Asherman's syndrome

The article "Endometrial ablation as an alternative to hysterectomy" is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, education program professional, Center for Perioperative Education.

A minimum score of 70% on the multiple-choice examination is necessary to earn 3.5 contact hours for this independent study. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is Feb 28, 2006.

Send the completed application form, multiple-choice examination, learner evaluation, and appropriate fee to

or fax the information with a credit card number to (303) 750-3212.

BEHAVIORAL OBJECTIVES

After reading and studying the article on endometrial ablation, the nurse will be able to

(1) define menorrhagia,

(2) discuss the types of hormone therapy available to treat menorrhagia,

(3) identify the fluid medium of choice used during each of the endometrial ablation approaches, and

(4) describe the phases of care for a patient undergoing endometrial ablation.

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

Endometrial Ablation as an Alternative to Hysterectomy

In the United States, two million women consult their physicians regarding abnormal or excessive menstrual bleeding each year. (1) Of these, approximately 700,000 undergo hysterectomies for symptomatic menorrhagia. The term menorrhagia is defined as menstrual bleeding lasting longer than seven days or bleeding that occurs in an amount exceeding 80 mL during a menstrual cycle. It is a condition that can be life-altering for women experiencing symptoms (eg, fatigue, anemia). (2) Women with menorrhagia experience embarrassing accidents and limitations to their normal daily activities. Some must change protection nearly every hour during their menstrual cycle.

Although hysterectomy is the definitive treatment for menorrhagia, studies show that 35% to 50% of uterine specimens taken from women who underwent a hysterectomy demonstrate no histological abnormality. (3) Procedural costs, risks, and complications, in addition to the significant percentage of specimens showing no abnormality, suggest that the majority of hysterectomies performed for menorrhagia are unnecessary. (4) Data suggest that a less invasive procedure in which the endometrial lining is destroyed but the uterus is preserved would be beneficial to patients with menorrhagia. Endometrial ablation is an alternative to hysterectomy for women with menorrhagia.

A definitive diagnosis of menorrhagia may be difficult to attain, however, because of the subjectivity of a patient's symptoms. Perception of excessive menstrual bleeding can be affected by patient's cultural background, level of activity, sense of cleanliness, degree of menstrual symptoms, and mental status. (5) It has been suggested that menorrhagia may be a consequence of a modern woman's lifestyle. It is thought to have increased in frequency with shortened breast-feeding intervals, fewer pregnancies, higher frequency of permanent sterilization, and later age of conception. Organic diseases also may contribute to a diagnosis of menorrhagia, including

* carcinoma,

* endometrial polyps,

* infection,

* myoma, or

* systemic illness. (6)

TREATMENT OPTIONS

Treatment for menorrhagia may include hormone therapy, endometrial curettage, endometrial ablation, or hysterectomy. Hormone therapy generally is the first treatment option. Oral contraception or hormone replacement therapies to correct imbalances initially are selected in an effort to alleviate the condition.

Hormone therapy. Sixty-five percent of women treated with hormone therapy experience good results. High-dose estrogen can be used initially to treat women who are hemodynamically stable but experiencing significant uterine bleeding. The result is a rapid regrowth of the endometrium. The estrogen acts to increase fibrinogen and factors V and IX. It also promotes clotting and the aggregation of platelets at the capillary level; however, the risk of deep vein thrombosis with high-dose estrogen use exists. Low-dose estrogen or oral contraceptives are prescribed after uterine bleeding has been controlled, but patients often experience nausea and vomiting. The quantity of menstrual flow can decrease by 50% to 60% when oral contraceptives are used long term (Table 1). (7)

Progestin usually is initiated concurrently with estrogen and continued for five to 10 days to help regulate and prevent episodes of heavy bleeding. It sometimes is considered an antiestrogen because it helps stop endometrial growth by promoting support and reorganization of the endometrial lining. A natural sloughing of the tissue occurs when progestin is discontinued, although menstruation may be heavy. Long-term side effects of progestin use may include

* fatigue,

* lipid profile changes,

* mood changes, and

* weight gain.

Nonsteroidal anti-inflammatory drugs (NSAIDS). Many women experiencing excessive uterine bleeding exhibit higher endometrial levels of prostaglandin than women who have normal menstruation. Prostaglandin is a hormone-like compound produced by the body that evokes an array of physiological actions in the body, including peripheral vasodilation, which actually may accentuate menorrhagia. Antiprostaglandins and NSAIDS are effective in treating menorrhagia by inhibiting the production of prostaglandin. The use of antiprostaglandins or NSAIDS should begin on the first day of the menstrual cycle and continue to the third day of menses. Dosages vary with the type of medication used, such as

* ibuprofen 400 mg three times per day,

* mefenamic acid 500 mg three times per day,

* meclofenamate sodium 100 mg three times per day, or

* naproxen sodium 275 mg every six hours after a loading dose of 550 mg.

Women with existing ulcer or bronchospastic disease and those allergic to aspirin should not use nonsteroidal anti-inflammatory medications. (8) Antiprostaglandins are effective in 20% to 30% of women experiencing menorrhagia. (9)

Gonadotropin-releasing hormone (GnRN) agonists. Another class of medications often prescribed by physicians for menorrhagia is GnRN agonists. They induce a "medical menopause" and are effective for short-term use. Long-term use of GnRN agonists can result in hypoestrinism, leading to hot flashes and, eventually, osteoporosis. They are available in injectable, intranasal, or subcutaneous implant forms. Injectable forms are effective for one to three months. The intranasal form is the most cost-effective and has minimal side effects because of the short duration of action. This route is most effective for compliant patients. The subcutaneous implant absorbs into the tissue and is effective for one month.

Androgenic steroids. Danazol is an androgenic steroid that greatly reduces menstrual blood loss, but it is expensive and has significant side effects. The most common side effects of danazol are weight gain and acne. A deepening of the patient's voice, which may not be reversible, also has been reported. The usual dosage is 200 mg to 400 mg per day for 12 weeks. A significant advantage of danazol compared to GnRN agonists is that it does not cause bone loss.

Medication therapy is effective in approximately 50% of women seeking treatment. The physician and patient must consider the advantage of medication therapy and the risks or side effects inherent to the medication of choice. Alternative methods of treatment are suggested if the patient experiences undesired side effects or medication therapy is ineffective in achieving diminished menstrual flow. (10)

Endometrial curettage. Endometrial curettage may be used as a second-line treatment if pharmacological efforts have been ineffective. Curettage is beneficial both diagnostically and therapeutically. Women 35 years of age or older should have a sample of endometrial tissue taken to rule out pathological causes of menorrhagia. Potential causes for excessive uterine bleeding during menstruation or metrorrhagia (ie, intermenstrual bleeding) (11) may include hyperplasia or adenocarcinoma. (12) Curettage is a temporary solution for menorrhagia and is helpful in reducing the menstrual bleeding for several cycles. Statistically, endometrial curettage for menorrhagia has less than 15% long-term effectiveness. (13)

Hysterectomy. Hysterectomy is regarded as the definitive treatment for dysfunctional uterine bleeding; however, it is a major surgical procedure that exposes women to significant physical complications. An estimated 4.5% of all hysterectomies performed each year in the United States may be a result of dysfunctional uterine bleeding. Vaginal hysterectomy often is selected because its cost and morbidity and mortality rates are lower. Abdominal hysterectomy may be selected over the vaginal approach due to uterine size or previous abdominal surgery. Laparoscopically-assisted vaginal hysterectomy has increased in popularity, but studies indicate a higher overall cost compared to both the vaginal and abdominal approaches as a result of longer procedure times and use of expensive disposable instruments. (14) The decision to perform a hysterectomy should be based on measurable values. Surgical time, length of hospitalization, convalescence, and cost are just a few values that the physician and patient should take into account before making an informed decision. Alternatives to hysterectomy broaden the choices and help individualize treatment. (15)

ENDOMETRIAL ABLATION

Endometrial ablation is the first surgical advance in the treatment of menorrhagia since hysterectomy. Researchers became interested in ablation procedures as a treatment option by studying patients with Asherman's syndrome. (16) Asherman's syndrome is a condition that is very rare but develops as a result of dilation and curettage (D&C) or endometrial infection. As demonstrated in Asherman's syndrome, extensive curettage or endometrial infection can cause intrauterine adhesions to develop with resulting amenorrhea. (17) It was believed that patients with menorrhagia would benefit from the destruction of the endometrium to slow or stop menstrual flow. Different methods of treatment have been developed since the mid 1980s, the first of which was the use of the neodymium: yttrium-aluminum-garnet (Nd: YAG) laser. (18)

In recent years, endometrial ablation has become a well-established treatment for menorrhagia and an alternative to hysterectomy for some patients. It is defined as the removal or destruction of the endometrial lining of the uterus. Ablation provides the patient and physician with an additional treatment option. Women who are opposed to hysterectomy for personal reasons and those who have no other pathological reason to undergo hysterectomy might consider ablation rather than hysterectomy. Some insurance companies require patients with a primary diagnosis of menorrhagia to undergo endometrial ablation before granting them preapproval for hysterectomy. The procedure is performed most frequently in an outpatient surgery setting; however, some physicians have performed the procedure in an office setting. Anesthesia may be accomplished using a

* paracervical block with or without sedation,

* regional anesthesia, or

* general anesthesia. (19)

Patients may be discharged as early as four hours after the ablative procedure. Surgery-related time off from work is reduced dramatically compared to hysterectomy. Many endometrial ablation therapies have been and are being investigated. Examples of these therapies include

* electrosurgical vaporization,

* fluid-filled balloon thermotherapy,

* hydrothermal ablation therapy,

* laser vaporization,

* microwave and radio frequency,

* photodynamic therapy, and

* use of cryogenics.

The specific, endometrial ablation treatment modalities that are discussed in this article are

* fluid-filled balloon thermotherapy,

* electrosurgical vaporization, and

* hydrothermal ablation therapy.

Surgical candidate selection. Candidates for endometrial ablation are women who have a definitive diagnosis of menorrhagia uncontrolled by medication. They should have completed childbearing and show no evidence of any malignant or premalignant pathology. A curettage procedure may be needed to rule out any malignant or premalignant conditions. Women with known or suspected endometrial carcinoma or premalignant changes of the endometrium should not be considered for endometrial ablation. Hysteroscopy may be performed before ablation to determine whether any large endometrial fibroids or anomalies exist that would exclude the patient as a candidate or indicate that ablation would not be as effective as hysterectomy. Women who have large uterine fibroids or problems that would require a hysterectomy are not candidates for an ablation procedure. Additionally, bleeding disorders should be ruled out preoperatively.

Ablation is less invasive and expensive than hysterectomy. Current endometrial ablation techniques offer patients safe and effective methods to achieve complete cessation of menstruation (ie, amenorrhea) or a significant decrease in menstrual flow (ie, hypomenorrhea). Advantages of endometrial ablation compared to hysterectomy are that

* there is no surgical incision or organ removal;

* it is safe, costs less, and can be performed in an outpatient setting;

* the patient's hormone status is unaffected; and

* it allows the patient to return to normal activities within a day or two postoperatively versus four to six weeks posthysterectomy.

Effectiveness of specific treatments vary; however, most procedures are 60% to 90% effective in reducing menstrual bleeding to a normal level. (20) Amenorrhea is achieved in 15% to 50% of women who undergo endometrial ablation. (21)

Prescribing preoperative medication therapy four to six weeks before endometrial ablation thins the endometrium, which expedites the surgical procedure. (22) Prescribing danazol or a GnRH agonist is the recommended medication therapy.

FLUID-FILLED BALLOON THERMOTHERAPY

Uterine fluid-filled balloon thermotherapy is a type of ablation procedure during which a balloon is inserted through the cervix and into the intrauterine cavity. The apparatus consists of a hand piece with a flexible catheter and a control unit that monitors the ablation process. The single-use disposable catheter is 16 cm long and 4.5 mm in diameter with a silicone balloon located at the distal end. The thermal balloon system is connected to its control unit via an umbilical cord.

The surgeon checks the integrity of the balloon and primes the balloon catheter by instilling 15 mL to 20 mL of 5% dextrose in water ([D.sub.5]W) into the proximal end of the balloon catheter while pointing the balloon catheter tip downward. The surgeon depresses the trumpet valve to instill and remove the fluid and air from the balloon. A negative pressure of -150 mm Hg to -200 mm Hg is created to purge the air from the balloon system. The negative pressure should be maintained for at least 10 seconds before proceeding. (23)

After the patient is positioned and prepped and draped in the normal fashion, the surgeon dilates the cervix to 5 mm and measures the intrauterine cavity using a uterine sound. The surgeon performs curettage to remove thick endometrial tissue and enhance the contact between the endometrium and balloon. He or she also may perform hysteroscopy to diagnostically evaluate the uterine cavity. The scrub person lubricates the thermal balloon with [D.sub.5]W after which the surgeon slowly inserts the balloon catheter into the uterus until the tip of the balloon touches the uterine fundus. The surgeon determines the depth of insertion by locating the appropriate depth mark on the external surface of the catheter compared to the uterine sounding obtained previously.

The surgeon depresses the trumpet valve and gradually fills the balloon in the uterus with [D.sub.5]W until intrauterine wall pressure of 160 mm Hg to 180 mm Hg is achieved and then maintained. This pressure typically requires approximately 5 mL to 15 mL of solution, but it may require up to 30 mL depending on the size and relaxation of the uterine cavity. When the surgeon adds additional solution to the balloon, he or she depresses and then releases the trumpet valve to stabilize pressure. When a constant pressure of 160 mm Hg to 180 mm Hg is reached, the circulating nurse presses the start button on the control unit to activate the heater.

The control unit monitors the wall pressure as the heater allows the internal balloon solution to reach 87[degrees] C (187[degrees] F) for eight minutes. The warm fluid within the balloon maintains contact with the endometrium for a preset time of eight minutes. Circulating fluid inside the balloon causes thermal injury to the endometrial tissue (Figure 1). The control unit is designed with safeguards to prevent patient injury. For instance, the thermal treatment will self-terminate if the pressure within the cavity drops below 45 mm Hg or elevates to more than 210 mm Hg.

[FIGURE 1 OMITTED]

After the treatment phase, the surgeon waits 30 seconds for the fluid to cool and then removes the fluid by depressing the trumpet valve and withdrawing the fluid. He or she removes the balloon catheter, and the procedure is completed. (24)

Patients usually are discharged within four hours after the procedure. The procedure is effective in reducing menstrual flow and alleviating preoperative menorrhagia. Studies indicate that 87% of patients achieve surgical success and that amenorrhea is achieved in 13.3% to 15% of patients. (25)

Contraindications. Thermal balloon therapy is contraindicated in patients with a submucosal myoma or bicornate or septate uterus. Verification of proper balloon placement is difficult if the uterus has an atypical shape; however, the balloon is very thin and pliable, generally allowing it to conform to a variety of intrauterine wall shapes. (26) Poor contact with the entire endometrial lining may precipitate nontreatment of certain areas within the uterus. (27) Women who have had previous endometrial resection or ablations should be evaluated fully before balloon therapy is chosen.

Complications. The thermal balloon procedure is performed without direct visualization, and no additional skills or training are required of the surgeon performing the procedure. Caution should be used if there is any indication that the uterus has been perforated during preoperative sounding or when inserting the balloon catheter. Fluid-filled balloon thermotherapy should be abandoned if a uterine perforation is suspected because the pressure exerted on the uterine wall would further injure the uterus and possibly injure adjacent structures. (28) Complications from the procedure are rare; however, there are reports of postoperative cramping lasting 24 hours. Endometritis is rare but also has been reported.

ELECTROSURGICAL VAPORIZATION

Electrosurgical vaporization of the endometrium using a roller ball, roller barrel, or wire loop electrodes is a skill-based hysteroscopic resection technique (Figure 2). Electrosurgical vaporization procedures were performed first in the 1980s and replaced the Nd: YAG laser primarily because of procedural costs. (29) The surgeon is able to view the endometrial lining during the entire procedure using a nonconductive, nonphysiological fluid medium, such as sorbitol or glycine, that is placed in a pressure bag to expand the uterus for global visualization of the intrauterine cavity.

[FIGURE 2 OMITTED]

The circulating nurse and scrub person place the D&C set and hysteroscopic resectiscope instruments on the sterile back table. A selection of resectiscope loops, roller balls, and roller barrels are available, depending on surgeon preference. The circulating nurse suspends a 3,000 mL bag of nonphysiological solution from a holder in a pressure bag.

After the patient is positioned and prepped, the surgeon and scrub person drape the patient in the normal fashion and include a fluid pouch or collection reservoir for fluid measurement. The single most important nursing activity during the procedure is fluid management and maintaining an accurate count of input and output of fluid. (30) Excessive distention pressures exceeding 200 mm Hg and flow rates exceeding 150 mL per L may precipitate intravasation. Metabolic changes, embolization, and death also are complications of excessive pressures used during hysteroscopy. It is important, therefore, that the circulating nurse remain vigilant in maintaining the continuous flow irrigation during the procedure. Bubbles in the inflow tubing or bubbles created as gaseous by-products of the procedure contribute to the risk of air embolization. Flushing the tubing before use and the careful handling of fluid bags during changes helps minimize this risk.

The surgeon uses a monopolar resectoscopic system to shave or vaporize the endometrial tissue 3 mm to 4 mm in depth. Endometrial shavings then are removed through the cervix. Tissue vaporized by a roller ball or roller barrel sloughs off naturally via the cervix and vagina. Use of the roller ball or roller barrel is considered safer than using a wire loop. (31)

Bipolar electrosurgical vaporization also is available for use in hysteroscopic procedures. Saline is used to expand and fill the uterine cavity in lieu of nonphysiological sorbitol or glycine. This technology most often is used to remove submucous fibroids, polyps, adhesions, and intrauterine septa, but it also can be used for ablation procedures according to manufacturers' literature. (32)

Five-year follow-up studies indicate that 90% of women undergoing endometrial resection for menorrhagia averted the need for hysterectomy. Electrosurgical vaporization success rates are as high as 90%. The rate of amenorrhea is approximately 23% to 50% after two years and 34% five years later. (33)

Complications. Each member of the surgical team plays a vital role in the management and prevention of hysteroscopic complications. All surgical team members must be prepared to recognize and respond to suspected complications during any hysteroscopic procedures in an efficient manner. The surgeon should be experienced in the use of the hysteroscopic instrumentation and principles of fluid management and have knowledge of electrosurgery and techniques to control bleeding. The circulating nurse and anesthesia care provider must understand the principles of fluid management and remain alert to potential hemodynamic complications. The scrub person is responsible for ensuring the proper assembly and functioning of all instruments.

The four major complications of any hysteroscopic resection procedure, such as electrosurgical vaporization, are intravasation, uterine perforation, hemorrhage, and infection. Intravasation occurs when hypotonic fluid is absorbed into the body's vascular system through opened vascular channels because intrauterine pressure exceeds the patient's mean arterial pressure. The rate of absorption of hypotonic solutions, such as sorbitol and glycine, increases with time and exposure. Large amounts of fluid that is unaccounted for can lead to fluid overload, hyponatremia, and encephalopathy. The circulating nurse and anesthesia care provider must take extreme care to monitor fluid input and output. Any significant discrepancy in fluid volumes may be the first indication that excessive intravasation has occurred. In this event, the patient's serum sodium level should be measured immediately. (34)

Practitioner technique and differences in uterine tissue thickness can result in uterine perforation during endometrial resection. Uterine perforation can result in burns to the bowel. Burns to the patient's cervix, vagina, or vulva during resectoscopic procedures can occur, although this is infrequent. (35)

Other potential complications of hysteroscopic resection procedures are hypokalemia, cerebral edema, pulmonary edema, and hypothermia. (36) The presence of gas bubbles is an inherent by-product of electrosurgical procedures performed in liquid. The presence of these bubbles can cause air emboli, although this rarely occurs. A continuous-flow fluid management system is crucial in preventing the accumulation of bubbles, which requires the surgeon to remove them from the intrauterine cavity during resection. (37)

With newer and safer techniques available, hysteroscopic resection procedures for endometrial ablation are being performed less frequently. Additionally, roller ball or roller barrel electrodes are selected rather than wire loops to reduce the potential for complications.

HYDROTHERMAL ABLATION THERAPY

The US Food and Drug Administration approved hydrothermal ablation in April 2002 as a therapy for endometrial ablation. Hydrothermal ablation is performed under direct visualization using warmed physiological saline in the uterine cavity. The saline is instilled and circulated using a small hysteroscope and a delivery system. A closed system control unit with a microprocessor controls the installation of the saline, fluid temperature, and therapy time. (Figure 3).

[FIGURE 3 OMITTED]

The circulating nurse suspends a 3,000-mL bag of saline on the IV pole provided on the control unit. The delivery system consists of an unsterile fluid-management reservoir and a sterile procedure kit consisting of a heater canister, cassette assembly, fluid tubing, and a disposable sheath that connects to the hysteroscope (Figure 4). The procedure kit is a single-use item; however, the heater canister can be steam sterilized 10 times. The heater canister can be prepackaged and steam sterilized in the sterile processing department or sterilized at the time of surgery at 143[degrees] C (270[degrees] F) for 10 minutes. The canister should be allowed to cool before assembly for the procedure. At Mt Carmel St Ann's Hospital, Westerville, Ohio, the number of uses for each canister is monitored by marking the outer canister with a permanent marker after each procedure. This has proven to be an effective tracking method and has allowed enough time to order replacement canisters.

[FIGURE 4 OMITTED]

The control unit's microprocessor checks all components for leakage and also provides a series of instructions displayed on the monitor screen for setting up the delivery system. The microprocessor also monitors fluid loss and alerts the operator if a loss of 10 mL is detected at any time during the setup or ablation procedure. The control unit allows the delivery system to be checked and prepared for use before the patient is admitted to the room. The microprocessor unit uses room temperature saline to purge air from the delivery system.

The circulating nurse opens the disposable procedure kit supplied by the manufacturer and passes it to the scrub nurse. The scrub nurse assembles the hysteroscope and sheath and passes the remaining disposable supplies to the circulating nurse to begin the unit procedure setup.

A routine D&C procedure bed is recommended for the hydrothermal ablation treatment. After the patient is positioned, the surgeon dilates the patient's cervix to 8 mm, which allows the surgeon to insert the hysteroscope with the specially designed insulated sleeve. Cervical dilation should be limited to 8 mm; therefore, the scrub person places the larger dilators in a less accessible area on the sterile table. If the patient has been pretreated with hormone therapy, the surgeon may not perform endometrial curettage.

The surgeon performs a direct hysteroscopic examination to observe for pathology that may have been missed during the patient's pretreatment screening. Distension of the uterus is achieved using room temperature saline. Loss of fluid through the fallopian tubes is not an issue because the hydrothermal ablation system does not use a fluid pump but rather uses a gravitation system for fluid instillation. The intrauterine pressure never exceeds 55 mm Hg; which is well below the pressure of 70 mm Hg to 75 mm Hg required to open the fallopian tubes. (38) This is an important feature of the system, because it would be undesirable and dangerous to leak superheated fluid into the patient's peritoneal cavity.

The circulating nurse assists the surgeon during the procedure by operating the hydrothermal ablation unit and observing the ablation process. After the surgeon completes the hysteroscopy, he or she withdraws the sheath back to the level of the internal os of the cervix so that the ablation treatment area remains in the uterine cavity and does not extend into the cervix (Figure 5). The surgeon views the vaginal, vault to observe for leakage of fluid from the cervix during the ablation procedure to protect the patient from potential vaginal burns. One or two tenaculums may be needed to ensure a tight cervical seal so that fluid does not leak through the cervical opening. (39) The surgeon directs the system to start the fluid warming cycle. When the fluid reaches 90[degrees] C (194[degrees] F), the microprocessor is triggered to begin the 10-minute ablation cycle, during which the surgeon directly observes endometrial tissue destruction. Studies indicate that uniform endomyometrial necrosis occurs to a depth of 2 mm to 4 mm by the end of the 10-minute treatment. To conclude the treatment cycle, the control unit initiates a one-minute cooling cycle to ensure that the superheated saline has cleared the delivery system tubing before removal of the telescopic sheath from the cervix.

[FIGURE 5 OMITTED]

Studies indicate that hydrothermal ablation therapy is effective in the overall reduction of bleeding in 92.4% of women who receive this treatment. Amenorrhea is achieved in 26% to 40% of women treated. (40) Figures 6 and 7 show a hysteroscopic comparison view of the endometrium before and after the procedure. The endometrial tissue appears white hysteroscopically.

[FIGURE 6-7 OMITTED]

Complications The advantages of using the hydrothermal ablation system for endometrial ablation is that direct visualization is possible during the procedure. Complications associated with nonelectrolyte solution absorption are not an issue. The use of saline as the contact medium in the uterine wall ensures that all areas in the cavity are treated globally regardless of irregular uterine shape or the presence of endometrial polyps. Vaginal burns resulting from fluid leaking from the cervix during the treatment phase is one potential complication that could occur during hydrothermal ablation.

PHASES OF CARE

Although there are several methods of performing endometrial ablation, the patient's perioperative care remains basically the same. Following is a general description of the perioperative course a patient can expect to follow.

Preoperative phase. Preoperative preparation of the patient is geared toward the patient's individual health needs and depends on her medical health and laboratory data. Thermal ablation procedures can be performed in an office setting; however, the majority of these procedures are done in an outpatient surgery center or hospital because of the need for accurate monitoring of fluid absorption and observation for potential complications. At Mt Carmel St Ann's Hospital, the surgeon explains the risks, complications, and expectations to the patient during a preoperative office visit and obtains verbal consent to perform the procedure. The patient, however, signs the actual informed consent form the day of surgery. The surgeon may obtain a history and perform a physical examination of the patient during the preoperative office visit and then deliver it to the preoperative area on the day of surgery. The surgeon also may choose to obtain the history and perform the physical examination the morning of surgery.

The morning of surgery after the patient is admitted to the preoperative area, the preoperative nurse uses time in the preoperative area to measure and record the patient's blood pressure, pulse, respirations, temperature, height, and weight. The preoperative nurse questions the patient about her NPO status, allergies, previous surgeries, medical health history, and the presence of physical limitations. Although time is limited in the preoperative area, the nurse takes this opportunity to assess the patient's understanding of the procedure, answer questions, and calm fears. The preoperative nurse teaches the patient what to expect in the preoperative and post-operative areas. Most often, patients are optimistic about the surgical outcome and an improved quality of life. The nurse advises the patient about potential postoperative uterine discomfort, methods of rating pain, and medications available for alleviating discomfort. The patient is encouraged to empty her bladder before entering the OR to avoid unnecessary catheterization.

The nurse may draw blood for a pregnancy test the morning of surgery. If the patient is undergoing electrosurgical vaporization, the nurse also draws blood so that an electrolyte panel can be performed. An electrolyte panel is not necessary for balloon or hydrothermal ablation.

The circulating nurse visits the patient in the pre-operative area to provide continuity between the pre-operative and intraoperative patient care areas. This provides the opportunity for introductions and questions and allows the circulating nurse to review the patient's medical record because information obtained in the preoperative area may affect care provided in the OR. After assessing the patient, the circulating nurse prepares a nursing care plan specific to this patient (Table 2). The anesthesia care provider also interviews the patient and discusses her desires for sedation, analgesia, or anesthesia.

Preparation for surgery. The perioperative nurse must expand his or her expertise constantly to deal with newer technologies. Older technologies available at many institutions are being used less frequently as state-of-the-art technologies are being purchased. Although similarities exist between all ablation modalities discussed in this article, fluid-filled balloon thermotherapy, electrosurgical vaporization, and hydrothermal ablation techniques will be discussed individually in regard to OR preparation.

The circulating nurse configures the OR bed to accommodate either candy-cane shaped or boot-type stirrups for the lithotomy position. The surgeon's preference and the patient's medical history will determine which type of stirrup is used. Arm boards should be available for arm support. (41) The circulating nurse increases the temperature in the OR for patient comfort, if necessary.

The scrub person begins setting up the sterile D&C instruments. Additional instruments to be set up depend on the type of ablation technique being used. The circulating nurse ensures that the appropriate surgical unit and solutions are available in the room. For fluid-filled balloon thermotherapy and electrosurgical vaporization procedures, the circulating nurse and scrub person add

* hysteroscopic instrumentation,

* a video monitor,

* the camera,

* [D.sub.5]W, and

* the balloon for balloon therapy procedures.

For electrosurgical vaporization, the circulating nurse ensures that

* saline is hung on an IV pole for pretherapy hysteroscopic examination;

* the electrosurgical unit (ESU), disposable resector loop, and roller ball or barrel are present;

* a nonconductive, nonphysiological solution (eg, sorbitol, glycine) is used with a pressure bag when using resectoscopic vaporization ablation techniques; and

* drapes designed for measuring drainage to accurately calculate intake and output of fluid are available.

For the hydrothermal ablation approach, the circulating nurse and scrub person add

* a small 2.7-mm to 2.9-mm hysteroscope with a disposable sheath,

* a camera with a light cord,

* a monitor,

* the procedure kit, and

* the reusable heater canister.

Additional hysteroscopic instrumentation is not required for the hydrothermal ablation approach unless specified by the surgeon. The system undergoes a computerized system check, and the circulating nurse prepares the device before the patient enters the OR, which saves time and is more cost effective for the patient. The microprocessor unit provides the circulating nurse with a series of messages displayed on the monitor directing the operator regarding the sequential setup of the hydrothermal components. The time required to set up the components is approximately six to 10 minutes.

Intraoperative phase. The circulating nurse and anesthesia care provider assist the patient onto the OR bed. The patient assumes a supine position with good body alignment on the OR bed. The circulating nurse places warm blankets on the patient for comfort and a safety strap approximately 2 inches above the patient's knees. The anesthesia care provider extends the patient's arms to the side on padded arm boards and secures them in a less than 90-degree angle with palms up to protect the ulnar nerve. (42) The circulating nurse remains at the patient's side to assist the anesthesia care provider with application of monitoring devices and induction of anesthesia. General anesthesia frequently is the anesthesia of choice for this procedure. When the patient reaches the desired level of anesthesia with airway management complete, the circulating nurse and an assistant simultaneously raise the patient's legs to the lithotomy position and secure them in the selected stirrups. (43) The nurse places the ESU dispersive pad on an area of large muscle mass. The circulating nurse cleanses the patient's skin using a prep solution that does not contain alcohol. Povidone-iodine is a solution commonly used if the patient is not allergic to iodine. The nurse then dries excess prep solution from the vaginal vault. (44) The surgeon and scrub person drape the patient following sterile procedure.

After the selected treatment is complete, the surgeon and scrub person wipe the patient's skin clean of the prep solution. Then the surgeon and circulating nurse simultaneously lower the patient's legs slowly and place a perineal pad between the patient's legs for drainage. The circulating nurse removes the ESU dispersive pad and checks the area for redness. The patient may be awake enough to move herself to the stretcher. If not, surgical team members move the patient using a transfer device. The circulating nurse and anesthesia care provider transport the patient to the postanesthesia care unit (PACU) where the circulating nurse gives report to the PACU nurse.

Postoperative care. The postoperative plan for the patient undergoing endometrial ablation is similar to that of a patient having a D&C procedure. The PACU nurse obtains the patient's electroencephalogram baseline vital signs. He or she monitors the patient's vital signs and perineal pad at regular intervals. The patient may experience minor postoperative discomfort and uterine cramping, which usually is controlled by IV or intramuscular pain medication in the PACU.

Discharge teaching and instructions are given to the patient and her family members before leaving the facility. Common postoperative side effects of endometrial ablation include cramping, vaginal discharge, and nausea. The vaginal discharge may consist of a small amount of thin, watery discharge mixed with blood. The patient may experience a pinkish discharge for two to three days, which gradually turns clear and watery in appearance lasting from two to 10 days. Uterine cramping may persist for 24 to 72 hours postoperatively. (45) The patient should be able to return to work or her normal activities within a day or two, depending on the type of work. The nurse reminds the patient that a yearly Pap smear and gynecological visit still are needed.

CONCLUSION

Endometrial ablation is a procedure that offers an effective surgical treatment option for women with menorrhagia who want to avoid hysterectomy. Many different treatment modalities currently exist, and researchers continue to explore newer and safer methods. Surgeons choose procedure options that offer patients choices customized to their medical needs and lifestyle. The potential risks and complications also are a major consideration in the treatment plans considered. Women undergoing an endometrial ablation procedure statistically report a satisfaction rate of 80% or higher one year after the procedure for all of the modalities described in this article. (46) Success is defined as the absence of menorrhagia. Amenorrhea rates vary considerably between the treatment options. In one study, two- and three-year follow-up data show that fluid-filled balloon thermotherapy achieves an amenorrhea rate of 13.3% to 31%, depending on the product used. (47) Electrosurgical vaporization using a roller ball achieved a rate of amenorrhea at 34.8% five years after treatment. Approximately 79% to 87% of patients were satisfied with the results of their surgery. Further procedures, such as hysterectomy, were averted in 80% of the women after a five-year follow-up. (48) Hydrothermal ablation therapy is the newest technology and, therefore, lacks long-term follow-up studies documenting success rates. Preliminary reports suggest a success rate similar to vaporization studies. Twelve month postoperative studies for the hydrothermal ablation therapy indicate that patients achieved an amenorrhea rate of 40%. Patient satisfaction and reduction of menstrual flow was achieved in 77% to 82% of patients. (49)

Knowledge of the procedure and equipment needed to accomplish the desired patient outcome often rests on the shoulders of perioperative nurses. The ability to solve problems based on knowledge is a skill that perioperative nurses possess.

Examination

ENDOMETRIAL ABLATION AS AN ALTERNATIVE TO HYSTERECTOMY

1. The term menorrhagia is defined as

a. menstrual bleeding lasting longer than seven days.

b. painful menstruation.

c. abnormal bleeding between menstrual periods.

d. temporary cessation of menstruation.

2. Treatment for menorrhagia would not include

a. endometrial ablation.

b. endometrial curettage.

c. hormonal therapy.

d. tubal ligation.

3. Long-term use of androgenic steroids, such as danazol, can result in

a. irreversible deepening of the patient's voice.

b. increased thrombotic activity.

c. lipid profile changes.

d. hypoestrinism.

4. Endometrial ablation is a surgical procedure that

a. can be used as a treatment for endometrial cancer or hyperplasia.

b. cauterizes endometrial fibroids.

c. removes or destroys the endometrial lining of the uterus.

d. cures endometriosis.

5. Uterine fluid-filled balloon thermotherapy is a procedure that causes thermal injury to the endometrium when--is circulated in a balloon catheter placed in the uterine cavity.

a. warm sorbitol

b. superheated air

c. warm 5% dextrose in water

d. superheated carbon dioxide

6. Sorbitol or glycine are the fluid mediums of choice when using this ablation method.

a. fluid-filled balloon thermotherapy

b. hydrothermal ablation therapy

c. microwave and radio frequency vaporization

d. monopolar electrosurgical vaporization

7. Saline is the fluid medium of choice for this ablation method.

a. fluid-filled balloon thermotherapy

b. hydrothermal ablation therapy

c. microwave and radio frequency vaporization

d. monopolar electrosurgical vaporization

8. Loss of fluid through the fallopian tubes is not an issue during hydrothermal ablation therapy because a gravitation system is used for fluid instillation rather than a fluid pump.

a. true

b. false

9. Which of the following nursing diagnoses is specific to a patient undergoing endometrial ablation?

a. risk for aspiration related to intraoperative positioning

b. risk for acute pain related to tissue trauma secondary to the surgical procedure

c. knowledge deficit regarding home care related to unfamiliarity with information

d. risk for fluid volume imbalance related to intravasation of hypotonic fluids and potential blood loss

10. The patient no longer is required to have an annual Pap smear after having undergone endometrial ablation.

a. true

b. false

AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. AORN recognizes those activities as continuing education for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019.

Answer Sheet

ENDOMETRIAL ABLATION AS AN ALTERNATIVE TO HYSTERECTOMY

Please fill out the application and answer form on this page and the evaluation form on the back of this page. Tear the page out of the Journal or make photocopies and mail to:

or fax with credit card information to (303) 750-3212.

A score of 70% correct on the examination is required for credit. Additionally, please verify by signature that you have reviewed the objectives and read the article, or you will not receive credit.

Signature --

Event #03048 Session #7231

Contact hours: 3.5

Fee: Members $17.50; Nonmembers $35

Program offered February 2003. The deadline for this program is Feb 28, 2006.

1. Record your AORN member identification number in the appropriate section below (see your member card).

2. Completely darken the spaces that indicate your answers to examination questions one through 10. Use blue or black ink only.

3. Our accrediting body requires that we verify the amount of time you required to complete this 3.5 contact hour (175 minute) program.--

4. Enclose fee if information is mailed.

Learner Evaluation

ENDOMETRIAL ABLATION AS ALTERNATIVE TO HYSTERECTOMY

The following evaluation is used to determine the extent to which this Home Study Program met your learning needs. Rate the following items on a scale of 1 to 5.

OBJECTIVES

To what extent were the following objectives of this Home Study Program achieved?

(1) Define menorrhagia.

(2) Discuss the types of hormone therapy available to treat menorrhagia.

(3) Identify the fluid medium of choice used during each of the endometrial ablation approaches.

(4) Describe the phases of care for a patient undergoing endometrial ablation.

PURPOSE/GOAL

To educate the perioperative nurse about endometrial ablation as an alternative to hysterectomy.

CONTENT

(5) Did this article increase your knowledge of the subject matter?

(6) Was the content clear and organized?

(7) Did this article facilitate learning?

(8) Were your individual objectives met?

(9) How well did the objectives relate to the overall purpose/goal?

TEST QUESTIONS/ANSWERS

(10) Were they reflective of the content?

(11) Were they easy to understand?

(12) Did they address important points?

LEARNER INPUT

(13) Will you be able to use the information from this Home Study in your work setting?

a. yes b. no

(14) I learned of this Home Study via

a. the Journal I receive as an AORN member.

b. the Journal that I obtained elsewhere.

c. the AORN web site.

d. SSM Online.

(15) What factor most affects whether you take an AORN Journal Home Study?

a. need for contact hours

b. price

c. subject matter relevant to current position

d. number of contact hours offered

What other topics would you like to see addressed in a future Home Study Program? Would you be interested or do you know someone who would be interested in writing an article on this topic?

Topic(s): --

Author name(s) and address(es): --

NOTES

(1.) D Westcott, "Endometrial ablation," Just the Berries for Family Physicians, http://www.theberries.ns.ca (accessed 19 Nov 2002).

(2.) M P Vessey et al, "The epidemiology of hysterectomy: Findings in a large cohort study," British Journal of Obstetrics and Gynaecology 99 (May 1992) 402-407.

(3.) J M Cooper, M L Erickson, "Global endometrial ablation technologies," Obstetrics and Gynecology Clinics of North America 27 (June 2000) 385-396.

(4.) B H Chen, L C Giudice, "Dysfunctional uterine bleeding," The Western Journal of Medicine 169 (November 1998) 280.

(5.) C Barrow, "Balloon endometrial ablation as a safe alternative to hysterectomy," AORN Journal 70 (July 1999) 80.

(6.) Chen, Giudice, "Dysfunctional uterine bleeding," 280-284.

(7.) M Curtis, M Hopkins, eds, Glass's Office Gynecology, fifth ed (Baltimore: Williams & Wilkins, 1999) 253-254.

(8.) Ibid, 255-256.

(9.) Chen, Giudice, "Dysfunctional uterine bleeding," 280-284.

(10.) Curtis, Hopkins, eds, Glass's Office Gynecology, fifth ed, 255-256.

(11.) A H DeCherney, M L Pernoll, Current Obstetric and Gynecologic Diagnosis and Treatment, eighth ed (Eagleswood Cliffs, NJ: Prentice Hall, 1994) 665.

(12.) L J Copeland, J F Janell, eds, "Dysfunctional uterine bleeding," in Textbook of Gynecology, second ed (Philadelphia: Saunders Company, 2000) 539.

(13.) "Novasure product information," Novasure, http://www.novacept.com/index_physicians.html (accessed 11 Nov 2002).

(14.) Chen, Giudice, "Dysfunctional uterine bleeding," 280-284.

(15.) G A Vilos, J T Pispidikis, C K Botz, "Economic evaluation of hysteroscopic endometrial ablation versus vaginal hysterectomy for menorrhagia," Obstetrical Gynecology 88 (August 1996) 241.

(16.) Westcott, "Endometrial ablation."

(17.) W A Newman Dorland, "Asherman's syndrome," in Dorland's Illustrated Medical Dictionary, 29th ed (Philadelphia: W B Saunders Co, 2000) 1749; S I Magalini, S C Magalini, "Asherman syndrome," in Dictionary of Medical Syndromes, fourth ed (Philadelphia: Lippincott-Raven, 1997) 58.

(18.) A Lethaby et al, "Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding," Cochran Database of Systematic Reviews (Oxford: Update Software, 2000) 3.

(19.) S L Corson, "A multicenter evaluation of endometrial ablation by hydrothermablator and rollerball for treatment of menorrhagia," The Journal of the American Association of Gynecologic Laparoscopists 8 (August 2001) 361.

(20.) Chen, Giudice, "Dysfunctional uterine bleeding," 283.

(21.) R Hart, A Magos, "Endometrial ablation," Obstetrics and Gynecology 9 (August 1997) 226.

(22.) American College of Obstetricians and Gynecologists, Dysfunctional Uterine Bleeding (ACOG Technical Bulletin No 134) (Washington: American College of Obstetricians and Gynecologists, 1989.)

(23.) K Buckshee, K Banerjee, H Bhatla, "Uterine balloon therapy to treat menorrhagia," International Journal of Gynaecology and Obstetrics 63 (November 1998) 140.

(24.) National Women's Health Resource Center, Inc, "Ask the expert: Endometriosis," National Women's Health Report 20 (June 1998) 4; G A Vilos et al, "Endometrial ablation with thermal balloon for treatment of menorrhagia," The Journal of the American Association of Gynecologic Laparoscopists 3 (May 1996) 384.

(25.) "Endometrial ablation and the BEI Medical Systems hydrothermablator," MTG Newsletter, Peer Review Network, Inc 8 (May 2001) 3-4.

(26.) Ethicon/Johnson and Johnson, "Thermachoice II uterine balloon therapy," UBT System Operating Manual (Menlo Park, Calif: Ethicon, 1999) 6-11.

(27.) F D Loffer, "Three-year comparison of thermal balloon and rollerball ablation in treatment of menorrhagia," The Journal of the American Association of Gynecologic Laparoscopists 8 (February 2001) 48-54.

(28.) Hart, Magos, "Endometrial ablation," 227

(29.) G Brooks, "Resectoscopic endometrial ablation: The resection technique," Johnson & Johnson, http://www.moise.co.kr/eng/hysteroscopic3.htm (accessed 19 Nov 2002).

(30.) J A Davis, C D Miller, "Fluid infusion during hysteroscopic surgery," Versapoint Resectoscopic System (London: Ethicon, 1999).

(31.) D Morrison, "Management of hysteroscopic surgery complications," AORN Journal 69 (January 1999) 206.

(32.) G Vilos et al, "Genital tract electrical burns during hysteroscopic endometrial ablation: Report of 13 cases in the United States and Canada," The Journal of the American Association of Gynecologic Laparoscopists 8 (February 2000) 141.

(33.) Davis, Miller, "Fluid infusion during hysteroscopic surgery."

(34.) Ibid.

(35.) D A Grainger, B L Tjaden, "Thermal balloon and rollerball ablation to treat menorrhagia: Two-year results of a multicenter prospective randomized clinical trial," The Journal of the American Association of Gynecologic Laparoscopists 7 (May 2000) 178-179.

(36.) H O'Connor, A Magos, "Endometrial resection for the treatment of menorrhagia," The New England Journal of Medicine 18 (July 1996) 151.

(37.) J M Cooper, M L Erickson, "Global endometrial ablation technologies," Obstetrics and Gynecology Clinics of North America 27 (June 2000) 388.

(38.) M H Goldrath, M Barrionuevo, M Husain, "Endometrial ablation by hysteroscopic instillation of hot saline solution," The Journal of the American Association of Gynecologic Laparoscopists 4 (February 1997) 235-240.

(39.) Connor, Magos, "Endometrial resection for the treatment of menorrhagia," 151; "Endometrial ablation and the BEI Medical Systems hydrothermablator," 7.

(40.) D R McEwen, "Intraoperative positioning of surgical patients," AORN Journal 63 (June 1996) 1072.

(41.) Ibid.

(42.) "Recommended practices for positioning the patient in the perioperative practice setting," in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2002) 299-304.

(43.) Ethicon/Johnson and Johnson, "Thermachoice II uterine balloon therapy," 9-10.

(44.) B Hutchisson, M G Baird, S Wagner, "Electrosurgical safety," AORN Journal 68 (November 1998) 834.

(45.) Morrison, "Management of hysteroscopic surgery complications," 197.

(46.) Buckshee, Banerjee, Bhatla, "Uterine balloon therapy to treat menorrhagia," 142.

(47.) Corson, "A multicenter evaluation of endometrial ablation by hydrothermablator and rollerball for treatment of menorrhagia," 361; Cooper, Erickson, "Global endometrial ablation technologies," 387.

(48.) Connor, Magos, "Endometrial resection for the treatment of menorrhagia," 151; "Endometrial ablation and the BEI Medical Systems hydrothermablator," 15.

(49.) Corson, "A multicenter evaluation of endometrial ablation by hydrothermablator and rollerball for treatment of menorrhagia," 361; Cooper, Erickson, "Global endometrial ablation technologies," 361; "Endometrial ablation and the BEI Medical Systems hydrothermablator," 3-4.

Diane D. League, RN, CNOR, CRNFA, is the clinical nurse specialist at Mt Carmel St Ann's Hospital, Westerville, Ohio.

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