Hugo Verhoeven, MD: "My name is Hugo Verhoeven and I'm from the Center for Reproductive Medicine in Dusseldorf, Germany. I'm on the Editorial Board for OBGYN.net, and I'm reporting from the 30th meeting of the AAGL in San Francisco, California. I'm sitting today with Phil Brooks who is an Associate Professor at UCLA."
Philip Brooks, MD: "Actually, Clinical Professor."
Hugo Verhoeven, MD: "A Clinical Professor, and he's the past president of the American Association for Gynecological Laparoscopists. You are now in private practice also?"
Philip Brooks, MD: "Right, I'm in private practice."
Hugo Verhoeven, MD: "And the most important thing, Phil, is we've known each other for I think twenty years."
Philip Brooks, MD: "More, I think."
Hugo Verhoeven, MD: "You're a good friend, you know what happened to me and I know what happened to you."
Philip Brooks, MD: "You bet."
Hugo Verhoeven, MD: "It is a real pleasure that you have time to get together with me. One of the major indications for hysterectomy in the past was irregular bleeding or heavy bleeding, so a lot of patients underwent hysterectomy just for these indications. Almost every year we talk about the ablation of the endometrium, so let's go a little bit to the past. What were the first steps in the development of techniques for endometrial ablation?"
Philip Brooks, MD: "It's interesting that you ask because gynecologists have been looking for many, many decades for methods of destroying the uterine lining so that we could treat this benign kind of bleeding with some other method rather than major surgery, especially for patients who were too sick or didn't want to have a hysterectomy. They've tried radiation and they've tried some of the toxic chemicals inside the uterus - quinacrine, and a lot of different things have been tried with either terrible success or with too much in the way of toxicity and risk. The first contemporary serious impact was with the laser, and Milton Goldrath was the first to define that. It was modified later by Frank Loeffer and this goes back to about the seventies when this was first developed. Primarily, the YAG laser was the one that had deep enough penetration and it's been about twenty-five years that we've had a technique that was hysteroscopically driven that would work. The problem is that it didn't make a serious dent in the 650,000 hysterectomies in the United States, maybe 250,000 of which were for abnormal bleeding or still are."
Hugo Verhoeven, MD: "Why weren't more people convinced that this technique was something sensational for the patients?"
Philip Brooks, MD: "I believe in my traveling around and teaching this technology that it was too skill intensive. You had to learn it, you had to become good at it, and if you weren't there was the fear of risks or dangers - perforation, bowel burns, or fluid overload. All of those risks are awesome to somebody who is just learning these techniques and the expense of buying a laser, leasing the laser, or having it available at your institution at a time when healthcare costs were skyrocketing and hospitals were backing down from investing in large capitol outlays. So the bottom line was very few physicians felt comfortable in doing it and it was left in the hands of a few people. As a matter of fact, let me just say before we go on about the new methods, what I really believe to be a critical issue is that hysteroscopists and gynecologists in the field have made some very strong desires to make this more available to more physicians and less skill intensive so that more of us can do it easily. If you can make it simple and if you can make it safe, you can avoid the costs and the risks by outpatient or possibly even with local anesthesia which is my area of interest that I've been doing and working out to develop a protocol. I do them only under local anesthesia now and to make this so it is cost effective for the third party payers to reimburse us, relax comfortably, and make it worth my time and my efforts to learn this technology."
Hugo Verhoeven, MD: "Different techniques are available now from twenty years ago, you described the laser but now there are many other possibilities."
Philip Brooks, MD: "Right, from the laser we went to electrosurgery with the resectoscope learning from the urologists and shaving the endometrium or using rollerballs but, again, over the two decades that that was used and approved that hasn't made a serious impact. More people are doing it but it has, again, been relegated to the hands of the experts. The risks are still significant and because of these risks they're only done under general anesthesia. So the next step was the simple - what we call - global endometrial ablation, and that is the ability to ablate the endometrium simply and safely with a minimal amount of anesthesia, and in some cases no general anesthesia at all. In my practice we're using no general medication; I am non-steroidal antiinflammatory so we avoid the risks of an anesthetic, of hospitalization, the costs of the hospital, the anesthesia, etc., and we can do this in the office."
Hugo Verhoeven, MD: "What's the technique you're using?"
Philip Brooks, MD: "I have been a principle investigator and have used probably three or four of the different techniques - two different kinds of balloons and now being a principle investigator of the one that I happen to be using virtually exclusively in my private practice is the Hydro ThermAblator® or the HTA. This is a system of injecting water with a sealed insulated cannula, using a hysteroscope to look and make sure you're in the cavity, filling the uterus with physiologic saline under room temperature conditions, and then there's a controller - a computer on the system that measures a whole lot of things like the intrauterine pressure and it keeps it down to 55 mm of mercury. As you probably know, at 55 mm of mercury you don't open the cornu so there's no leakage into the oviducts, and there's an acorn seal to the exocervix so there's no leakage back. Once the computer is sure, number one, you're in the right cavity, and number two, that the circulation of the liquid isn't leaking because the computer will send as little as 10 ml of leakage so if we have 10 ml of leakage even accumulative the computer will not heat up the solution. So we test it at room temperature, the computer then says to me - okay you got a tight seal, there's no leakage, press a button when you're ready. I press the button and the computer in the console heats the saline to 90 degrees centigrade and keeps the circulation so it stays at 90 degrees. There's about a two minute warm-up and then a ten minute burn or cooking denatures the protein and seals the blood vessels. Then there's about a one minute cool-down and that's the end of it, and with an appropriate amount of the right medication it is virtually painless. We use atropine to prevent the vasovagal reaction from the distention of the uterus, .2 of atropine and we use 30 mg of Toradol. Toradol is a non-steroidal anti-pain or anti-inflammatory and it's injectable. It's given thirty minutes before the patient has the procedure so I have the patients take a non-steroidal orally before they leave home and a Vicodin, which is a hydrocodone. It's like a codeine derivative, and they take that before they come to my office. Then we give them the Toradol, the atropine, and then a paracervical block and that's all. When they leave my office they take one more of this Cataflam which is a diclofenac, it's an anti-prostaglandin, and that lasts for about probably four to six hours. They get home, the paracervical wears off, they have cramps for probably four to six hours, and by that night or the next day the discomfort is all gone, and we've done it all at the office. Of 29 patients that I have now done exclusively with this technique, we have had 3 that have required either some cramp shot, 50 mg of demerol or my partner who's not nearly as comfortable and confident has given two of his patients 1 cc of Resaid and 1 mg of Resaid intravenously just as an anti-anxiety. I don't particularly like anything systemically other than the Vicodin and the Toradol so I don't use that but he has given that. Of the 29 patients only 3 have had accessory medication for pain."
Hugo Verhoeven, MD: "Let's talk about the risks. We know from the resectoscope and from the laser that sometimes very small parts of the endometrium were not resected and could be the cause of a hematometra and later on eventually cramping and pain. Secondly, are you doing a D&C before doing the coagulation because of a risk of an endometrium carcinoma?"
Philip Brooks, MD: "Sure, it is imperative that all patients with abnormal bleeding be worked up thoroughly. In all of our FDA trials patients had to have endometrial sampling or biopsies and hysteroscopies as well as Pap smears to confirm that there was nothing atypical. Endometrial ablation is not appropriate and has not been approved for patients with atypical hyperplasia or serious amounts of hyperplastic disease. So, yes, all patients must be worked up to rule out any atypia not just adenocarcinoma but atypical hyperplasia or persistent adenomatous hyperplasia that should be converted and thinned out. We do recommend that the uterine lining be as thin as possible. The GnRH agonists are very good - you can shed the uterine lining with hormones with progestins, birth control pills for two weeks, and then do this immediately after withdrawal bleed. Danocrine will thin the endometrium - any of the GnRH agonists have been used and a vigorous curettage. The problem with curettage, however, is if you do it immediately before the procedure while it provides a good specimen you've got blood and clots you have to deal with and that clogs up your outflow ports, and it may interfere with circulation so we're not big fans of doing D&C's immediately before the procedure. Although it's been reported, a vigorous D&C taking 3 to 5 minutes of very thoroughly curette of the endometrium have been reported as a way of preparing the endometrium. We would rather do it chemically but it can be done very much so with a birth control pill shed of the lining for one cycle or two weeks even. The study that we did with one of the balloons had a birth control pill shedding of the lining."
Hugo Verhoeven, MD: "So is there a risk of a hematometra?"
Philip Brooks, MD: "We haven't seen any. A hematometra is probably more common when you traumatize the internal os or you get down too low with a resection technique, and I haven't seen it in any of the patients that we've done the Hydro ThermAblator® on. One of the reasons is that the sheath goes immediately to but not into the internal os. You stop at the opening to the lower segment, you scan the entire uterine cavity hysteroscopically to make sure you're in the right place, and then you turn on the saline and heat it up. So we get a denaturation of the protein, we get a sealing of the blood vessels, and we get a destruction by heat of the endometrial tissue but we don't get serious scarring of the myometrium which I think the cicatrization is what probably causes the hematometra."
Hugo Verhoeven, MD: "An occlusion of the endometrial cavity or a cicatrix?"
Philip Brooks, MD: "We hysteroscope the patients after the ablation, and Milt Goldrath did a whole series early on with the laser. You don't obliterate the cavity like Asherman syndrome, what you do is you shrink the cavity with cicatrization. Every one of them has a cavity and for that matter when they fail we know they fail because they're bleeding. They come in and they have egressed through the cervical canal so we don't obstruct the cavity with endometrial ablation, we markedly cicatrize or scar down the endometrial lining, and perform a cicatrix so that they have a narrowing of the cavity but not a serious obstruction and adhesion formation."
Hugo Verhoeven, MD: "Last question, are there some contraindications or patients you cannot treat with this technique?"
Philip Brooks, MD: "Certainly endometrial ablation doesn't work well if the patient has severe adenomyosis or the patient has large intracavitary myomas or a huge cavity. Those patients need to be treated the way you would normally treat those diseases, and maybe if the patient has an intracavitary myoma then the ablation should be done with a resectoscope so that you can get the myoma or the giant polyp out so that's number one. The HTA, unlike the balloons, will work in a deformed cavity due to a septum or maybe a submucous myoma that only minimally impacts the contour of the cavity. You can destroy endometrium and the surface over the myoma with the HTA so that's another reason I like it. But you can't do patients with atypical endometrium, and you shouldn't do patients with roaring cervicitis or a history of PID without covering with antibiotics maybe, that's been in the literature. Certainly depending upon the anatomy, if you can't get through the cervical canal because of stenosis that may be a relative contraindication."
Hugo Verhoeven, MD: "Phil, certainly some of our listeners or readers are very fascinated about this technique, do you have some recommendations for them?"
Philip Brooks, MD: "I think that certainly look at the techniques. I really believe that the future will hold a system that is safe for patients, minimizes risks by allowing us to do this with a minimal amount of general anesthesia, that is highly effective in reducing the amount of bleeding that a woman has, and can be done in a clinic or in a private office - I think this will have a great deal of success. My recommendation is look at them, learn how - there are workshops all around that are being given to try and teach this and to introduce these technologies to clinical practices and physicians. We hope that they will become the standard of education in the residencies. I believe that if a resident today gets through a GYN residency without learning how to use a hysteroscope, I think he is at a meager or inadequate training program. I'm a very dedicated hysteroscopist, I think you do more by looking, seeing, and being able to operate inside the uterus than with imaging or indirect techniques, and I think they're complimentary. I think we need to learn about how to do ultrasound and saline infusion but I think we need to be able to be facile with either office or operative hysteroscopy for all of us. We are here to protect women and to care for women, and I think we do it best by looking inside the uterus with a telescope just as we've learned to do with the laparoscope."
Hugo Verhoeven, MD: "As usual, I learned quite a lot. Thank you very much, Phil."
Philip Brooks, MD: "It's been a delight."
Hugo Verhoeven, MD: "It's always a pleasure talking to you."
Philip Brooks, MD: "Thank you."
Hugo Verhoeven, MD: "Thank you."