For many women, these procedures succeed in reducing or eliminating menses without hysterectomy or long-term medical therapy (51,200). Success rates vary and depend on the duration of follow-up and the definition of success. For many patients, amenorrhea is the goal, whereas for others, it is normalization of menses. About 75% to 95% of patients are satisfied with the surgical procedure after 1 year. Amenorrhea rates range from about 30% to 90% (depending in part upon the technique), but 40% to 50% of patients have amenorrhea, is a useful number to quote to patients considering the procedure. In comparative studies, there is no advantage of laser over electrosurgical techniques (198,201). The nonresectoscopic techniques have similar clinical outcomes, thus reducing the need for resectoscopic ablation. However, the nonresectoscopic approaches all have limitations defined by the size or configuration of the endometrial cavity. Consequently, for those women with heavy menstrual bleeding who are not suitable for nonresectoscopic techniques because of large uteri (>12 cm sounded length), resectoscopic endometrial ablation remains a viable option (161,202).
The long-term efficacy and impact of ablation or resection on women with adenomyosis is unknown. Because some endometrium inevitably cannot be ablated, there is the potential for endometrial cancer; therefore, postmenopausal women who underwent ablation or resection should take progestin as a part of hormonal therapy (203).
Sterilization Sterilization can be performed under hysteroscopic guidance, an approach that eliminates the disadvantages and risks associated with abdominal or laparoscopic techniques (204). Two such techniques are available and others are under development. The Essure® system comprises a nickel-titanium coil with a Dacron filament that can be inserted relatively quickly in an office or procedure room setting (see Chapter 10). The Adiana® device uses a rice grain–sized porous silicon plug that is positioned in the proximal tube following the application of an aliquot of RF radiofrequency current. It is designed for office use under local anesthesia. North American protocols require that hysterosalpingography be performed 3 months after the procedure to ensure that bilateral tubal occlusion took place.
Synechiae Asherman syndrome is the presence of adhesions in the endometrial cavity that can result in infertility or recurrent spontaneous abortion with or without amenorrhea. These synechiae may be detected on a hysterogram or sonohysterogram, but are best shown with diagnostic hysteroscopy. Relatively thin, fragile synechiae may be divided with the tip of a rigid diagnostic hysteroscope (205). Thicker lesions may require division by semirigid or rigid scissors or energy-based instruments such as a resectoscope or an operative hysteroscope with either a radiofrequency electrode or an Nd:YAG laser. Reproductive outcome depends on the extent of the preoperative endometrial damage (206,207). This is another hysteroscopic procedure that is amenable to performance in the office, at least in selected cases without complete obliteration, but the surgeon must be careful to maintain orientation within the endometrial cavity.
Diagnostic hysteroscopy procedures traditionally were performed in the office or clinic settings, and operative hysteroscopy usually was performed in an operating room or hospital surgical center. Much is changing; in a number of centers, 90% of the operative hysteroscopies are performed in an office procedure room setting using local and verbal anesthesia. The patient should understand the rationale for the procedure, and the anticipated discomfort, the potential risks, and the expectant, medical, and surgical alternatives. The nature of the procedure and the chance of therapeutic success should be explained, and she should be given a realistic estimate of success based on the operator’s experience.
Diagnostic Hysteroscopy: Risks