof. Bruno Van Herendael, MD: Well, the book, we do it together with Rafael Valle from Northwestern Chicago and Stephan Opichocki from the University of Bari, Italy, and it deals with all aspects of outpatient hysteroscopy, that means the patients come with a complaint to the office and what we do is diagnosing and we then can also treat nowadays because special instruments, bipolar instruments, and using simple saline solution liquid, we can actually treat small polyps, small myomas under 2cm without anesthesia, just the patients actually, so I can see and treat the thing that patients come and actually can see what’s happened, what’s causing the problem and be treated at the same time. That’s the idea about the book.

Hugo Verhoeven, MD: That book is for experts, for doctors, not for patients?

Prof. Bruno Van Herendael, MD: That book is actually not for experts, but for doctors. In the sense that it is not a cookbook for doing hysteroscopy, but it is actually a book for both the beginner and the expert so that he can actually learn and see what he can do.

Hugo Verhoeven, MD: It’s available worldwide

Prof. Bruno Van Herendael, MD: It will be available worldwide in the spring of 2003, yes.

Hugo Verhoeven, MD: Well, Bruno, thank you very much.

Prof. Bruno Van Herendael, MD: Thank you.

Hugo Verhoeven, MD: It’s a pleasure after twenty-five or thirty years to sit here together and I wish you a great evening.

Prof. Bruno Van Herendael, MD: Thank you very much. Thank you.