Pre- and postoperative hormonal treatment in patients with hysteroscopic surgery.

Hysteroscopic surgery is widely used for the treatment of patients suffering from infertility and menorrhagia. Preoperative and postoperative treatment plays an important role in this kind of surgery. The indications for hormonal pre- and postoperative treatment are very different and depend on the type of surgery and the condition of the patient. For a septum dissection, preoperative treatment is not necessary. Postoperative estrogen therapy can be helpful especially after dissection of a large septum. For intrauterine adhesiolysis, preoperative treatment is without benefit. In cases of adhesions of grades 3 and 4, postoperative treatment entailing insertion of an IUD and application of estrogens for about 3 months is recommended. A higher amenorrhea rate after endometrium ablation can be reached by pretreatment with a GnRH analogue or danazol. For resection methods, pretreatment is not necessary in any case. The success rate of endometrium ablation (reduction of blood loss) is not influenced by pretreatment. Pretreatment can be useful in coagulation techniques in patients suffering from secondary anemia and in high-risk patient. In patients who need hormone replacement therapy after endometrium ablation, gestagen application is necessary. For prevention of bleedings, a continuous combined hormone replacement therapy should be used and so a bleeding-free treatment is possible. The residual endometrium will so be protected against hyperplasia. Another alternative postoperative method after endometrial ablation is insertion of a levonorgestrel IUS. Our studies show advantages for protection of the endometrium, for contraception and a high amenorrhea rate. Prior to a hysteroscopic myoma resection, pretreatment with GnRH analogues is indicated for all myomas with a diameter of more than 3 cm and/or an intramural portion or for patients suffering from secondary anemia. The aim of the pretreatment is not only to obtain a thin endometrium but also to reduce the size and vascularization of the myomas. The failure rate in patients not treated with GnRH analogues is higher especially in large intramural myomas. Pre- and postoperative hormonal treatment can be effective, especially in the treatment of patients suffering from menorrhagia. The indications for hormonal pre- and postoperative treatment should be very strong. A hysteroscopic surgeon should be also have some experience in hormonal treatment.