Ambulatory management of heavy menstrual bleeding

Abstract

Heavy menstrual bleeding (HMB) has significant adverse effects on the quality of life of many women, placing an economic burden on both health services and society at large. Thus, it is essential that all women with HMB have easy access to the proper diagnostic and therapeutic work-up in an outpatient fashion, avoiding the more time-consuming inpatient management. This new outpatient approach for HMB is one of the latest development of gynecological practice and can offer both diagnostic and therapeutic procedures. This manuscript aims to show the current possibilities of the modern management of HMB, which can be safely and effectively accomplished in the outpatient setting: global and directed endometrial biopsy, levonorgestrel intrauterine system insertion as well as minimally invasive surgical procedures (encompassing a variety of operative hysteroscopic procedures and second-generation endometrial ablation) are described below.

Keywords: ambulatory setting; endometrial biopsy; heavy menstrual bleeding; levonorgestrel intrauterine system; office operative hysteroscopy; second-generation endometrial ablation.

Figure 1.

Technique of ‘grasp biopsy’. (A) The biopsy forceps are placed against theendometrium to be biopsed with the jaws open and then pushed into the tissue and along it for around 0.5–1 cm. (B) Once a large portion of mucosa has been detached, the two jaws are closed. (C) The whole hysteroscope is removed from the uterine cavity, without pulling the tip of the instrument back into the channel.

Figure 2.

Surgical ambulatory unit for hysteroscopy at the University ‘Federico II’ of Naples.

Figure 3.

Versapoint electrosurgical system (Gynecare, Ethicon Inc., NJ, USA). (A) Versapoint I (introduced in 1997); (B) Versapoint II (introduced in 2011).

Figure 4.

The VersaPoint system (Gynecare; Ethicon Inc., NJ, USA) also include three disposable co-axial bipolar electrodes designed to cut, desiccate (coagulate) and vaporize tissue: the Twizzle (on the top), specifically for precise and controlled vaporization (resembling cutting), the Spring (in the middle), used for diffuse tissue vaporization and the Ball, to coagulate tissues. The Twizzle electrode is preferred to the others because it is a more precise ‘cutting’ instrument and it can work closer to the myometrium with a lower power setting and consequently with less patient discomfort.

Figure 5.

Reusable 5 Fr bipolar electrode (Karl Storz, Tuttlingen, Germany) inserted into the operative channel of the Office-Continuous – Flow – Operative Hysteroscopes, “size 5” (Karl Storz, Tuttlingen, Germany).

Figure 6.

Slicing technique for endometrial polyps larger than internal uterine ostium. IUO: Internal uterine ostium.

Figure 7.

OPPIuM technique. (A) Incision of endometrial mucosa, which covers the fibroid by means of 5 Fr bipolar electrode. (B) Identification of the cleavage surface between the fibroid and pseudo capsule.