What is endometrial ablation used for and what are the considerations before undergoing the procedure?

From the Guidelines

Endometrial ablation is a procedure used to reduce or stop heavy menstrual bleeding by permanently removing the endometrial lining of the uterus, and it should only be considered for women who have completed childbearing and have failed medical therapy, as indicated by the most recent guidelines 1.

Key Considerations

Before undergoing endometrial ablation, several important considerations must be addressed, including:

• The procedure is only suitable for women who have completed childbearing, as pregnancy after ablation carries significant risks including miscarriage and abnormal placentation 1.
• A thorough pre-procedure evaluation includes ruling out uterine cancer through endometrial biopsy, confirming normal Pap smear results, and ensuring the absence of active pelvic infection.
• The uterine cavity should be evaluated with ultrasound, hysteroscopy, or sonohysterography to rule out structural abnormalities like fibroids or polyps that might interfere with the procedure.

Procedure Details

The procedure can be performed using various techniques including radiofrequency, heated fluid, freezing, microwave energy, or electrosurgical methods, with recovery typically taking a few days to two weeks depending on the specific method used.

Outcomes and Risks

Patients should understand that while ablation significantly reduces menstrual bleeding in 90% of women, with 30-50% experiencing complete cessation of periods, it is not a sterilization procedure, and reliable contraception remains necessary afterward 1. Additionally, possible long-term complications of endometrial ablation include postablation Asherman syndrome, synechiae, cervical stenosis, contracture of the endometrium, strictures, endometrial distortion, and delayed endometrial cancer diagnosis 1.

Recommendations

Based on the most recent and highest quality study 1, endometrial ablation should only be performed after failure of medical therapy, and patients should be thoroughly counseled on the potential risks and benefits of the procedure.

From the Research

Overview of Endometrial Ablation

• Endometrial ablation is a surgical procedure used to treat heavy menstrual bleeding (HMB) in premenopausal women 2, 3, 4, 5, 6.
• The procedure involves removing or destroying the lining of the uterus (endometrium) to reduce or stop menstrual bleeding.

Indications and Considerations

• Endometrial ablation is considered for women with HMB who have not responded to medical therapy and want to avoid hysterectomy 2, 3, 4.
• The procedure is not recommended for women who want to preserve their fertility, as it can lead to infertility and complications in future pregnancies 5.
• Women with a history of dysmenorrhea, tubal ligation, or other uterine pathology should be carefully selected and counseled about the potential risks and benefits of endometrial ablation 3, 5.

Types of Endometrial Ablation Techniques

• First-generation techniques, such as endometrial laser ablation, transcervical resection of the endometrium, and rollerball endometrial ablation, require hysteroscopic visualization and are considered the gold standard 2, 4.
• Second-generation techniques, such as thermal balloon endometrial ablation, microwave endometrial ablation, and bipolar radiofrequency endometrial ablation, are less invasive and do not require hysteroscopic visualization 2, 3, 4, 6.
• Third-generation techniques are also available, but there is limited evidence on their efficacy and safety compared to first- and second-generation techniques 2.

Efficacy and Safety

• Endometrial ablation is effective in reducing HMB, with success rates ranging from 70% to 90% 2, 3, 4, 6.
• Second-generation techniques are associated with shorter operating times, less blood loss, and fewer complications compared to first-generation techniques 2, 3, 4.
• However, endometrial ablation is not without risks, including perforation, infection, and future pregnancy complications 2, 3, 4, 5.

Long-Term Outcomes

• Long-term data on endometrial ablation show that hysterectomy rates are around 20% at 2 years, with a further 3-5% having repeat ablations 6.
• Second-generation techniques are associated with higher amenorrhea rates and lower rates of repeat or further intervention compared to hysteroscopic approaches 6.
• Chronic pelvic pain can resolve or develop de novo after endometrial ablation, and pregnancy outcomes are poor, emphasizing the need for continued contraception 6.