Endometrial thermoablation for treatment of menorrhagia: comparison of two methods in outpatient setting

BACKGROUND: Menorrhagia is one of the commonest reasons for gynecologic consultations. Inhibitors of fibrinolysis and non-steroidal anti-inflammatory drugs (NSAIDs) are generally used as therapy for the condition with an acceptable response in some patients. Endometrial ablation is one choice in patients suffering from menorrhagia. It can be performed in patients with no endometrial histological or anatomical pathology. In this method, the functional endometrial tissue is ablated under general anesthesia in an outpatient setting. METHODS: We compared two methods that are widely used in Finland (Menotreat and Cavaterm) in thermoablation of endometrial tissue in 31 patients that were randomized into two treatment groups. RESULTS: Endometrial ablation was effective in the treatment of menorrhagia in patients with normal endometrial structure. About 70% of the patients described the result of the treatment as 'very good'. Only one patient underwent a hysterectomy during the 6-month follow-up period because of problems related to uterine bleedings. The two methods were similar in efficacy and patient acceptance. CONCLUSIONS: Both thermoablation techniques were well accepted by our patients and showed similar and good efficacy and patient acceptance.     

Endometrial ablation

PURPOSE OF REVIEW: Although endometrial ablation has now been accepted practice for more than 20 years, it continues to be a source of research, controversy and speculation. This is illustrated by the 175 articles found in PubMed between the years 2000 and 2003 under the search term 'endometrial ablation' commissioned as part of the preparation for this article. RECENT FINDINGS: The so-called first-generation methods (laser, resection, rollerball) have now got long-term follow-up data of up to 20 years. A few of the second-generation devices have published long-term follow-up data of 5 years. All of the second-generation devices assessed in randomized trials with the first-generation methods compare favourably; however, there are few data on cost effectiveness. Similarly, there are few data comparing endometrial ablation with the Mirena intrauterine device. SUMMARY: Conventional endometrial ablation has been extensively validated; however, many of the newer techniques have inadequate patient numbers or lengths of follow-up on which to evaluate their long-term efficacy, safety or cost effectiveness fully. The anticipated decline in hysterectomy rates with the advent of endometrial destruction methods has not occurred, and this may indicate a lower threshold for surgical management.     

Placenta accreta and intrauterine fetal death in a woman with prior endometrial ablation: a case report

BACKGROUND: Few cases of pregnancy following endometrial ablation have been reported. Placenta accreta and poor perinatal outcome are potential risks due to underlying endometrial destruction and uterine scarring. CASE: A 41-year-old, white woman presented for initial prenatal care at 12 weeks, 3 years after endometrial ablation with resection of a leiomyoma. The patient's prenatal care was unremarkable until 20 weeks, when she presented with intrauterine fetal death. Labor was induced with misoprostol, and a stillborn fetus resulted. The placenta failed to deliver spontaneously after 6 hours and continuing doses of misoprostol. An attempt at manual extraction failed to demonstrate a clear cleavage plane between the placenta and endometrium. The patient underwent a hysterectomy for placenta accreta, which was confirmed on pathology. CONCLUSION: Endometrial ablation may predispose the patient to abnormal placentation and intrauterine fetal death. Physicians should counsel their patients appropriately about the likelihood of this outcome.     

Hysteroscopic resection of endometrial polyps: a study of 195 cases

OBJECTIVE: To ascertain the therapeutic efficiency of hysteroscopic resection for the treatment of endometrial polyps in women with abnormal uterine bleeding and postmenopausal metrorrhagia. SETTING: University hospital. DESIGN: Retrospective consecutive patient follow-up. MATERIAL AND METHODS: From 1987 to 1997, 195 patients with haemorrhagic endometrial polyps were treated with hysteroscopic resection in our department. RESULTS: Five complications occurred, but no major complications were noted. A total of 89.2% of the patients remained in contact after hospitalization. After long term follow-up (5.2 years), successful results were obtained in 80% of the patients with polyp resection without associated endometrial ablation. Further surgery (hysterectomy) was required in only five women. CONCLUSION: Transcervical resection is the gold standard for treatment of endometrial polyps.     

The role of Essure sterilization performed simultaneously with endometrial ablation

PURPOSE OF REVIEW: To review operative procedures, specific risks, complications and evaluation of efficacy of Essure tubal sterilization performed simultaneously with endometrial ablation. RECENT FINDINGS: Dysfunctional uterine bleeding is a significant health problem in premenopausal women. Endometrial ablation is an effective therapeutic option for the management of menorrhagia and an alternative to hysterectomy. Most women undergoing endometrial ablation are of reproductive age, and, because pregnancy after endometrial ablation could be complicated, many of these women require permanent birth control. Since the introduction of Essure tubal sterilization, this permanent contraception method has been widely used and offers an hysteroscopic approach similar to endometrial ablation techniques. Combining these two procedures offers the advantage of performing the two procedures simultaneously, but inherent rules and technical procedures must be followed to avoid any kind of injury such as heat conduction, material injuries, specific complications and specific follow-up. SUMMARY: The combination of safety and efficacy of endometrial ablation and hysteroscopic sterilization makes a compelling argument for their concomitant use.     

Advanced endometrial adenocarcinoma following endometrial ablation: a case report and review of the literature

Endometrial ablation is an alternate method to hysterectomy when treating dysfunctional uterine bleeding (menorrhagia, metrorrhagia and postmenopausal) that does not respond to hormonal treatment or curettage among a carefully evaluated and selected patient population. Its safety and efficacy have been confirmed in large studies. We present a case of advanced staged endometrial carcinoma diagnosed after endometrial ablation that followed uneventful preoperative work-up.     

Treatment of non-atypic endometrial hyperplasia using thermal balloon endometrial ablation therapy

BACKGROUND/AIM: Traditionally endometrial hyperplasias have been treated with progestins. Unfortunately, quite often hyperplasias are resistant to treatment, or they recur after therapy. The aim of the study was to compare traditional progestin administration with thermal balloon endometrial ablation in the treatment of non-atypic endometrial hyperplasia. METHODS: Women with endometrial hyperplasia (n = 34) were randomized in a 1:1 allocation ratio. Endometrial biopsy samples were taken 6 and 12 months after the treatment; if any signs of hyperplasia were detected, hysterectomy was performed. In addition, the hospital records were checked in September 2003 to observe for any later hysterectomy. Main outcome measures were recovery from hyperplasia and avoidance of hysterectomy. RESULTS: In patients treated with thermal ablation, the hyperplasias persisted at 6 or 12 months in 4 out of 17 patients, whereas the rate was 6 out of 17 patients in the progestin therapy group. According to patient records, 1 further patient treated with thermal ablation and 3 further patients treated with progestin were hysterectomized after the last visit. A total of 14 of the 34 patients (41%) have been hysterectomized so far. CONCLUSIONS: These preliminary results suggest that thermal balloon endometrial ablation therapy seems to be as effective as traditional progestin administration in the treatment of non-atypic endometrial hyperplasia. The hysterectomy rate during the follow-up period was, however, considerably high, and, therefore, hysterectomy might be considered even a first-choice treatment for endometrial hyperplasias.     

NovaSure impedance controlled endometrial ablation: long-term follow-up results

STUDY OBJECTIVE: A 7-year follow-up evaluation of the safety, efficacy, and long-term outcome of endometrial ablation when using the NovaSure system in patients with menorrhagia secondary to abnormal uterine bleeding (AUB). DESIGN: Prospective, single-arm study (Canadian Task Force classification II-1). SETTING: St. Imre Teaching Hospital, Budapest, Hungary. PATIENTS: Seventy-five premenopausal women with menorrhagia secondary to AUB. INTERVENTIONS: Endometrial ablation using the NovaSure System without the use of endometrial pretreatment. MEASUREMENTS AND MAIN RESULTS: Loss of menstrual blood was measured using pictorial blood loss assessment chart diaries. Treatment times, complications, and rate of surgical re-interventions were recorded. No intra or postoperative complications were noted. Median follow-up period at the time was 7.8 years (range 6-8.6 years). The proportion of patients with fewer than 7 and 7 or more years of follow-up was 28.8% and 71.2%, respectively. The median treatment time was 92 seconds (range 40-120 seconds). At 7-year follow-up, 97.1% of evaluable patients reported amenorrhea. However, all patients (100%, actuarial rate: 97% with 95% CI [83%-100%]) experienced a successful reduction in bleeding to normal levels or less. Six of 75 patients underwent hysterectomy, and one of 75 had a repeat ablation representing a total of 92% (95% CI: 83%-96%) avoidance of additional surgery during the follow-up period. CONCLUSIONS: Clinical results demonstrate that the use of NovaSure System is safe and effective, with a low rate of surgical re-intervention at 7-year follow-up.     

Psychiatric morbidity following endometrial ablation and its association with genuine menorrhagia

Objective To explore the relation between pre-operative psychiatric morbidity, menstrual blood loss and psychiatric outcome in women receiving endometrial ablation for heavy periods.
Design A prospective cohort study.
Setting The menorrhagia clinic at Leeds General Infirmary.
Population One hundred and twenty consecutive women referred to the Clinic for endometrial ablation.
Methods Psychiatric interview and actual menstrual blood loss measurements at presentation pre-operatively and one year post endometrial ablation.
Main outcome measure Psychiatric status using the semi-structured interview, Present State Examination , with measurement of menstrual blood loss.
Results Endometrial ablation was performed on 92 women. Of the 87 women evaluated 51 (59%) had clinically significant psychiatric symptoms, mainly depression and anxiety. Psychiatric morbidity fell to 21.8% at one year after endometrial ablation. Women with the best psychiatric outcome (6% post-operative psychiatric morbidity) were those with genuine menorrhagia (≥80 mL) and low psychiatric morbidity pre-operatively. Those who fared worst (39% post-operative psychiatric morbidity) were women with high pre-operative psychiatric morbidity and low menstrual blood loss. Of seven women with very low losses [mean 19 mL (SD 17)] who did not proceed to surgery after counselling, six (86%) had significant psychiatric morbidity.
Conclusions Pre-operative psychiatric status and menstrual blood loss are predictors of outcome of surgery for women with reported heavy periods.     

Comparison of the long-term histopathologic and morphologic changes after endometrial rollerball ablation and resection: a prospective randomized trial

STUDY OBJECTIVE: To compare long-term histologic features of endometrial rollerball ablation versus resection. DESIGN: Randomized clinical trial (Canadian Task Force classification I). SETTING: Akdeniz University School of Medicine. PATIENTS: Women with menorrhagia undergoing endometrial ablation. INTERVENTION: Comparison of patients with menorrhagia undergoing endometrial resection and ablation. MEASUREMENTS AND MAIN RESULTS: Endometrial rollerball ablation (n = 23 women) and resection (n = 25) were followed by second-look office hysteroscopy with endometrial biopsy. Mean follow-up to second look hysteroscopy after rollerball ablation and loop resection was 33.4 +/- 2.1 and 31.1 +/- 2.6 months, respectively. Complete atrophy and partial adhesion or obliteration of the cavity and fibrosis were observed at second-look hysteroscopy and were similar in both groups. Whereas all random biopsy specimens after both ablation and resection revealed diminished endometrial glands with varied necrosis and scarring, the number of endometrial glands per field was not correlated with amount of bleeding or menstrual pattern. Bleeding patterns were similar between the groups. No precancerous or malignant lesion was found after the procedures. CONCLUSION: Although efficacy of both endometrial ablation and resection is related to initial thermal destruction and correlated with postablation hysteroscopic and histologic findings, endometrial regrowth may be expected and is not a failure of ablation. Both procedures revealed histopathologically and clinically similar results.     

The long-term effectiveness of endometrial laser ablation: a survival analysis

OBJECTIVES: To assess the long-term effectiveness of endometrial laser ablation and factors that predict long-term outcome. SETTING: A university teaching hospital. STUDY DESIGN: Postal questionnaires were sent to all women who underwent endometrial laser ablation between 1992 and 1998. RESULTS: Of 215 patients who underwent endometrial laser ablation, 174 (80.9%) returned the questionnaire. Duration of follow-up was 1.5-9 years. The procedure was reported as a success by 138 (79.3%) and a failure by 36 (20.7%). Twenty-four patients (13.8%) subsequently underwent hysterectomy for excessive bleeding. Using survival curve estimates the percentage that remained free of failure was 95.3% at 1 year and 76.2% at 4 years. Increasing patient age was significantly associated with reduced risk of failure (hazard ratio 0.91 for every year increase in age). An inexperienced operator significantly increased the hazard of failure. CONCLUSION: Endometrial laser ablation is effective in the long-term in the majority (76.2%) of patients. Older women can expect to have a lower risk of failure.     

Evaluation of HydroThermAblator and rollerball endometrial ablation for menorrhagia 3 Years after treatment

STUDY OBJECTIVE: To compare the safety and efficacy of endometrial ablation using HydroThermAblator (HTA) and rollerball (RB) for treatment of menorrhagia. DESIGN: Prospective, randomized, multicenter study (Canadian Task Force classification I). SETTING: Nine private practice and university centers in the United States. PATIENTS: Two hundred seventy-six women. INTERVENTION: Hysteroscopic endometrial ablation with the HTA (187 women) and RB (89). MEASUREMENTS AND MAIN RESULTS: Bleeding was assessed by pictorial diaries for 12 months, with patient interviews at 24 and 36 month. Amenorrhea rates, reduction of bleeding to normal levels or less, and patient satisfaction were tracked for 36 months, with rates in the HTA group of 53%, 94%, and 98% and in the RB group of 46%, 91%, and 97%, respectively. CONCLUSION: Endometrial ablation with the HTA is a safe, effective, and durable treatment of menorrhagia in a broad patient population. It offers advantages over RB by reducing anesthesia requirements, reducing operating time, and eliminating risks of excessive fluid absorption, and is more easily learned.     

Endometrial Ablation: Complications and Outcome

Objective: to review the peri-operative complications and outcome of endometrial ablation.Design: review of 100 consecutive endometrial ablations using electrosurgery.Setting: teaching hospital.Patients: one hundred patients with disabling dysfunctional uterine bleeding, unresponsive to medical therapy, who chose endometrial ablation instead of hysterectomy.Results: peri-operative complications were minimal with the exception of one uterine perforation resulting in hysterectomy. The short-term success rate of surgery was 90 percent. Life table analysis suggests that by thirty months, success rates will have declined to 65 percent.Conclusions: endometrial ablation using electrosurgery has a low rate of peri-operative complications. Short-term success rates are high but life table analysis suggests long-term success rates may be much lower.     

Hysteroscopic endometrial ablation is an effective alternative to hysterectomy in women with menorrhagia and large uteri

STUDY OBJECTIVES: To examine the feasibility, safety, and outcome of hysteroscopic endometrial ablation, and to determine the volume of fluid absorbed during resection versus rollerball coagulation in women with menorrhagia and large uteri. DESIGN: Retrospective review (Canadian Task Force classification II-2). SETTING: University-affiliated teaching hospital. PATIENTS: Forty-two consecutive patients (mean +/- SD age 45.6 +/- 6 yrs) with uterine size greater than 12 weeks (cavity >12 cm). Intervention. Endometrial ablation; 26 (62%) women were pretreated to thin the endometrium. MEASUREMENTS AND MAIN RESULTS: Resection was performed in 27 patients (65%) and rollerball coagulation in 15 (35%). Ablation was successfully performed in all patients in a day surgery setting. Multiple regression analysis examined the relationship of uterine size, pretreatment, procedure, and duration of surgery to amount of glycine absorbed. Glycine absorption was higher with resection than with coagulation (p = 0.04). Fluid absorption correlated with type of procedure (r = 0.32, p = 0.04) but not with duration of the procedure, uterine size, or pretreatment. One patient with uterine fibroids and one with endometrial adenocarcinoma had hysterectomy. With follow-up of 39 (95%) of 41 women (excluding the one with adenocarcinoma) for 14 +/- 2 months, 38 (93%) were very satisfied. Thirty (73%) had amenorrhea, six (15%) had hypomenorrhea (<3 pads/day), and three (7%) had eumenorrhea (<10 pads/day). CONCLUSION: Hysteroscopic endometrial ablation may be a feasible, safe, and effective alternative to hysterectomy in women with menorrhagia and large uteri.     

Endocavitary surgical procedures, an alternative to myomectomy in patients with symptomatic fibroids

Endometrial ablation can be used in heavy menstrual bleeding due to symptomatic submucosal myomas in women without desire of pregnancy. Those methods used alone, lead to an improvement on bleeding but results are not as good as in women without myomas. They can be associated with hysteroscopic myomectomy and, then, the results on bleeding are better than myomectomy alone. Second generation endometrial ablation methods must be used preferentially as they present less surgical complications than first generation methods. As the pregnancies that may occur after endometrial ablation have high risk of complications, a contraceptive mean is highly recommended after surgery. Transcervical sterilisation by intratubal insert (Essure) can also be proposed, but for women with Essure placed before endometrial ablation, only Thermachoice and bipolar resection have proven their safety. Finally, economical outcomes of endometrial ablation in myomas haven't been assessed yet.     

Adenocarcinoma diagnosed at endometrial ablation

Background: Endometrial ablation is a surgical alternative to hysterectomy. Cases exist in the literature of endometrial adenocarcinoma found at endometrial ablation. If endometrial cancer is occult it might not be detected during ablation, especially if destructive techniques are used.Case: A 41-year-old woman had a history of menorrhagia. A previous D&C showed benign proliferative endometrium. Investigations for menorrhagia found no abnormalities. The diagnosis was dysfunctional uterine bleeding. Endometrial ablation was done and the pathologic examination of the resected endometrium found focal, well-differentiated adenocarcinoma of the endometrium.Conclusion: This case shows the importance of patient selection, evaluation, and surveillance after endometrial ablation. Resection of the endometrium is superior to destructive techniques because it provides tissue for pathologic evaluation. We recommend close postoperative surveillance in such cases.     

Improving results of hysteroscopic submucosal myomectomy for menorrhagia by concomitant endometrial ablation

STUDY OBJECTIVE: To evaluate the effect of endometrial ablation on the outcome of premenopausal patients undergoing hysteroscopic myomectomy for menorrhagia or menometrorrhagia DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Private practice. PATIENTS: One hundred seventy-seven women with one or more submucosal myomas experiencing menorrhagia or menometrorrhagia. INTERVENTION: Hysteroscopic myomectomy without endometrial ablation in 104 patients and with concomitant endometrial ablation in 73 patients. MEASUREMENTS AND MAIN RESULTS: Bleeding was controlled in 95.9% of patients with endometrial ablation and in 80.8% of patients without endometrial ablation (p = .003). Complete removal of the myoma led to better results (p = .039), which were further improved by endometrial ablation (p = .022). Endometrial ablation improved bleeding in patients whose myomas could not be completely removed, but the difference was not statistically significant (p = .23). Subsequent hysterectomies were not decreased by endometrial ablation (p = .48) or by complete removal of the myoma (p = .83). Hysterectomies for bleeding problems were decreased by endometrial ablation. Pain and dysmenorrhea were a frequent cause of hysterectomy. CONCLUSION: Endometrial ablation at the time of hysteroscopic myomectomy improves results in the control of bleeding.     

NovaSure impedance-controlled system for endometrial ablation

STUDY OBJECTIVE: To assess the efficacy and safety of the NovaSure endometrial ablation system in women with severe dysfunctional uterine bleeding (DUB). STUDY DESIGN: Prospective, single-arm, controlled, observational pilot study (Canadian Task Force classification II-1). SETTING: Free-standing center for gynecologic endoscopy. PATIENTS: One hundred seven premenopausal women whose menorrhagia was unresponsive to medical therapy, who had completed childbearing, and who had undistorted uterine cavities. INTERVENTION: Endometrial ablation with the NovaSure system. MEASUREMENTS AND MAIN RESULTS: Diaries were used to qualify patients for the study, as well as for posttreatment evaluation of menstrual blood loss and bleeding pattern (amenorrhea, spotting, hypomenorrhea, eumenorrhea, menorrhagia). No drug or mechanical endometrial pretreatment was administered. Position of the uterus was not a factor in patient selection. No intraoperative or postoperative complications occurred. Treatment time averaged 94 seconds. Of 107 women, 106 completed 6 months of follow-up and 105 had 12 months. Amenorrhea was 46% and 58%, respectively. CONCLUSION: The NovaSure System is safe and is effective in treating women with DUB. Endometrial pretreatment is not necessary, and presence of blood in the uterine cavity during treatment is not a limiting factor.     

Endometrial ablation with a new thermal balloon system

STUDY OBJECTIVE: To assess the efficacy of Thermablate EAS, a new, simple, hand-held, portable endometrial ablation instrument, in the treatment of menorrhagia. DESIGN: Retrospective observational study (Canadian Task Force classification II-1). SETTING: Urban hospital and private clinic facilities in Bombay, India. PATIENTS: Sixteen women with menorrhagia. INTERVENTION: Endometrial ablation with the Thermablate EAS. MEASUREMENTS AND MAIN RESULTS: Follow-up at 6 months showed eight patients (50%) to have amenorrhea and six (38%) hypomenorrhea. The only failure was in a patient with cystic hyperplasia. No complications occurred. CONCLUSIONS: Thermablate EAS is a promising instrument for endometrial ablation.