***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Please cite this paper as : Sambrook A , Jack S , Cooper K.  Outpatient microwave endometrial ablation :  5‐year follow‐up of a r and omised controlled trial  without endometrial preparation versus st and ard day surgery with endometrial preparation . BJOG 2010;117:493–496 STUDY OBJECTIVES To determine the safety and efficacy of endometrial resection , and to provide an indicator of the operative problems and treatment outcomes . DESIGN Prospect i ve study . SETTING Academic practice tertiary care setting . PATIENTS One hundred twenty-six consecutive women undergoing endometrial resection because of menorrhagia , who wished to retain their uterus . INTERVENTION Hysteroscopic endometrial resection performed as a day procedure . MEASUREMENTS AND MAIN RESULTS In 126 women , 2 cases of uterine perforation were readily identified on the operating monitor screen ; they had no serious sequelae . Three patients had heavy uterine bleeding , which was controlled by intrauterine tamponade . No women had other serious complications . CONCLUSION Hysteroscopic endometrial resection is a safe , successful , and cost-effective treatment of menorrhagia OBJECTIVE To compare danazol and gestrinone treatment as preoperative endometrial preparation for operative hysteroscopy . DESIGN Prospect i ve , r and omized clinical study . SETTING University department of gynecological , obstetrical sciences and reproductive medicine . PATIENT(S ) One hundred thirty-five patients with endouterine pathologies ( endometrial polyps , submucous myoma , septate uterus ) . INTERVENTION(S ) Patients pretreated with gestrinone ( n = 68 ) and with danazol ( n = 67 ) underwent operative hysteroscopy . MAIN OUTCOME MEASURE(S ) Endometrial response to the medical pretreatment , side effects , procedure time , intraoperative bleeding , infusion volume , patient satisfaction . RESULT ( S ) Side effects were infrequent in both groups , though the patients ' personal satisfaction was in favor of gestrinone . The rate of endometrial response was higher for the gestrinone group ( 97.1 % vs. 83.6 % ) . Operative time ( mean + /- SD ) was 12 + /- 1.8 and 15.2 + /- 1.9 minutes for the gestrinone and danazol groups , respectively . The gestrinone group showed a lower incidence of moderate bleeding ( 3 % vs. 22.4 % ) and a lower infusion volume ( 2,100 + /- 200 mL vs. 2,400 + /- 250 mL ) . Regarding cervical dilatation time , no significant difference was found between the two groups ( 1.6 + /- 0.3 minutes vs. 1.5 + /- 0.4 minutes ) . CONCLUSION ( S ) Both treatments are good ways to prepare the endometrium for operative hysteroscopy . However , the data suggest that gestrinone pretreatment is preferable to danazol The aim of this study was to determine whether or not the use of medical pre-treatment of the endometrium improves the outcome of transcervical resection of the endometrium with regards to long-term operative outcome , histological findings and patient satisfaction . A prospect i ve r and omized trial comparing three endometrial pre-treatment agents ( danazol , medroxyprogesterone acetate or nafarelin ) with no pre-treatment was conducted . The main outcome measures were : ( i ) thickness of the endometrium and myometrium resected ; ( ii ) histological stage of the endometrium at the time of operation ; ( iii ) the presence or absence of menses and ( iv ) patient satisfaction 1 year post-operatively . Of the three pre-treatments studied , danazol produced a lower median endometrial thickness than the control , showed the greatest ability to induce atrophy of the endometrial gl and s and stroma ( not statistically significant ) and produced the highest rate of amenorrhoea ( not different to the control ) . Danazol and nafarelin produced significantly lower median endometrial thickness than no pre-treatment . There were , however , no significant differences in the rates of amenorrhoea in any of the pre-treatment groups compared with that in the control group . No improvement in clinical outcome or patient satisfaction is conferred by the use of medical pre-treatments if transcervical resection of the endometrium is performed in the proliferative phase of the menstrual cycle OBJECTIVE To investigate the management of menorrhagia in primary care and its impact on referral and hysterectomy rates . DESIGN Prospect i ve observational study . SETTING 11 general practice s from the Somerset Morbidity Project . SUBJECTS 885 women consulting their general practitioner with menorrhagia over four years . MAIN OUTCOME MEASURES Proportions of these women investigated and treated with drugs in primary care , referred to a gynaecologist and undergoing operative procedures . The relation between investigation and prescribing in primary care and referral to and surgery in secondary care . RESULTS Less than half of women had a vaginal examination ( 42 % , 95 % CI 39 % to 45 % ) , or a full blood count ( 39 % , 95 % CI 36 % to 43 % ) . Almost a quarter of women , 23 % ( 95 % CI 20 % to 26 % ) , received  no drugs  and 37 % ( 95 % CI 34 % to 40 % ) received  norethisterone .  Over a third , 38 % ( 95 % CI 34 % to 40 % ) , of women were referred , and once referred 43 % ( 95 % CI 38 % to 48 % ) of women were operated on . Women referred to a gynaecologist were significantly more likely to have received  tranexamic acid and /or mefenamic acid  in primary care ( chi(2)=16.4 , df=1 , p<0.001 ) . There were substantial between practice variations in management , for example in prescribing of  tranexamic acid and /or mefenamic acid  ( range 16 % to 72 % ) and referral to gynaecology ( range 24 % to 52 % ) . There was a significant association between high referral and high operative rates ( Spearman 's correlation coefficient=0.86 , p=0.001 ) . CONCLUSIONS Substantial differences in management exist between practice s when investigating and prescribing for menorrhagia in primary care . Rates of prescribing of effective medical treatment remain low . The decision to refer a woman impacts markedly on her chances of subsequently being operated on . Effective management in primary care may not reduce referral or hysterectomy rates In a prospect i ve study in 40 patients the pretreatment for endometrial ablation with a gestagen ( Orgametril 10 mg/die ) , danazol ( 600 mg/die ) and an injection of a GnRH-analogon ( Decapeptyl-Depot ) was compared with a control group without pretreatment .  The subjective estimation of the surgeon ( endometrial thickness and depth of coagulation ) showed a sufficient pretreatment in 90 % of all cases following danazol- and GnRH-analogon-pretreatment . In 90 % of the danazol- and GnRH-analogon pretreated group the histological findings showed also an atrophic or little proliferative endometrium . In a follow up of 6 months after endometrial ablation the highest amenorrhoea-rates were reached following danazol- and GnRH-analogon pretreatment . These two regimes should be used for the pretreatment for endometrial ablation Objective To compare the effectiveness of  goserelin and danazol prior to endometrial laser ablation and assess different dosage regimens This r and omized , double blind , placebo-controlled study compared the usefulness of danazol 400 mg vaginally versus 600 mg orally in women as a preoperative preparation for hysteroscopic surgery . Ninety-one fertile women were r and omly allocated to Group A ( 46 patients received 400 mg of danazol placed into the posterior vaginal fornix and three oral tablets of commercially available folic acid as a placebo ) , and Group B [ 45 women treated with 600 mg of danazol orally ( 200 mg three times daily ) and two vaginal tablets of Lactobacillus rhamnosus as a placebo ] . The patients underwent an operative hysteroscopy , transvaginal sonography , blood tests , and a histological assay . A visual analog scale ( VAS ) score to compute the degree of the surgeon 's satisfaction was used . The outcome measures were as follows : an evaluation of the changes in the endometrial thickness , the prevalence of endometrial atrophy , changes in the blood tests , any collateral effects , the degree of difficulty and view , the duration of the surgical procedure , any complications during the operative hysteroscopy and associated side effects , and the surgeon 's satisfaction with the endometrial preparation . The vaginal administration route was associated with a more pronounced effect on the endometrial thickness . Significantly more patients receiving vaginal danazol ( 45/46 ) had a hypotrophic endometrium than those receiving oral danazol ( 37/45 , P<0.01 ) . In addition , the patients receiving danazol vaginally had a shorter operating time , lower infusion volume , fewer side effects , and a higher surgeon satisfaction . Vaginal danazol adequately prepares the endometrium for an operative hysteroscopy by thinning the endometrium effectively with few side effects and little impact on the metabolic parameters OBJECTIVE To evaluate the efficacy of GnRH analogue treatment before hysteroscopic resection of submucous myomas in patients with abnormal uterine bleeding . DESIGN Multicenter , prospect i ve , r and omized , clinical study . SETTING Tertiary-care university hospitals . PATIENT(S ) Thirty-nine consecutive patients with submucous myomas grade d as G0 or G1 according to the European Society for Gynecological Endoscopy classification ( myoma size 10 - 35 mm ) . INTERVENTION(S ) Patients were r and omized to either direct surgery or 2 months of GnRH analogues before undergoing hysteroscopic resection of the submucous myoma . MAIN OUTCOME MEASURE(S ) Operating times , fluid absorption , difficulty of the operation , surgeon satisfaction with the procedure , intra- and postoperative complications , postoperative pain , and patient satisfaction were recorded . RESULT ( S ) Patients treated with GnRH analogue had significantly shorter operative times ( 15.9+/-3.1 minutes vs. 21.3+/-4.0 minutes ) and significantly reduced fluid absorption ( 378+/-137 mL vs. 566+/-199 mL ) compared with no preoperative medical treatment . Operative difficulty and overall surgeon satisfaction were significantly better in the GnRH analogue group . Patient satisfaction was similar in the two groups . CONCLUSION ( S ) GnRH analogue treatment before hysteroscopic resection of G0-G1 10 - 35 mm submucous myomas was effective in reducing operative times , fluid absorption , and difficulty of the procedure STUDY OBJECTIVE To compare the effectiveness and safety of thermal balloon ablation without pretreatment with endometrium-thinning agents compared with delayed ablation with pretreatment for women with perimenopausal menorrhagia . DESIGN Prospect i ve , r and omized , controlled trial ( Canadian Task Force classification I ) . SETTING Hospital-based ambulatory medical center . PATIENTS Thirty women age 46 to 51 years with severe enough perimenopausal menorrhagia to make them c and i date s for either hysterectomy or endometrial ablation . Two patients with submucosal myomas and six who had undergone cesarean section were included . INTERVENTIONS Thirteen patients were r and omly assigned to be treated within 30 days and received a single intramuscular administration of gonadotropin releasing hormone ( GnRH ) analog ;  17 women were allocated to be treated within 3 days of enrollment without uterine preparation . A thermal balloon was inserted transcervically under general anesthesia , and after inflation in the endometrial cavity with 5 % dextrose in water , was heated to 87 degrees C for 8 minutes . MEASUREMENTS AND MAIN RESULTS Immediate and long-term major and minor complications and success rates were analyzed . Bleeding patterns and mean duration of menstrual flow were compared between groups at 6-month follow-up . No major intraoperative or postoperative complications occurred in either group , including the women who had recently undergone hysteroscopic myomectomy or had a history of cesarean section . Minor side effects were similar in both groups , and did not exceed 5 % . Overall , at 6-month follow-up , 7 women were amenorrheic , 20 hypomenorrheic , and 3 eumenorrheic . No significant differences were noted between women treated with immediate or delayed ablation in either the distribution of bleeding patterns or days of flow per cycle ( mean + /- SEM 1.8 + /- 0.42 vs 2.1 + /- 0.75 days , respectively ) . CONCLUSION This pilot study suggests that prompt treatment of perimenopausal menorrhagia with thermal balloon endometrial ablation is as effective and safe as deferred therapy combined with GnRH analog as an endometrium-thinning agent . In light of our results , the theory that previous cesarean section and presence of small submucosal myomas constitute relative contraindications for the procedure merits further consideration . ( J Am Assoc Gynecol Laparosc 6(2): 
    Output:
    
It has been suggested that these agents will reduce operating time , improve the intrauterine operating environment and reduce absorption of fluid used for intraoperative uterine cavity distension .
For other intraoperative and postoperative outcomes , any differences were minimal , and no benefits of GnRHa pretreatment were noted in studies in which women underwent second-generation ablation techniques .
When reported , the long-term effects of endometrial thinning agents on benefits such as postoperative amenorrhoea were reduced with time .
The quality of reporting of adverse events was generally poor , but , when described in the studies , they included menopausal symptoms such as hot flushes , vaginal dryness , hirsutism , decreased libido and voice changes , as well as other side effects such as headache and weight gain .
AUTHORS ' CONCLUSIONS Low- quality evidence suggests that endometrial thinning with GnRHa and danazol before hysteroscopic surgery improves operating conditions and short-term postoperative outcomes .
GnRHa produced slightly more consistent endometrial thinning than was produced by danazol , although both achieved satisfactory results .
The effect of these agents on longer-term postoperative outcomes was reduced with time .
No benefits of GnRHa pretreatment were apparent with second-generation ablation techniques .
Also , side effects were more common when these agents were used