New surgical treatments for menorrhagia.

CONTEXT: Hysterectomy is a common and effective treatment for menorrhagia but is associated with substantial post-operative convalescence time and morbidity. In the early 1990s endometrial resection or ablation became a well-established day-case alternative for the surgical treatment of menorrhagia. Both endometrial resection and ablation require general anaesthesia, a high level of skill in hysteroscopic surgery, and can be long procedures. More recently, various new techniques have been developed that can be done in an outpatient setting under local anaesthesia and with a low risk of complications. The effectiveness of most new second-generation ablation technologies has not been confirmed in randomised trials and it is possible that these techniques will not prove to be as effective or as safe as originally thought. STARTING POINT: Massimiliano Pellicano and colleagues (Am J Obstet Gynecol 2002; 187: 545-50) compared a second-generation ablation technique, thermal destruction of the endometrium with a heated-water-filled silicone balloon with hysteroscopic endometrial resection. 82 women were randomised and followed up for 2 years. Thermal destruction was quicker than hysteroscopic resection, and was associated with a similar level of postoperative satisfaction and reintervention rate. This study suggests that thermal destruction is as effective a technique as endometrial resection. WHERE NEXT? Many second-generation ablation techniques are now available. Some may prove more effective than others, but much larger studies are needed to address safety. The development of progestagen-releasing intrauterine devices, which provide effective treatment for menorrhagia and are also an effective and reversible form of contraception, may mean that the uptake of second-generation surgical ablation techniques is less widespread than some proponents of these new technologies suggest.