Introduction: Despite endometrial ablation/resection being a very successful treatment for women with heavy menstrual bleeding, re-intervention with additional surgery is needed in 12%-25% of cases. Introducing a levonorgestrel-intrauterine system (LNG-IUS) immediately after ablation could preserve the integrity of the uterine cavity and suppress the regenerated or non-ablated endometrial tissue. Therefore, this combined treatment can perhaps lower the re-intervention rate. The aim of this systematic review was to assess the impact of the combined treatment. Material and methods:The MEDLINE, EMBASE, and Cochrane library were systematically searched. No language restrictions were applied. All types of studies were included reporting on the results of endometrial ablation or resection combined with immediate insertion of LNG-IUS for treatment of heavy menstrual bleeding. The primary outcome was the number of hysterectomies after the ablation procedure.Secondary outcomes included re-intervention rates, removals of LNG-IUS, bleeding pattern, patient satisfaction, adverse effects, and complications. Our protocol was registered in PROSPERO, an international prospective register of systematic reviews under registration number CRD42020151384.Results: Six studies with a retrospective design and one case series with a followup duration varying from 6 to 55 months were included. In total, 427 women were treated with the combined treatment. The studies described a lower hysterectomy and re-intervention rate after combined treatment compared with treatment with endometrial ablation/resection alone. Hysterectomy rate varied from 0% to 11% after combined treatment compared with 9.4% to 24% after endometrial ablation/resection alone. Bleeding patterns and patient satisfaction appeared to be in favor of the combined treatment group. No intra-or post-operative complications or complications in the removal of LNG-IUS were described. The most reported adverse effects after combined treatment were weight gain, mood changes, and headaches. An additional S U PP O RTI N G I N FO R M ATI O N Additional supporting information may be found online in the Supporting Information section. How to cite this article: Oderkerk TJ, van de Kar MMA, van der Zanden CHM, Geomini PMAJ, Herman MC, Bongers MY. The combined use of endometrial ablation or resection and levonorgestrel-releasing intrauterine system in women with heavy menstrual bleeding: A systematic review. Acta Obstet

Background It is estimated that between 12 to 25% of women who undergo an endometrial ablation for heavy menstrual bleeding (HMB) are dissatisfied after two years because of recurrent menstrual bleeding and/or cyclical pelvic pain, with around 15% of these women ultimately having a hysterectomy. The insertion of a levonorgestrel-releasing intrauterine system (LNG-IUS) immediately after endometrial ablation may inactivate residual untreated endometrium and/or inhibit the regeneration of endometrial tissue. Furthermore, the LNG-IUS may prevent agglutination of the uterine walls preventing intrauterine adhesion formation associated with endometrial ablation. In these ways, insertion of an LNG-IUS immediately after endometrial ablation might prevent subsequent hysterectomies because of persisting uterine bleeding and cyclical pelvic pain or pain that arises de novo. Hence, we evaluate if the combination of endometrial ablation and an LNG-IUS is superior to endometrial ablation alone in terms of reducing subsequent rates of hysterectomy at two years following the initial ablative procedure. Methods/design We perform a multicentre randomised controlled trial in 35 hospitals in the Netherlands. Women with heavy menstrual bleeding, who opt for treatment with endometrial ablation and without contraindication for an LNG-IUS are eligible. After informed consent, participants are randomly allocated to either endometrial ablation plus LNG-IUS or endometrial ablation alone. The primary outcome is the hysterectomy rate at 24 months following endometrial ablation. Secondary outcomes include women’s satisfaction, reinterventions, complications, side effects, menstrual bleeding patterns, quality of life, societal costs. Discussion The results of this study will help clinicians inform women with HMB who opt for treatment with endometrial ablation about whether concomitant use of the LNG-IUS is beneficial for reducing the need for hysterectomy due to ongoing bleeding and/or pain symptoms. Trial registration Dutch Trial registration: NL7817. Registered 20 June 2019, https://www.trialregister.nl/trial/7817.

ObjectiveTo investigate whether a previously performed endometrial ablation is associated with the development and diagnosis of endometrial cancer.MethodsFirst, a systematic review was performed of the articles reporting the incidence of endometrial cancer in patients treated with endometrial ablation. Second, a systematic review was performed to identify all individual cases of endometrial cancer after ablation to evaluate presenting symptoms, diagnostic work-up, potential risk factors, and the type and stage of the endometrial cancer. A systematic search was performed, using Medline, EMBASE, and the Cochrane Library databases, from inception through February 24, 2022.ResultsBased on 11 included studies, the incidence of endometrial cancer in a population of 29 102 patients with a prior endometrial ablation ranged from 0.0% to 1.6%.A total of 38 cases of endometrial cancer after ablation were identified. In 71% of cases (17 of 24 cases), vaginal bleeding was the first presenting symptom. With transvaginal ultrasound it was possible to identify and measure the endometrial thickness in eight cases. Endometrium sampling was successful in 16 of 18 described cases (89%). In 18 of 20 cases (90%) pathologic examination showed early-stage endometrioid adenocarcinoma (International Federation of Gynecology and Obstetrics stage I).ConclusionPrevious endometrial ablation is not associated with the development of endometrial cancer. Diagnostic work-up is not impeded by previous endometrial ablation. In addition, endometrial cancers after endometrial ablation are not detected at an advanced stage.

Heavy menstrual bleeding (HMB) affects approximately 10% to 30% of women of reproductive age and is often treated conservatively with insertion of a levonorgestrel-releasing intrauterine system (LNG-IUS) or endometrial ablation/ resection (EA). The LNG-IUS induces atrophy of endometrial tissue, whereas EA is a minimally invasive, uteruspreserving procedure that destroys endometrial tissue and superficial myometrium. Approximately 12% to 25% of the women require reintervention with additional surgery 2 to 5 years after EA treatment. Treatment failure after EA presents with persistent or recurrent vaginal bleeding thought to occur because of ongoing bleeding from areas of untreated or regenerated endometrium and can require hysterectomy. Introduction of an LNG-IUS after EA could suppress regeneration and nonablated endometrial tissue resulting in a reduction of symptoms and lower hysterectomy rate.This systematic review aimed to determine whether combined treatment with LNG-IUS insertion immediately after EA can lower the reintervention rate among women with HMB. A systematic search was conducted using the Medline, EMBASE, and Cochrane Library databases from inception through September 16, 2020. Studies reporting the results of this combined treatment with or without a control group were included. The primary study outcome was hysterectomy rate after treating with EA and LNG-IUS. Secondary outcomes included reintervention rate, reasons why women required additional treatment, removal rate of LNG-IUS, bleeding pattern, patient satisfaction, and adverse events. Included studies were assessed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool for nonrandomized cohort studies.A total of 7 studies were included in this systematic review, of which 4 were historic cohort studies with a control group, 2 were historic cohort studies without a control group, and 1 was case series. A total of 747 women were included, 472 of whom were treated with EA and LNG-IUS, with a follow-up duration between 6 and 55.2 months. The 4 controlled studies showed a hysterectomy rate in the combined treatment group between 0% and 11%, whereas treatment with EA alone showed a rate between 9.4% and 24%. The 4 studies investigating nonhysteroscopic EA plus LNG-IUS showed hysterectomy rates between 0% and 1%. Four studies reported reintervention rates, with 3 controlled studies showing a lower reintervention rate among the combined treatment cohort (0%-8.7%) compared with the EA alone cohort (19%-29.2%). Reintervention rate was significantly lower at 12 and 24 months after combined treatment compared with EA alone. Patient satisfaction was reported in 3 studies, with satisfaction rates in favor of the combined treatment group. The adverse event rate associated with LNG-IUS after combined treatment resulting in removal was 1.6%.The results of this review show that hysterectomy rate after combined treatment with EA and LNG-IUS seems to vary between 0% and 11% compared with a rate between 9.4% and 24% associated with EA ...

Objectives: Up to 60% of women remove their levonorgestrel-releasing Intrauterine System (LNG-IUS) prematurely, mostly because of irregular bleeding disturbances up to six months after insertion. Assuming ongoing bleeding is due to atrophic bleeding of the endometrium, treatment with ooestrogen could be effective. No study in literature supports ooestrogen therapy for irregular bleeding in LNG-IUS users. Study design:A prospective cohort study was conducted in two hospitals to evaluate the effect of oral ooestradiol (started six months after LNG-IUS insertion) on irregular bleeding days. The participating women received 2mg ooestradiol daily for six weeks. We observed the discontinuation rate, the occurrence of adverse events and side effects due to ooestradiol. Women completed questionnaires at baseline and three months after start of the treatment.Results: Nineteen women were included. A median of 21 irregular bleeding days per month at baseline decreased to a median of five irregular bleeding days per month (p=0.003) after the use of ooestradiol for six weeks. Three out of nineteen women had their LNG-IUS removed at three months follow-up because of persistent irregular bleeding. No adverse events were reported, however, 68% of the participants reported side effects. Conclusion:In this study we observed a decrease in the number of irregular bleeding days in LNG-IUS users with ongoing irregular bleeding (>6 months after insertion), after administering oral ooestradiol for six weeks. We propose to conduct a larger prospective trial to evaluate ooestradiol as treatment option for irregular bleeding.

Samenvatting We presenteren een bijzondere casus van een recidief/metastase in de nier van een primair oesofaguscarcinoom. Trefwoorden tumorrecidief • oesofaguscarcinoom • renaalcelcarcinoom • metastase Case report. A surprising renal involvement as tumor recurrence of a primary esophageal carcinoma Abstract We present a case of a surprising renal involvement as tumor recurrence of a primary esophageal carcinoma. Keywords tumor recurrence • esophageal carcinoma • renal cell carcinoma • metastasis Introductie Kanker van de oesofagus treft meer dan 450.000 personen