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Endometrial Ablation

Endometrial ablation (EAB) is a safe and effective minimally invasive surgical procedure in the treatment of abnormal uterine bleeding (AUB) in patients not desiring future fertility and when medical management is insufficient and provides an alternative to more invasive surgical techniques like hysterectomy.

EAB is divided into first-generation (resectoscopic) and second-generation (non-resectoscopic) techniques. Non-resectoscopic techniques, including are technically easier to perform than resectoscopic techniques, have shorter operative times, and can be done in procedure rooms rather than formal operating rooms. Both techniques have comparable results with respect to patient satisfaction and reduction of heavy menstrual bleeding.

The first-generation endometrial ablative techniques are hysteroscopic methods, including rollerball ablation, laser ablation and transcervical resection of the endometrium. The most common methods second-generation techniques include the use high-temperature fluids within a balloon (e.g. Thermachoice) and bipolar radiofrequency electrical energy (e.g. Novasure).

Both first-generation and second-generation EAB have low complication rates. Uterine perforation, fluid overload, hematometra, and cervical lacerations are more common with first-generation EAB; perioperative nausea/vomiting, uterine cramping, and pain are more common with second-generation endometrial ablation. Overall, approximately 30-40% of women report amenorrhea at 1 year and 50% at 2-5 years following ablation, with patient satisfaction ranging from 80-90%.

Contraindications to EAB include pregnancy, known or suspected endometrial hyperplasia or cancer, desire for future fertility, active pelvic infection, IUD currently in situ, and being post-menopausal.  In general, EAB should be avoided in patients with congenital uterine anomalies, severe myometrial thinning, and uterine cavity lengths that exceed the capacity of the ablative technique (usually greater than 10-12 cm). 

Pregnancies following ablation have been associated with adverse outcomes including fetal malpresentation, preterm delivery, growth restriction, abnormal placentation, and perinatal mortality. 

Progestin therapy or correction of anovulation is recommended instead of endometrial ablation for women with chronic anovulation because of concerns about hyperplasia. Women should be informed that amenorrhea is not guaranteed with endometrial ablation and that reduction or normalization of menstrual flow is more likely.

Risks of the procedure in general and related to the specific ablative technique should be reviewed pre-operatively, including failure and post-ablation pain.  Approximately 25% of patients who have had an endometrial ablation undergo a hysterectomy within 5 years of their ablation for treatment of persistent AUB or pain.   Predictors of treatment failure include age < 45, parity > 5, pre-operative dysmenorrhea, and a history of tubal ligation.   Women who have had a tubal ligation are at risk of post-ablation tubal sterilization syndrome, a condition characterized by cyclic pelvic pain due to residual active endometrium near the cornua leading to obstructed hematometra.

Despite these high levels of efficacy, studies consistently show that approximately 20% of patients receiving EA will ultimately require a hysterectomy to relieve their symptoms.

 

Further reading:

ACOG committee opinion no. 557: Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Obstet Gynecol. 2013 Apr;121(4):891-896. doi: 10.1097/01.AOG.0000428646.67925.9a. PMID: 23635706.

Famuyide A. Endometrial Ablation. J Minim Invasive Gynecol. 2018 Feb;25(2):299-307. doi: 10.1016/j.jmig.2017.08.656. Epub 2017 Sep 6.

Leathersich SJ and McGurgan PM. Endometrial resection and global ablation in the normal uterus. Best Pract Res Clin Obstet Gynaecol. 2018 Jan;46:84-98. doi: 10.1016/j.bpobgyn.2017.09.006. Epub 2017 Sep 28.

 

Initial Approval: March 2019. Reaffirmed November 2020. Reaffirmed May 2022. Minor revision March 2024.  Revised February 2026.

 

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