Update on the management of menometrorrhagia: new surgical approaches.

Hysterectomy has traditionally been the definitive surgical approach for heavy menstrual bleeding. However, the more modern concept of 'save the uterus' has led to new surgical approaches for the treatment of heavy menstrual bleeding, based on second-generation endometrial destruction (ablation/resection) techniques, including microwave endometrial ablation, thermal balloon endometrial ablation, radiofrequency electrosurgery, hydrothermal ablation and cryoablation. As pregnancy following endometrial ablation is still possible, we proposed to combine endometrial ablation and sterilization with Essure(®) micro-inserts in women with confirmed menometrorrhagia and the desire, or medical need, for permanent tubal sterilization. Although large diameter resectoscopy provides excellent results in the surgical treatment of myomas, the technique requires dilation of the cervical canal (difficult in nulliparous or menopausal patients), and requires general or epidural anaesthesia and, therefore, must be performed in an operating theatre. A major advance in terms of hysteroscopic procedures is the 'see and treat' approach (i.e. when performing an initial diagnostic hysteroscopy, it is now possible to treat the pathology concurrently). Newer hysteroscopic techniques, often not requiring anaesthesia or analgesia, include OPPIuM (Office Preparation of Partially Intramural Myomas) and use of a mini-resectoscope, allowing office diagnostic-operative hysteroscopic procedures.