Mentor: Meg Autry, MD
Editor: Daniel Breitkopf, MD
Endometrial ablation can be performed by several different minimally invasive procedures which cause surgical destruction of the endometrium to treat abnormal uterine bleeding (AUB). The techniques for endometrial ablation are grouped into 2 major categories: resectoscopic and non-resectoscopic. Resectoscopic endometrial ablation, often referred to as first generation, relies on direct hysteroscopic visualization of the endometrial cavity. Non-resectoscopic techniques, known as second generation, use various energy sources including bipolar radiofrequency and heated water 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 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. Absolute 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.
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.
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Initial Approval March 2019
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