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The treatment of menorrhagia in the twentieth century changed after 1960 with the introduction of hormonal therapy as well as an array of laboratory, imaging and minimal access tests for more accurate diagnosis. Since 1981, hysteroscopy has been used for diagnosis as well as the control of thermoablative treatments of bleeding non-malignant endometrium, including laser, electrocoagulation and electroresection. The success rates, complications, intermediate range outcome and cost comparisons with hysterectomy favor hysteroscopic methods. But the long term data on both hysteroscopic ablation and hysterectomy are not yet complete. In an effort to simplify techniques, reduce costs, and reduce complications, a variety of non-hysteroscopic methods and devices have appeared. Only two balloon devices have satisfactory success data as well as sufficient field experience to provide some degree of reliability regarding complications, which appear to be very low. Most of the devices have had clinical trials, which suggest equivalence to hysteroscopic endometrial ablation, but the determination of clinical safety requires at least several thousand cases. However, the levels of effectiveness for most of these devices make them candidates for commercial use. Hysterectomy may move from a primary surgical treatment of menorrhagia to a second-line treatment after ablation, particularly if some of the non-hysteroscopic methods become well accepted. If they are found to be safe, the costs and ease of use for the gynecologist and patient will make them attractive as a first-line surgical option. Hysterectomy, whether abdominal, vaginal, or laparoscopic will then be applied to ablation failures or non-candidates. This has the potential to change gynecological training and practice significantly in the future.

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BACKGROUND: Endometrial ablation is a relatively new technique for treating abnormal uterine bleeding not associated with malignancy. Long-term outcome data after endometrial ablation are limited, and incidence of endometrial adenocarcinoma after ablation is unknown. CASE: A 55-year-old black woman who had endometrial ablation for abnormal uterine bleeding after excluding uterine cancer presented 5 years later with similar symptoms and a histologic diagnosis of well-differentiated adenocarcinoma of the uterus. She refused surgery and had radiation treatment for probable stage I endometrial adenocarcinoma. CONCLUSION: It is unlikely in this high-risk patient that the endometrial ablation masked an undetected malignancy or delayed the diagnosis. Given the interval, the adenocarcinoma might have occurred de novo.

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OBJECTIVE: To compare reproductive benefits of hysteroscopic myomectomy and polypectomy for infertility to outcomes in infertile couples with normal hysteroscopic findings. METHODS: Women with diagnoses of infertility who had hysteroscopic evaluations by a single surgeon between 1975 and 1996 were sent a routine follow-up questionnaire regarding their reproductive histories. All 92 subjects who were located responded to the questionnaire, and 78 met inclusion criteria: age under 45 years, at least 12 months of infertility, and at least 18 months of follow-up with attempts to conceive, including in vitro fertilization in women with bilateral tubal occlusion. RESULTS: Of the 78 subjects, 36 had myomectomies, 23 had polypectomies, and 19 had normal cavities. Among the three groups, there were no significant differences in age, type of infertility, length of infertility, or follow-up after the procedure. Polypectomy subjects had significantly higher pregnancy and live birth rates than women with normal cavities. Women who had myomectomies larger than 2 cm had significantly higher pregnancy and live birth rates, achieving statistical significance at a myoma size of 3 cm or greater for live births. Spontaneous abortion rates among first pregnancies after myomectomy, polypectomy, or normal study were similar: 31.5%, 27.7%, and 37.5%, respectively. CONCLUSION: Both hysteroscopic polypectomy and hysteroscopic myomectomy appeared to enhance fertility compared with infertile women with normal cavities. Despite concern that hysteroscopic resection of a large myoma might ablate a large surface area of the endometrial cavity, the reproductive benefit appears greater than the risk.

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Transcervical sterilization techniques as of 1980 are reviewed. A personal and literature search is reported on developments between 1980 and 1992. The potential of endometrial ablation for a transcervical method of fertility control is explored. An appraisal of the more promising methods for future study is made, including silastic tubal plugs, quinacrine, Femcept delivery of an iodine mixture and endometrial ablation.

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Symptomatic submucous myomata are now diagnosed and evaluated with hysteroscopy in the office or operating room. Excision under hysteroscopic control using a resectoscope or other equipment and techniques is described and the long term outcome is reported. The hysteroscopic approach to the symptomatic submucous myoma has dramatically changed the treatment options for patients who classically would be offered abdominal myomectomy or hysterectomy.

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A thermal balloon and control system designed to produce endometrial ablation blindly is described. A latex balloon on a plastic catheter is inserted into the uterus and connected to a control unit. The unit monitors the pressure and temperature of 5% dextrose in water, which has been injected into the balloon to make it conform to the size and shape of the endometrial cavity. The balloon contains a shielded heating element that is activated to heat the liquid in the balloon to a temperature of 92C. The pressure control deactivates the heating element if the pressure falls below 45 mmHg or rises above 165 mmHg. A timer controls and measures the elapsed interval of heating. The device was tested in human uterine specimens for the potential for uterine perforation, uterine rupture, and thermal effects. Subsequently, the device was tested in six patients in Mexico and four patients in London during hysterectomy just after the abdomen was opened. Thermistor probes were placed at various loci in the uterus to monitor temperature during activation of the thermal balloon. Serosal temperatures were unchanged and endometrial temperatures rose to about 90C. The extent of uterine tissue damage was determined in Mexico City by the zone of visible coagulation of the cut wall of the uterus following removal. In London, tissue diaphorase was measured to determine the depth of destruction of the cellular oxidative enzymes. These measurements varied from 3.3-10 mm under the conditions of time and temperature used. The safety features and the potential for clinical application are discussed.

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Asherman's Syndrome was described by Asherman in 1948 as Amenorrhea Traumatica. Since the introduction of hysteroscopic surgery about 1970, an enlarging experience with the repair as well as the induction of intrauterine adhesions has been collected. The pathology and histologic processes involved in surgical repair and induction of scar in the uterus are discussed. The influence of the hormonal milieu as well as the special nature of endometrial repair as observed from the histologic evolution of the endometrium in menstruation are thought to be important factors in the induction and correction of intrauterine scar. While probably a special case, the endometrial model for healing appears to be fundamentally the same as other tissues.

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One hundred fifty-six of 177 patients admitted to the St. Luke's/Roosevelt Hospital Center between November 1973 and November 1988 for hysteroscopic treatment of menorrhagia and/or uterine leiomyomas were followed for long-term complications and necessity for repeat surgery. Ninety-four patients underwent submucous resection alone and 62 patients underwent endometrial ablation with or without submucous resection. Among the submucous-resection group, 24.5% reported late postoperative problems and 15.9% underwent further surgery. After 9 years of followup, 83.9% of the patients had not required further surgery. Among the ablation group, 22.5% experienced recurrence of increased bleeding and 8.1% had another surgical procedure. After 6 years of follow-up, 91.3% of the patients had not required further surgery. Twenty-one patients became pregnant after submucous resection, with 18 infants delivered. No patients who underwent endometrial ablation became pregnant. This modality of treatment appears to be effective over the long term, although effectiveness appears to diminish with time.

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The incidence of congenital anomalies of the uterus has generally been obtained from studies of women undergoing evaluation for infertility, and has been reported as 1-10%. However, the true incidence of uterine malformations is not known. This study reviews hysterosalpingograms obtained for evaluation of tubal closure after transcervical sterilization in normal multiparous women using methylcyanoacrylate and the FEMCEPT device. Of the 840 hysterosalpingograms studied, 16 congenital uterine anomalies were identified, for an incidence of 1.9%. The presence of anomalies in this population of women may more closely represent the incidence of congenital uterine anomalies in the general population.

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The management of 540 patients with the diagnoses of "pelvic mass/uterine leiomyomata" was reviewed with respect to preoperative evaluation, surgical procedures, and final pathologic diagnosis. Approximately 6170 patients were admitted to the Gynecology Service at St. Luke's-Roosevelt Hospital Center from July 1984 to June 1985. During this period, 36 of 432 diagnostic laparoscopies (8.3%) and 503 of 1666 laparotomies (30.2%) were performed to evaluate or treat these women. The final diagnoses in the 249 patients admitted with the impression of leiomyomata were: leiomyomata, 235 (94.4%); benign adnexal masses, seven (2.8%); cancers, four (1.6%); and miscellaneous, three (1.2%). Of the 291 patients evaluated for pelvic mass, the findings were: benign ovarian or tubal cysts, 98 (33.7%); leiomyomata, 42 (14.4%); cancers, 40 (13.7%); benign cystic teratomas, 38 (13.1%); endometriosis, 28 (9.6%); miscellaneous, 23 (7.9%); and pelvic inflammatory disease, 22 (7.6%). Correlation between the patient's age, preoperative impression, and final diagnosis is presented with particular attention to the 44 patients (8.1%) in whom malignancy was found. All the possibilities that such masses may represent must be considered preoperatively, and the patient be informed of her risk of malignancy.

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Results are presented of multicenter studies on the intrauterine delivery of 0.6 ml methyl cyanoacrylate with the FEMCEPT device (BioNexus Inc., Raleigh, North Carolina) for the purpose of causing permanent obstruction of the fallopian tubes. The studies included 1279 women and were conducted under several different protocols that required either one or two methyl cyanoacrylate application procedures. Based on hysterosalpingograms obtained about 16 weeks after the last methyl cyanoacrylate application, one procedure resulted in a tubal closure rate of 71.4% and two procedures resulted in a tubal closure rate of 89.4%. Complications of the procedure were infrequent and none required surgical treatment. Cumulative pregnancy rates among women with hysterosalpingogram-demonstrated bilateral tubal closure were similar for the one- and two-application procedures that used nonradiopaque methyl cyanoacrylate and were significantly lower (p less than 0.05) compared with a single application of radiopaque methyl cyanoacrylate. The 3-year pregnancy rate for two applications of nonradiopaque methyl cyanoacrylate was 1.7 +/- 1.2 per 100 women.

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Twenty-eight patients who underwent resection of a submucous fibroid under hysteroscopic control are reported with a follow-up for one to seven years. Seven patients underwent subsequent hysterectomy for various reasons. Two required repeat hysteroscopic resection and 17 returned to normal menses without difficulty. Five of these patients subsequently had a total of eight pregnancies, with five living children. The implications of this option of therapy are discussed.

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A previous report described the development of a blind method to deliver methylcyanoacrylate (MCA) transcervically. Using 0.6 ml of a stable MCA whose polymerization time was closely controlled, we reported a 78% bilateral tubal closure rate in 23 cases with hysterosalpingographic control. Subsequent to the previous report, we initiated a study in which patients were randomly assigned to one of three treatment groups: a single MCA injection, a single MCA injection after uterine lavage, or two MCA injections 1 month apart. In addition, a radiopaque MCA has been developed with which it is possible to determine tubal entry after its application by means of the FEMCEPT device. Patients treated with radiopaque MCA have been studied to determine whether it is possible to predict tubal closure on the basis of tubal entry and distribution patterns. The results of these studies and their implications for contraceptive effectiveness of the FEMCEPT/MCA system will be reported.

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The authors describe a 5-year experience with 27 patients who had confirmed intrauterine scars at hysteroscopy, all of whom underwent resection of the scar. Of the 27, 14 became pregnant at least once, and 13 did not conceive. Hysteroscopic and hysterographic evidence of intrauterine scar was in general more severe in those who did not become pregnant. There were no cases of abdominal placentation in the 18 pregnancies after surgical repair, although there was 1 case of postpartum hemorrhage. Details of technique, including postoperative use of estrogen and the intrauterine device, are discussed.

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Four patients with symptomatic intrauterine retention of fetal bones are discussed. Presenting complaints included infertility, irregular vaginal bleeding, vaginitis, and spontaneous passage of fetal bones. Two patients had uterine anomalies; 1 patient had a retained twin pregnancy. Pelvic ultrasound and x-ray films of the pelvic cavity are helpful in making a diagnosis. Hysteroscopy is invaluable both in confirming the diagnosis and in achieving successful removal of fetal bone.

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PIP: The article reports on the results of 131 sterilizations by tubal occlusion obtained by injection of MAC (methylcyanoacrylate). The procedure is conducted by using a special device, called a Femcept. In the series presented here there were no complications and no side effects, and the obstruction of the tubes, tested by hysterosalpingography, was bilateral in 78% of cases. A second treatment with MAC can be done. This method does not involve surgery, anesthesia, or any specific experence or equipment; it is safe, quick, economic, and can be done on an outpatient basis.^ieng

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MCA is a tissue adhesive which can be delivered transcervically to the Fallopian tubes by means of the FEMCEPT device. In the patients treated with this system, both prior to hysterectomy and on an ambulatory basis, there have been no significant complications or side effects. In the most recent series of ambulatory patients treated with the REMCEPT-MCA system, the bilateral tubal closure rate was 78%.

PIP: Clinical trials of methylcyanoacrylate (MCA), a tissue adhesive injected to occlude fallopian tubes for tubal sterilization, were conducted in ambulatory patients and are presented. 3 small series of patients are described; most received .4-ml injections, but 23 of the 131 total subjects received .6-ml injections. Outcome was determined by hysterosalpingography. Bilateral closure rate after 1 treatment in series 1 (n=28) was 64%. In the 2nd series the bilateral closure rate was 54% after 1 injection; after a 2nd injection in the 2nd series, the rate was 78%, but overall the closure rate for this group after 2 injections was 65% (n=102). In the 3rd series, bilateral closure rate was 78% after 1 injection; this series used .6-ml injections and represents a dramatic improvement over the preceding series. Complications include pain at site of injection, mild to moderate cramping, and transient vagal reaction. The procedure takes 5 minutes or less. 2 uterine pregnancies have occurred to date, and no ectopic pregnancies were reported. MCA is a low-viscosity fluid in a monomeric form which rapidly polymerizes when placed in contact with body fluids.

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