3/1/2019

Endometrial Ablation

Author: Sara Whetstone, MD, MHS

Mentor: Meg Autry, MD

Editor: William Po, MD

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Endometrial ablation can be performed by several different minimally invasive procedures which cause surgical destruction of the endometrium to treat abnormal uterine bleeding (AUB). First generation technique involves the use of a resectoscope with direct visualization of the endometrial cavity. The resectoscopic technique has become less common with the introduction of non-resectoscopic techniques that use various energy sources including bipolar radiofrequency, Microwave, Cryotherapy and Hydrothermal modalities to accomplish global endometrial destruction. Both types of procedures appear equivalent in reduction of menstrual bleeding and patient satisfaction. Approximately 30-40% of women report amenorrhea at 1 year and 50% at 2-5 years following ablation. Patient satisfaction with the procedure is quite high, ranging from 80-90%.

Endometrial ablation is primarily intended to treat premenopausal women with heavy menstrual bleeding (HMB) who do not desire future fertility. Women who choose endometrial ablation often have failed or declined medical management. Contraindications to endometrial ablation 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, endometrial ablation 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). Progestin therapy or correction of anovulation is recommended instead of endometrial ablation for women with chronic anovulation because of concerns about hyperplasia.

The need for surgical treatment is based on the clinical stability of the patient, the severity of bleeding, contraindications to medical management, the patient’s lack of response to medical management, and the underlying medical condition of the patient. The choice of surgical modality should be based on the aforementioned factors plus the patient’s desire for future fertility.

Women who desire endometrial ablation should be made aware of all medical and surgical options to treat AUB. Women should be informed that amenorrhea is not guaranteed with endometrial ablation and that reduction or normalization of menstrual flow is more likely. Endometrial ablation is an effective alternative to hysterectomy for AUB. 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.

The pre-operative evaluation requires assessment of the structure and histology of the endometrium. Women should have endometrial sampling prior to ablation. The uterine cavity should be evaluated for length and presence of structural anomalies and intracavitary lesions, which can be done with uterine sounding, ultrasound, saline infusion sonogram, or hysteroscopy. Women who elect to proceed with endometrial ablation must be counseled about the need for contraception as ablation does not reliably prevent pregnancy. Pregnancies following ablation have been associated with adverse outcomes including fetal malpresentation, preterm delivery, growth restriction, abnormal placentation, and perinatal mortality.

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 2023

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This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

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