Endometrial Ablation
- Article Author:
- Nicole Minalt
- Article Author:
- Christinne Canela
- Article Editor:
- Sarah Marino
- Updated:
- 11/3/2020 9:34:55 AM
- For CME on this topic:
- Endometrial Ablation CME
- PubMed Link:
- Endometrial Ablation
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 and Physiology
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, 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 an interprofessional team that includes a gynecology nurse and obstetrical specialist. 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.
During and after the procedure the nurse should monitor the vital signs and for any signs of bleeding. If there are untoward changes, the nurse should immediately report their findings to the clinician providing primary management of the case.
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. The best outcomes will be achieved by an interprofessional team caring for the patient. [Level V]