ABNORMAL UTERINE

BLEEDING –SURGICAL
MANAGEMENT
ALWIN KURIAN RAJU
• UTERINE CURRETTAGE
HYSTEROSCOPIC ABLATION ENDOMETRIUM RECTOSCOPE,ROLLER BALL LASER

FIRST GENERATION
• MINIMAL INVASIVE SURGERY
(ABLATIVE TECHNIQUE) SECOND GENERATION
- RITEA,BALLOON THERAPY,MICROWAVE ABLATION,
- UTERINE ARTERY TAMPONADE IN ACUTE BLEEDING
-BILATERAL UTERINEN ARTERY EMBOLISATION
• HYSTERECTOMY
UTERINE CURETTAGE
• Predominantly as a diagnostic tool for elderly women but it has also
got hemostatic and therapeutic effect by removing the necrotised and
unhealthy endometrium

• Done following ultrasonography for detection of endometrial

pathology

• D&C and endometrial study are required if genetal tb or endometrial

cancer is suspected or medical therapy fails
ENDOMETRIAL ABLATION/RESECTION
• The idea of endometrial ablation from oligomennorhea occurring in
ashermanns syndrome due to synechiae
• These are safe ,effective with lesser morbidity,as well as cost effective with
quicker recovery
• Fertility is not possible following ablative therapy
INDICATIONS
-failed medical treatment
-Women who do not wish to preserve menstrual or reproductive fn
-uterus –normal size and not bigger than 10 weeks of pregnancy size
-women who prefer to preserve her uterus
TECHNIQUES
1. FIRST GENERATION
Hysteroscopic endometrial ablation by rectoscope,loop,rollerball coagulation
and laser (transcervical endometrial resection)

2. SECOND GENERATION
Radiofrequency induced thermal ablation,cavaterm ballon therapy,microwave
endometrial ablation,laser therapy

3. Uterine tamponade
4. Bilateral uterine artery embolisation
HYSTEROSCOPIC ENDOMETRIAL ABLATION

• Performed soon after menstrual period soon after the endometrium is thinned out
Contraindications
Uterine size more than 12 weeks pog
Uterine fibroid
Scarred uterus
Young women desirous of pregnancy
Adenomyosis
Genital infection
Uterine cancer or preinvasive cancer
TCRE under general anaesthesia using a hysteroscope destroys 4-5mm endometrium and
forms uterine synachiae
RITEA(radiofrequency induced thermal
endometrial ablation)
Blind procedure using rf electromagnetic thermal energy
Destroys endometrium at 66 degree Celsius
0.6mm metallic probe is inserted under GA and rotated over 360 degree for 20
min
Advantage
-cheaper than tcre
-hysteroscope not required
-Less skill required
-lesser risk
CAVATERN BALLOON THERAPY
• Invented by NEUWIRTH in 1994
• Instrument comprises of a central computer system ,battery and a disposable silicon
rubber catheter 5mm in diameter
Under local anaesthesia the catheter is inserted transcervically into uterine cavity and
balloon is bistended towith 15-30ml sterile solution containing 5% glucose or
1.5%glycine

Heating element in the balloon raises the temperature to 87 degree Celsius and this
temp is maintained for 8 min over a pressure of 160-180mm hgto exert a tamponade
effect
• About 6mm of endometrium gets destroyed(so preoperative thinning of endometrium
is not required)
Microwave ablation
• Utilizes magnetic energy and works at frequency of 9.2Ghz
• Done under local anaesthesia(as an opd procedure)
• No need odf endometrial thinning here also
• Temperature of 80 degree Celsius is mainatained for 3 mins
• Total operating time is 12 mins
• Hysteroscopy not needed here also
UTERINE TAMPONADE
• Advocated by GOLDWRATH
• used in acute episodes of bleeding
• Foleys catheter is inserterd and distended wuth 30ml fluid leaving the
catheter for 24hrs
• Novasure is the latest and safest procedure takes just 90 mins to
complete the procedure
• Endometrial laser iontrauterine therapy (ELITT) is a newer laser therapy
that destroys entire endometrium as well as 1-3.5mm myometrium (an
opd procedure ;takes about 7min)
• Machine is known by the name ‘gynelase’
BILATERAL UTERINE ARTERY
EMBOLISTAION
• Primarily used in uterine fibroids
• Also useful in aub complicated by varicose uterine vessels
HYSTERECTOMY
• INDICATIONS
 If medical treatment fails or contraindicated
If older women ›40 yrs not desirous of childbearing and who opt
hysterectomy as primary treatment or ablation fails
Presence of endometrial hyperplasia and atypia on histology is an
indication for hysterectomy
Can be vaginal,abdominal ,laproscopic or assisted vaginal method