Is endometrial ablation suitable for abnormal uterine bleeding in a patient with a history of tubal ligation and molar pregnancy?

Endometrial Ablation is Not Recommended for Patients with Prior Tubal Ligation and History of Molar Pregnancy

Endometrial ablation is contraindicated for patients with a history of molar pregnancy, and while tubal ligation provides contraception, the combination still presents significant risks that outweigh potential benefits.

Risks of Endometrial Ablation with History of Molar Pregnancy

• Endometrial ablation is specifically contraindicated in patients with a history of molar pregnancy due to the risk of undetected recurrent gestational trophoblastic disease that could be masked by the ablated endometrium 1
• The ablated endometrium makes it difficult to detect early signs of gestational trophoblastic disease recurrence on ultrasound, which typically appears as a hyperechoic area with multiple cystic spaces 1
• Monitoring for recurrent gestational trophoblastic disease, which requires endometrial sampling and hCG monitoring, is complicated by endometrial ablation 1

Complications Related to Prior Tubal Ligation

• Patients with a history of tubal ligation and dysmenorrhea should consider alternative treatments as they are more likely to experience postablation pain and treatment failure 2
• Studies have shown that patients with associated adenomyosis or prior tubal ligation were significantly more likely to have continued bleeding after endometrial ablation 3
• Post-ablation tubal sterilization syndrome is a recognized complication that can cause pain-related obstructed menses (hematometra) 4

Treatment Failure and Long-term Complications

• Approximately 20-25% of patients experience symptom recurrence within 5-7 years after endometrial ablation 1
• Treatment failure of endometrial ablation for heavy menstrual bleeding has been specifically associated with the presence of adenomyosis 5
• Serious complications can occur even with tubal ligation, as demonstrated in a case report of placenta percreta and incomplete uterine rupture after endometrial ablation with tubal occlusion 6

Alternative Treatment Options

• The levonorgestrel intrauterine device is a cost-effective alternative with higher quality of life and fewer complications compared to endometrial ablation 2
• Hysterectomy remains the definitive treatment with higher quality of life and fewer complications for patients who do not desire future fertility 2
• Hysterectomy eliminates the risk of new fibroid formation and allows for simultaneous treatment of concomitant intrauterine disease such as adenomyosis, endometriosis, high-risk cervical dysplasia, uterine prolapse, or intrauterine malignancy 5

Recommendation for This Patient

• Given the patient's history of both tubal ligation and molar pregnancy, hysterectomy would be the most appropriate treatment for abnormal uterine bleeding 5, 1
• If the patient strongly desires uterine preservation, medical management options should be considered first, with the levonorgestrel intrauterine device being the preferred option 2
• If surgical intervention is necessary and the patient refuses hysterectomy, the risks of endometrial ablation should be thoroughly discussed, including the potential for treatment failure, continued bleeding, and complications related to monitoring for recurrent gestational trophoblastic disease 1, 4