To the Editor:
I read with interest the study by Deb and colleagues who have surveyed UK gynecologists to determine their preferred method for performing endometrial ablation (EA) (1). Certainly there is value in determining the relative use of various EA techniques on a national level, remembering that the outcome will likely vary considerably among various countries and provider systems.
However, what I thought required comment is the use of the terms “first generation” and “second generation ablative methods” to describe resectoscopic (including hysteroscopic laser) and the collection of “newer” methods that employ hypothermic or hyperthermic energy in an attempt to destroy the endometrium. These “second generation” systems are sometimes called “global ablation” techniques, even though none has been demonstrated to even come close to consistently destroying the entire endometrium.
The concept of surgical destruction of the endometrial lining for the treatment of abnormal uterine bleeding (AUB) is not new – techniques that include those described as “second generation” by far predated resectoscopic or laser ablation in our literature. The first published report of endometrial ablation that I am aware of was by Fritsch who reported complications using steam endometrial ablation 1898 (2). The first published clinical series was that of Bardenheuer who in 1937 reported on the clinical results of a monopolar radiofrequency electrosurgical probe inserted blindly into the endometrial cavity (3). Hypothermic, or cryoablation was published in a number of series in the late 1960s and early 1970s by Cahan and Brocunier (4) and then and then Droegemueller (5,6). It was more than a decade until the introduction of endoscopically guided techniques for endometrial ablation, first using a hysteroscope to directed Neodymium:Yttrium Aluminum Garnet (Nd:YAG) laser energy to coagulate and vaporize the endometrium (7) and then the urological resectoscope to remove endometrial tissue with a radiofrequency (RF) electrosurgical loop electrode (8). It behooves us all to craft descriptions and classifications of procedures that respect the work of our predecessors and the legacy of our specialty, and to minimize the use marketing terms used to sell pharmaceutical agents and medical devices, particularly when they inaccurately depict our history.Malcolm G. Munro, MD
Departments of Obstetrics and Gynecology
Kaiser Permanente, Los Angeles Medical Center
University of California, Los Angeles
1. Deb S, Flora K, Atiomo W. A survey of preferences and practices of endometrial ablation/resection for menorrhagia in the United Kingdom. Fertil Steril 2008;90:1812-7.
2. Fritsch H. I. Uterusvapokauterisation, tod durch septische peritonitis nach spontaner sekundarer perforation. Centralblatt fur Gynakologie 1898;52:1409-18.
3. Bardenheuer F. Elektrokoagulation der Uterusschleimhaut zur Behandlungklimakterischer Blutungen. Zentralblatt fur Gynakologie 1937;4:209-11.
4. Cahan WG, Brockunier A, Jr. Cryosurgery of the uterine cavity. Am J Obstet Gynecol 1967;99:138-53.
5. Droegemueller W, Greer BE, Makowski EL. Preliminary observations of cryocoagulation of the endometrium. Am J Obstet Gynecol 1970;107:958-61.
6. Droegemueller W, Greer B, Makowski E. Cryosurgery in patients with dysfunctional uterine bleeding. Obstet Gynecol 1971;38:256-8.
7. Goldrath MH, Fuller TA, Segal S. Laser photovaporization of endometrium for the treatment of menorrhagia. Am J Obstet Gynecol 1981;140:14-9.
8. DeCherney AH, Diamond MP, Lavy G, Polan ML. Endometrial ablation for intractable uterine bleeding: hysteroscopic resection. Obstet Gynecol 1987;70:668-70.
Published online in Fertility and Sterility DOI: 10.1016/j.fertnstert.2009.01.095
The Authors Respond:
We acknowledge the comments made by Dr. Munro, especially regarding the use of terms ‘first generation’ and ‘second generation’ devices to describe the various methods of endometrial destruction in current use.
In our study, we used these terminologies in consistence with the widely read and accepted national evidence based clinical guidelines (NICE guidelines) in the U.K.(1, 2). These guidelines and various other studies have used the term ‘first generation’ endometrial ablative devices to include transcervical resection of endometrium, and rollerball endometrial ablation, and used the term ‘second generation’ devices to include microwave endometrial ablation, thermal balloon ablation, bipolar radiofrequency ablation, cryoablation, and hydrotherm ablation. (3, 4)
With great respect, we acknowledge the work of our predecessors and their legacy in our specialty, without which the current developments would not have reached to their present state.Shilpa Deb, M.B.B.S., M.R.C.O.G
Clinical Research Fellow in Reproductive Medicine
University of Nottingham
Queen’s Medical Centre
Nottingham, United Kingdom
1. National Evidence Based Clinical Guidelines. Heavy menstrual bleeding. Issue date: January 2007: Number 4. Available at http://guidance.nice.org.uk/CG44
2. Royal College of Obstetricians and Gynaecologists. National Evidence Based Guidelines. The management of menorrhagia in secondary care, vol.101. London: RCOG press, 1999:470-3
3. Lethaby A, Hickey M, Garry R. Endometrial destruction techniques for heavy menstrual bleeding. Cochrane Database Syst Rev 2005; CD001501
4. Garside R, Stein K, Wyatt K, Round A. Microwave and thermal balloon ablation for heavy menstrual bleeding: a systematic review. BJOG 2005; 112:12-23.
Published online in Fertility and Sterility DOI: 10.1016/j.fertnstert.2009.01.094