Radiofrequency induced endometrial ablation.

Radiofrequency endometrial ablation is an experimental technique which requires a minimum of training and appears to be safe so long as a strict protocol is maintained. The success rate in over 1000 patients in multiple centes gives an incidence of amenorrhoea or oligomenorrhoea in excess of 80%. Therefore, as long as patients are strictly selected more than eight out of 10 hysterectomies for dysfunctional uterine bleeding can be avoided. The technique is particularly suitable for women with severe cardiopulmonary disease because there is no risk of pulmonary or cerebral oedema due to fluid intravasation.

Validation of a method of treating menorrhagia by endometrial ablation.

Menstrual blood loss was measured by intravenous injection of radioactive iron (59Fe) and whole-body counting in 19 women complaining of menorrhagia due to dysfunctional bleeding. Fifteen patients were then treated by radiofrequency endometrial ablation, after which blood loss was re-measured. The majority of the patients were bleeding excessively before treatment (mean 281 (SD 156) ml per cycle averaged over two cycles, range 49-665 ml, n = 19). In the 15 treated patients, average blood loss was reduced to 52 (SD 39) ml per cycle and the mean reduction in blood loss was highly significant (P < 0.001). These quantitative data correlate well with the patients' subjective reports.

Endometrial ablation.

Endometrial ablation or resection is a new method of treating women with severe functional bleeding or submucous fibroids, thus avoiding hysterectomy. The different methods are described, together with their complications and short-term results.

Treatment of menorrhagia by radiofrequency heating.

A new technique is described for the treatment of menorrhagia by heating the whole of the endometrial cavity of the uterus. A capacitively coupled probe at 27.12 MHz is inserted into the uterine cavity, which causes the basilis layer to be raised to approximately 50-55 degrees C whilst the rest of the pelvic contents remain at approximately normal (body) temperature. A major advantage of the method is that no special hysteroscopic skills are required, unlike the two other techniques currently used for endometrial ablation: the Nd-Yag laser or the hysteroresectoscopic loop. Also no toxic flushing/distension fluids are necessary, as are required for all hysteroscopic surgery. The method, however, does require the application of a large amount of RF power to the probe and so care must be taken to position the probe correctly in order to prevent any serious complications. Of 32 patients given a single treatment at a power level of 550 W for 20 min, the 'success rate' was 84% with 31% becoming amenhorrhoiec and 53% showing significant reduction in menstrual bleeding. However, retreatment is possible and by this means, combined with improved treatment techniques, an even higher success rate could be achieved. In two of the earlier patients treated at 550 W a fistula was produced at the anterior vaginal wall which had to be surgically repaired. The probe was subsequently modified, since when this problem has not recurred. This new treatment approach offers an alternative to hysterectomy in the treatment of menorrhagia and may offer a number of significant advantages over methods currently used for endometrial ablation.

Experimental and clinical studies with radiofrequency-induced thermal endometrial ablation for functional menorrhagia.

A method of ablating the endometrium has been introduced into clinical practice that uses radiofrequency electromagnetic energy to heat the endometrium, using a probe inserted through the cervix. Preliminary studies suggest that over 80% of patients treated will develop either amenorrhea or a significant reduction in flow. The advantages of radiofrequency endometrial ablation over laser ablation or resection are the avoidance of intravascular fluid absorption, simplicity (no special operative hysteroscopic skills are required), speed of operation, and reduced cost compared with the Nd:YAG laser. In this paper, we describe the experimental studies performed during development of this new technique.

Large loop excision of the transformation zone (LLETZ) compared to carbon dioxide laser in the treatment of CIN: a superior mode of treatment.

A series of 199 patients with histologically confirmed cervical intraepithelial neoplasia (CIN) grade II or III were allocated by hospital number to receive out-patient treatment by carbon dioxide laser vaporization or large loop excision of the transformation zone (LLETZ). All patients received local anaesthesia. The women in the LLETZ group experienced less post operative haemorrhage, less discomfort, operative time was greatly reduced, and histological material was available for confirmation of the diagnosis. There was no significant difference in recurrence of CIN after treatment between the two groups. At 6 month follow-up, recurrence rates of 8.2% (CIN II) and 7.5% (CIN III) were observed in the laser-group and 5% (CIN II) and 5.3% (CIN III) in the LLETZ group. Further advantages of LLETZ are reduced capital expenditure and no hazard to the eyesight of the surgeon, but laser treatment is preferable in patients with widespread vaginal involvement.

Treatment of functional menorrhagia by radiofrequency-induced thermal endometrial ablation.

42 patients were enrolled in a trial of radiofrequency-induced thermal endometrial ablation for the treatment of functional menorrhagia. The radiofrequency electromagnetic energy was delivered via a probe placed within the endometrial cavity. 10 patients received 330 kJ of energy, 10 received 445 kJ, and the other 22 received 660 kJ. 19 (87%) of those receiving the highest dose became amenorrheic or had a considerable reduction in menstrual flow. The procedure is simple and the heat induced in the endometrium does not penetrate much beyond the inner layers of the myometrium. There is no need for distension of the uterine cavity with flushing media.

A prospective study of colposcopy in women with mild dyskaryosis or koilocytosis.

Colposcopy was performed in 91 women who had cervical cytology suggesting mild dyskaryosis or showing koilocytosis, all previous cytology having been normal. The final histological diagnosis was CIN III in 22%, CIN II in 18%, CIN I in 31%, koilocytosis alone in 14% and no abnormality in 15%. These results indicate that even with mild cytological atypia, a high proportion of patients will have more advanced disease when colposcopy-directed punch biopsy is performed.

Spontaneous abortion--an infectious aetiology?

The role of Chlamydia trachomatis, genital mycoplasmas, Campylobacter spp. and other aerobic and anaerobic bacteria in the aetiology of spontaneous abortion was investigated prospectively in 241 pregnant women at a community hospital. Sixteen women who had threatened abortions were a little younger, of lower social class and had had more previous spontaneous abortions than the 76 women who aborted or the 149 women whose pregnancies were not complicated in the early stages by haemorrhage. The demographic characteristics of the latter two groups of women were similar. C. trachomatis was isolated from the cervix of only one woman and she had no genital-tract bleeding at any stage in her pregnancy. Mycoplasma hominis was isolated most often from the women who had threatened abortions but otherwise the prevalence of the other various micro-organisms was similar in women who had spontaneous abortions, threatened abortions, and in those who had pregnancies uncomplicated by vaginal bleeding. It was clear, therefore, that C. trachomatis played no role in the aetiology of spontaneous abortion in the population studied and there was no suggestion that any of the other micro-organisms were involved either.

The detection of neural tube closure defects by exfoliative cytology of amniotic fluid.

Cytospin preparations of amniotic fluid samples from 200 pregnancies, taken between 16 and 20 weeks' gestation, were examined without knowledge of the fluid alpha-fetoprotein (AFP) level. The specimens were taken because of the possibility of neural tube closure defect. All but eight cases showed predominantly squamous cells, amnion cells, macrophages and blood cells. AFP levels in these fluids were within the normal range in 178 cases, unequivocal in 11, undetectable in 2 and raised in 1; none of the babies in these cases had a neural tube closure defect. In eight cases a large population of small cells with dark nuclei and a population of large, foamy macrophages were present in addition to the other cell types; all of these babies had a neural tube closure defect (five anencephaly and three anencephaly with spina bifida). This technique may provide a useful additional method of diagnosis of neural tube closure defects.

Vaginal breech delivery or cesarean section.

In 579 singleton breech deliveries the total perinatal mortality rate was 10.4% and the corrected perinatal mortality rate was 0.67%. There were 452 babies delivered vaginally (78.1%) and 127 delivered by cesarean section (21.9%). The perinatal mortality rate was very high in the premature breech delivery and in the low-birth-weight infant. Cesarean section should be used to avoid a traumatic vaginal delivery and it should be used more liberally in the mature breech, but it is unlikely that cesarean section rates in excess of 50% will significantly reduce the perinatal mortality mortality rate. More information is required as to whether extending the indications for cesarean section in the low-birth-weight infant will further reduce the perinatal mortality rate.

Changing pattern in a general practitioner obstetric unit.

Over the past nine years in Watford the proportion of hospital confinements has increased and domiciliary confinements have almost ceased. The proportion of patients originally booked into the general practitioner obstetric unit and subsequently transferred to the consultant unit has increased. Most patients are transferred during pregnancy, and the numbers transferred in labour are decreasing. The proportion of GPs attending their patients for delivery is low: local practitioners appear to be prepared for the consultant unit to supervise delivery with the practitioner co-operating in antenatal and postnatal care and family planning. There seems little doubt that the success of GP units depends on the enthusiasm and interest of individual practitioners.