Endometrial Ablation


Article Author:
William Gossman
Christinne Canela


Article Editor:
William Gossman


Editors In Chief:
Tod Aeby


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
7/11/2019 9:22:07 PM

Introduction

Endometrial ablation refers to minimally invasive surgical procedures designed to treat abnormal uterine bleeding in women who have completed childbearing. There are different ways physicians perform endometrial ablation. After the ablation, the residual endometrium is beneath the scar, and this prevents further bleeding. In the past, a hysterectomy was frequently done for menorrhagia, but this procedure can be done quickly, in an office, is relatively painless, and has minimal downtime. It may be an option for women who do not want a hysterectomy.[1][2]

Endometrial ablation is indicated for the treatment of heavy menstrual bleeding or perceived menorrhagia in premenopausal women who no longer desire future fertility. It is best reserved for women with ovulatory bleeding. It is also for patients with normal sized uteri.[3]

Anatomy

It is important to evaluate the endometrial cavity both structurally and histologically. An ultrasound is typically performed before ablation. This provides information on the length of the uterus as well as any structural abnormalities that may be present, and that may contraindicate the procedure. For example, depending on the size, submucosal leiomyomas may be a contraindication for the procedure. If there is suspicion for uterine cavity abnormalities, a saline infusion sonogram (SIS) or in-office hysteroscopy may be necessary to determine the situation and also determine if this should be addressed before ablation. An endometrial biopsy should be performed and reviewed before endometrial ablation to rule out hyperplasia or cancer. This also provides an assessment of the uterine length which affects the effectiveness of ablation and determines whether a patient is a candidate for the procedure. If hyperplasia or cancer is present and endometrial ablation is performed, it may interfere with future evaluations of the uterine lining, and therefore, it should be avoided. One should also ensure that the patient has a recent or an up to date PAP smear before the ablation. If necessary, an abnormal PAP will need to be evaluated before the ablation is done.[4][5]

Indications

Apart from the standard consent process for any surgical procedure, certain, important points need to be highlighted when the patient is agreed to this procedure. It is important that patients understand that following endometrial ablation, pregnancy is not advisable given possible pregnancy complications. Patients should, therefore, have a reliable contraceptive method (be it sterilization or another method) after the ablation. It is also important to emphasize that endometrial ablation is not a contraceptive method. The patient should also understand that the goal of endometrial ablation is normalization of their cycle, not amenorrhea. In patients with anovulatory bleeding, if an ablation is performed, it will not change the pattern or timing of the bleeding.[6][7][8]

Contraindications

Contraindications to the procedure include:

  • Pregnancy or desire to preserve fertility
  • Known or suspected endometrial hyperplasia or uterine cancer
  • Active pelvic infection
  • IUD in place
  • Previous transmyometrial uterine surgery (such as classical cesarean section or myomectomy)
  • Uterine anomaly such as septate, bicornuate, or unicornuate uterus
  • Relative contraindication: postmenopausal state, uterine cavity length greater than 10 cm to 12 cm or severe myometrial thinning, severe uterine retroflexion or anteflexion.

Preparation

It is important to obtain tissue before the ablation. An endometrial biopsy is usually not well tolerated in the office setting, but dilatation and curettage should be done instead to obtain cells for cytology. If any suspicious or obvious lesion is present, ablation should not be done until a biopsy has been obtained. Once the patient is positioned, several laser devices can be used to ablate the endometrial tissues. There is usually no need for anesthesia, but if the patient feels uncomfortable, regional anesthesia is an option.

Technique

There are two major techniques:

Resectoscopic Endometrial Ablation

Typically, this is performed with the use of a rollerball or monopolar or bipolar loop electrode. The endometrium is desiccated to the level of the basalis layer using thermal energy. With the rollerball, no tissue is removed. With the loop electrode, the tissues are resected and sent to pathology.

Global endometrial ablation (GEA) 

Many devices do not require the use of a resectoscope currently available to accomplish the destruction of the endometrium. They have become popular due to its ease of use and similar outcomes to resectoscopic techniques. Some of these GEA procedures can be performed in the office.

Complications

Postoperative complications include:

  • Distention fluid overload
  • Uterine trauma: including lacerations to the cervix, perforation of the uterus. With uterine perforation, there is the risk of injury to surrounding organs/structions
  • Lower tract thermal injury: burns of the vagina and vulva have been reported
  • Pregnancy-related complications: pregnancy is not recommended following ablation. Successful pregnancies have been reported following ablation; however, there appears to be a greater risk of complications including preterm birth, intrauterine scarring/uterine chambering (creating separate uterine compartments), postpartum hemorrhage risk of abnormal placentation (accreta). Miscarriage rate and ectopic pregnancy rates may be higher
  • Pain-related obstructed menses: Persistent endometrium after ablation is common, hematometra within the body of the uterine cavity (central hematometra) or at the cornual region may be seen as a result of obstructed menses
  • Postablation tubal sterilization syndrome presents with unilateral/bilateral pelvic pain and vaginal spotting after BTL and endometrial ablation
  • Failure to control menses: patients should be counseled that the goal is normalization of cycles. 85% will be satisfied with the procedure at the 1 year mark
  • May interfere with subsequent evaluation of the endometrium because of synechiae that may make endometrial sampling difficult
  • Infection

Clinical Significance

Overall, most patients have a satisfactory outcome. Unlike a hysterectomy, the procedure does not require hospital admission and is associated with much fewer complications. Data to compare the different methods of endometrial ablation are difficult because of lack of patient homogeneity and lack of controls. In any case, most methods have a success rate of over 90%.[9][10]

Compared to oral therapy: by 5 years: only 10% of those on medical therapy continued receiving medical treatment, 77% had surgery. Of those who underwent resectoscope ablation, 27% had further surgery. Those who were randomized to oral medical therapy were significantly less likely to satisfied than those undergoing ablation.

Compared to Mirena IUD: quality of life and satisfaction measures were similar for both groups at 1 year. Ablation may be more effective at 1 year, but by years 2 and 3, there was no difference.

Reoperation rates at 4 to 5 years: 18% to 38%

Enhancing Healthcare Team Outcomes

Patients with menorrhagia are often managed by a multidiscipliary team that includes a gynecology nurse. One treatment for menorrhagia is ablation. However, it is vital that clinicians who perform endometrial ablation fully assess the uterus before the treatment.  It is important to evaluate the endometrial cavity both structurally and histologically. An ultrasound is typically performed before ablation. This provides information on the length of the uterus as well as any structural abnormalities that may be present, and that may contraindicate the procedure. For example, depending on the size, submucosal leiomyomas may be a contraindication for the procedure. If malignancy is suspected, tissue should be obtained for histology.

The outcomes for endometrial ablation are good. It saves hospitalization and preserves the uterus. In more than 90% of women, the bleeding can be arrested.


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Endometrial Ablation - Questions

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Which of the following does not ablate the endometrial lining?



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Which of the following is not a contraindication to endometrial ablation?



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Endometrial Ablation - References

References

Yang H,Xu X,Jiang X,Yao Z, Treatment of menorrhagia due to aplastic anemia by hysteroscopic resection of endometrial functional layer and levonorgestrel-releasing intra-uterine system: Three case reports. Medicine. 2019 Apr;     [PubMed]
Wouk N,Helton M, Abnormal Uterine Bleeding in Premenopausal Women. American family physician. 2019 Apr 1;     [PubMed]
Eisele L,Köchli L,Städele P,Welter J,Fehr-Kuhn M,Fehr MK, Predictors of a Successful Bipolar Radiofrequency Endometrial Ablation. Geburtshilfe und Frauenheilkunde. 2019 Mar;     [PubMed]
Aminimoghaddam S,Pahlevani R,Kazemi M, Electrosurgery and clinical applications of electrosurgical devices in gynecologic procedures. Medical journal of the Islamic Republic of Iran. 2018;     [PubMed]
Geary RS,Gurol-Urganci I,Kiran A,Cromwell DA,Bansi-Matharu L,Shakespeare J,Mahmood T,van der Meulen J, Factors associated with receiving surgical treatment for menorrhagia in England and Wales: findings from a cohort study of the National Heavy Menstrual Bleeding Audit. BMJ open. 2019 Feb 19;     [PubMed]
Jiang J,Xue M, Radiofrequency endometrial ablation for treating heavy menstrual bleeding in women with chronic renal failure. International journal of hyperthermia : the official journal of European Society for Hyperthermic Oncology, North American Hyperthermia Group. 2018;     [PubMed]
Bofill Rodriguez M,Lethaby A,Grigore M,Brown J,Hickey M,Farquhar C, Endometrial resection and ablation techniques for heavy menstrual bleeding. The Cochrane database of systematic reviews. 2019 Jan 22;     [PubMed]
Faridi P,Fallahi H,Prakash P, Evaluation of the Effect of Uterine Fibroids on Microwave Endometrial Ablation Profiles. Conference proceedings : ... Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Annual Conference. 2018 Jul;     [PubMed]
Lee MHM, Effectiveness of bipolar impedance controlled radiofrequency (NovaSure) endometrial ablation for the treatment of menorrhagia in Hong Kong Chinese women{sup}☆{/sup}. Gynecology and minimally invasive therapy. 2017 Oct-Dec;     [PubMed]
Wortman M, Endometrial Ablation: Past, Present, and Future Part II. Surgical technology international. 2018 Nov 11;     [PubMed]

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