Page 12 - EVALUATION OF TREATMENT FOR HEAVY MENSTRUAL BLEEDING by Herman, Malou

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College of Obstetrics and Gynaecology (RCOG).17,18 If these treatments fail, both guidelines prefer the use of the levonorgestrel-releasing intrauterine system (LNG- IUS) as the next therapeutic option. Nevertheless, endometrial ablation could also be considered and is already frequently used in daily practice. Both LNG-IUS and endometrial ablation are local solutions used to obstruct endometrium proliferation. Which of these two options is the most effective and which of these two options is preferred by women is yet unknown. Both questions should be evaluated.
LNG-IUS versus endometrial ablation
Intrauterine devices were initially introduced as contraceptives; however, since the addition of progestagen, these devices have also been used as treatment for HMB. The LNG-IUS can be applied easily by the general practitioner and is effective in reducing the amount of blood loss. Literature on the effectiveness of the LNG-IUS in HMB shows that it reduces menstrual blood loss by about 80-95%. For women who presented to primary care providers, the LNG-IUS was even more effective than usual medical treatment at reducing the effect of bleeding on quality of life. However, the LNG-IUS has considerable discontinuation rates – up to 38% within 2 years – due to side effects, such as irregular bleeding (spotting), pain, and/or systemic progestogenic side-effects.
As an alternative, endometrial ablation is also very effective at decreasing blood loss, with amenorrhea rates of up to 50% and satisfaction rates of about 90%. Endometrial ablation is performed by the gynaecologist in day-care or outpatient clinics with or without general anaesthesia. It is more invasive than the LNG-IUS because the aim of the procedure is to destroy or remove the endometrial tissue and, consequently this treatment is irreversible. Women need to know that it does not provide contraception and that it shows higher dysmenorrhoea rates.
The first-generation endometrial ablation techniques were performed with direct hysteroscopy vision. These techniques involved a long learning curve and involved the risk of absorption of the distension fluid (Glycine or Sorbitol), resulting in fluid overload, which can result in fatal hyponatremic encephalopathy. The second- generation techniques were developed to overcome these disadvantages and are now the safest and easiest techniques to perform.4 Frequently used second- generation techniques are bipolar radiofrequency energy (Novasure), high temperature fluids within a balloon (Thermachoice, Thermablate, Cavaterm) and free, high temperature fluid (Hydrothermablator). Many of these second- generation ablation techniques have been evaluated for their short-term effect,
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