Normal menstruation and abnormal bleeding Normal menstrual cycle is 21~35 days, average 28 days; menstrual period is 2~8 days, average 3~5 days; normal menstrual flow is 30~50 ml, more than 80 ml is called excessive menstruation, and excessive menstruation is often combined with prolonged menstruation and frequent menstruation. Prolonged menstruation means menstruation for more than 8 days, and the interval between two menstrual periods is less than 21 days, which is called frequent menstruation. Abnormal uterine bleeding (AUB) is a common clinical symptom in obstetrics and gynecology; based on a 28-day menstrual cycle, any bleeding that cannot be called menstruation or does not conform to the normal range of bleeding is AUB; the common conditions of AUB are as follows: excessive menstruation: regular cycle, but prolonged menstruation period (>8d) or excessive menstruation (>80ml); excessive menstruation is often combined with prolonged and frequent menstruation; prolonged menstruation refers to menstruation of more than 8 days; intervals of less than 21 days are considered frequent menstruation. ml); Excessive menstrual flow: regular cycle, normal menstrual period but excessive menstrual flow (>80 ml); Irregular excessive uterine bleeding: irregular cycle, prolonged menstrual period and excessive menstrual flow; Irregular uterine bleeding: irregular cycle, menstrual period may be prolonged but not too much menstrual flow. (ii) Causes of abnormal uterine bleeding Neuroendocrine system disorders; DUB; diseases related to uterine tumors, such as leiomyoma, endometrial polyps, endometrial cancer, cervical cancer and uterine sarcoma, etc.; diseases related to pregnancy, such as ectopic pregnancy, various types of spontaneous abortion, as well as bleeding in mid- and late-pregnancy, etc.; diseases related to inflammation, such as endocervicitis, cervicitis, geriatric vaginitis, etc.; and family planning, such as artificial abortion, Abnormal bleeding caused by abortion, drug abortion, IUD; EMS-related diseases; symptomatic uterine blood, such as blood diseases, renal failure, oral anticoagulant drugs and HRT treatment, etc., can cause uterine bleeding. Endometrial ablation for abnormal uterine bleeding Abnormal uterine bleeding is a common and frequent disease, threatening women’s health and quality of life; traditional surgery TAH, traumatic, complications, most of the resected uterus has no organic pathology; endometrial ablation (EA) is an emerging minimally invasive technology in the field of gynecology in the modern era, in the cure of the disease at the same time, it can EA is an emerging minimally invasive technique in the field of gynecology, which can cure the disease while preserving the uterus without destroying the anatomy of the pelvic floor or affecting the endocrine function of ovaries. Mechanism of EA in treating abnormal uterine bleeding: destroying the whole layer of endometrium (functional layer and basal layer) and part of the myometrial tissue underneath it, so that the endometrium can not regenerate, and achieve the purpose of amenorrhea or reducing menstruation. (A) the evolution and development of endometrial removal In 1948, the first case of “traumatic amenorrhea syndrome” caused by severe destruction of the endometrium attracted the attention of gynecologists; in the early seventies, fluorine and nitrous oxide gases were introduced into the uterine cavity, in an attempt to destroy the endometrium by freezing. After that, expandable hot water balloon was inserted into the uterine cavity in an attempt to destroy the endometrium by physical heating; at the same time, the chemical element radium was also inserted into the uterine cavity, causing permanent amenorrhea by radiation damage to the endometrium by radioactive elements. However, due to the technical constraints at that time, the above methods came to a halt because they could not completely destroy the endometrium or were accompanied by other serious complications. After the 1980s, the hysteroscopic endometrial removal technique was applied in the clinic; with its intuition, ability to treat coexisting lesions in the uterine cavity at the same time, and good therapeutic effect, etc.; it was known as the “standard endometrial removal technique”. (2) Standard endometrial excision (SEA) The first generation of the endometrial excision technique is a hysteroscopic surgery under direct visualization. The first generation of endometrial removal technology is hysteroscopic surgery under direct vision: TCRE (transcervical resection of endometrial) and RBA/LEA (roller-ball/laser endometrial ablation). Although the forms of TCRE and RB/LEA are different, the depth and scope of their endometrial destruction are basically the same. Although TCRE and RB/LEA have different forms of action, the depth and extent of endometrial destruction are basically the same. Targets of EA treatment: ① excessive menstruation/abnormal uterine bleeding, ineffective drug treatment; ② patients require uterine preservation and have no hope of reproduction; ③ uterus ≤ 10 weeks of gestation; ④ preoperative hysteroscopy and endometrial biopsy to exclude pre-cancerous or cancerous changes of the endometrium; ⑤ excessive menstruation in combination with cardiac, hepatic, pulmonary, renal and other internal diseases, and those who can not tolerate hysterectomy. Characteristics of SEA: direct vision, the surgeon can grasp the scope of endometrial destruction, and at the same time remove the coexisting lesions in the uterine cavity; resected tissues for histological examination, etc.; the surgery requires pressure and perfusion medium – related complications may occur; the operation is difficult, and the technical requirements are high. Overall efficacy of SEA: 80~95% of menorrhagia is controlled; TCRE amenorrhea rate 25~45%, menstrual flow is reduced by 70~80%; anemia is corrected by ≥97% of patients with ≥90% of patients’ satisfaction with surgical results.SEA is a safe and effective alternative to hysterectomy for the treatment of menorrhagia and abnormal uterine bleeding.Depth and range of endometrial destruction of SEA affects the efficacy of the surgery; post-operative The rate of need for re-intervention due to bleeding, abdominal pain, etc. was 17%: including secondary EA, hysterectomy, and medication. Reasons for the above therapeutic interventions: incomplete destruction of the endometrium, regeneration of residual endometrium and adenomyosis. Limitations of SEA: SEA requires perfusion media with pressure to expand the uterine cavity, and its unique complications such as overabsorption of perfusate, fluid overload, dilutional hyponatremia, and technical difficulties have limited its popularity. EA techniques that are easy to operate and learn were developed one after another, and after the 1990s (Global endometrial ablation (GEA)) was introduced one after another, and the programmed, short-time, “holistic endometrial ablation technique” was applied to the clinic. (C) Global endometrial ablation (GEA) The second generation of endometrial ablation technology, except for hot saline circulation, do not need hysteroscopic intervention; surgical operations are programmed design, the operation process is simple and fast, no need to carry out cervical pretreatment, do not need to inflate the uterus pressure and perfusion medium (except for the saline circulation), and therefore safer and more convenient. 1, hot balloon endometrial removal (uterine balloon therapy, UBT) UBT by the guide rod and latex balloon and control devices; treatment of latex balloon filled with saline or 5% dextrose so that the intrauterine pressure of 160-180 mmHg; maintain the temperature inside the balloon 87 ℃ ± 2 ℃, for 8 minutes. The operation of UBT is easy to learn and does not require special training, even if the operator has no experience in hysteroscopic operation can also be competent in the operation; the operation process is mildly painful and only requires local anesthesia or even no anesthesia can be performed; the device is small in size and easy to carry, suitable for outpatient or community operation. The scope of endometrial destruction by UBT is easily constrained by the size and shape of the uterine cavity (because the balloon must be in extensive contact with the endometrium); any lesion that affects the anatomical shape of the uterine cavity (M,P,A) is unsuitable for this treatment; the clinician should be aware of its therapeutic limitations when choosing the surgical plan, so as to maximize the strengths and avoid the weaknesses, and to give full play to the best efficacy of the treatment. 2. Hydro Thermablation (HTA) HTA consists of hysteroscope, saline circulation device and control system. During the operation, the hysteroscope is placed into the uterine cavity, the circulation device is connected to the inlet/outlet orifices of the hysteroscope, saline is filled and rinsed into the uterine cavity, and the morphology of the uterine cavity is observed to observe the structural and pathologic changes. During the operation, the water outlet channel of the hysteroscope is closed and the heating system is activated; the temperature of the water in the uterine cavity rapidly rises to 90℃, and the endometrium reaches the expected destruction after about 10 minutes of operation; the system automatically stops the heating and cools down the temperature of the water in the uterine cavity to close to the room temperature, which is discharged out of the uterine cavity through the water outlet channel of the hysteroscope. HTA is the only surgical operation with direct visualization of the uterine cavity, as the circulating saline is not constrained by the morphology of the uterine cavity, thus it can maximize the destruction of the endometrium.Effectiveness of HTA: The overall satisfaction rate of the treatment in the HTA group is 98%, while that of the RBA group is 97%; HTA can achieve the same therapeutic effect as that of the RBA, and it is a reliable method of treating excessive menstruation. Precautions: the pressure of the uterine cavity should be set below the minimum pressure to make the fallopian tubes open, so as not to cause the fallopian tubes to open the mouth of the high temperature saline into the abdominal cavity, resulting in pelvic organs burns; cervical dilatation is not easy to be too loose (generally dilatation of 8mm), in order to prevent hot water leakage in the process of operation to damage the mucosa of the vagina. 3, microwave endometrial removal microwave transmitter and microwave control device; surgery, the transmitter disperses microwaves to warm up the endometrial tissue, the operator according to the temperature curve of the microwave control screen, slowly moving the transmitter, so that the temperature stays within the therapeutic range, to achieve uniform destruction of the entire uterine cavity lining. Precautions: the probe does not have to touch a certain part of the uterus; the procedure is shorter, taking only 3-4 minutes. Efficacy of MEA: Prospective randomized controlled study, five-year postoperative amenorrhea rate: 69% in the TCRE group, 65% in the MEA group (P ≤ 0.05); in the treatment of endometrial polyps and ≤ 3cm submucosal fibroids, the efficacy of the treatment can also be compared with the TCRE. Clinical research: MEA shows good therapeutic prospects in improving menorrhagia and correcting anemia, etc. Advantages of MEA: no endometrial pretreatment, saving treatment costs, no need for intraoperative expansion pressure and perfusion media, significantly lower than TCRE in terms of surgical complications; easy to learn, providing minimally invasive treatment for the operator who does not have the opportunity to receive training in TCRE. 4, NovaSure endometrial ablation NovaSure is a new type of endometrial ablation technology, through the three-dimensional bipolar role of the probe and radio frequency impedance controller to implement the surgical operation; radio frequency three-dimensional bipolar probe for the scalable sieve-like metal support structure, its shape and the shape of the uterine cavity to adapt to; surgery, the bipolar probe can be directed to send out the wave of radiofrequency wavelengths. During the procedure, the bipolar probes can send out radiofrequency waves with different wavelengths in a directional manner, which act on the endometrium and the muscular tissues underneath it, causing the water in the tissues to instantly vibrate at a high speed, warm up, vaporize, and the cells rupture and evaporate, thus realizing the destructive effect on the endometrium; average treatment time is 90 seconds. NovaSure efficacy: multicenter RCT: NovaSure treatment of excessive menstruation one year efficacy: normal or less than normal menstrual flow in the NovaSure group 90.9%, 87.8% in the RBA group; dysmenorrhea relief rate of the NovaSure group from 57% down to 21%, the RBA group from 56% down to 34%.NovaSure treatment of DUB efficacy. One year after surgery: amenorrhea rate 58.6%, spot menstruation 29.4%, normal 3.9%, another 3.9% failure. 5.Vacuum laser endometrial removal Vacuum laser endometrial removal is a new type of non-hysteroscopically mediated bipolar vacuum tube laser endometrial removal; composed of a scalable inverted triangle laser transmitter and laser control system. During the procedure, the wings of the laser transmitter are extended to diffusely disperse a laser beam with a wavelength of 830 nm, which is absorbed by the hemoglobin in the endometrial tissue and converted into thermal energy, producing a destructive effect on the entire endometrial layer and some of the myometrial tissues below it; the procedure takes 7 minutes. ELITT efficacy: prospective double-blind controlled study: 12 months after the operation: amenorrhea rate ELITT group 56%; TCRE group 23%; 36 months after the operation: amenorrhea rate ELITT 61%; TCRE group 24%. ELITT can achieve the same therapeutic effect of TCRE; ELITT postoperative amenorrhea and menstruation reduction rate is higher than that of SEA, which has been regarded as a “revolution” in GEA. It is known as the “revolution” in GEA. 6.Cryoendometrial ablation A method of destroying the endometrium by freezing. It consists of a refrigeration probe and a manipulation device. During the procedure, the refrigeration substance (liquid nitrogen or a gas mixture, etc.) inside the probe forms an oval-shaped ice ball of about 3.5 cm around the probe, creating a destructive effect on the surrounding endometrium. Surgery time is about 10-20 minutes; the depth of destruction of the endometrium is about 6-12mm. 7, TCA-EA endometrial removal through chemical methods of substances for trichloroacetic acid (trichloroacetic acid, TCA); TCA is a chemical corrosive agent, local application can cause tissue protein denaturation and chemical corrosion effect. EA only requires paracervical block anesthesia, after appropriate dilatation of the cervix, insert a 3cm × 6mm trocar into the cervix and fix it with cervical forceps, then insert a cotton swab dipped in 95% TCA solution into the uterine cavity and evenly smear the endometrial surface, once a week for three consecutive times. The cervix and vaginal mucosa should be protected to avoid the corrosion of TCA spillage; TCA-EA does not need special equipment, and the operation is simple, but it is not easy to grasp the scope and depth of the destruction of the endometrium.The efficacy of TCA-EA: The efficacy of TCA-EA in the treatment of excessive menstruation and DUB, one year after the operation: amenorrhea rate of 26.7%-31.1%; the rate of menorrhagia and normalization of menstruation is 95.6-97.8%; more than 90% of the patients are satisfied with the results of the treatment. TCA-EA provides a conservative treatment option for patients with DUB, as 90% of the patients were satisfied with the results of the treatment, and there were no toxic side effects or complications associated with the drug. Currently, the treatment of abnormal uterine bleeding is divided into two categories: SEA and GEA, which contain a variety of therapeutic methods, each with certain advantages and limitations. In clinical treatment, the corresponding methods can be selected according to the actual situation in order to achieve a more satisfactory therapeutic effect.