Is ablation (endometrial ablation) indicated for a patient with an average-sized uterus, homogenous myometrial texture, and no sizable focal lesions?

Endometrial Ablation is NOT Indicated in This Case

Based on the imaging findings described—an average-sized uterus with homogenous myometrium, no focal lesions, and a thin endometrium measuring only 2 mm—endometrial ablation is not indicated without additional critical clinical information.

Essential Missing Information Required Before Any Treatment Decision

The imaging findings alone are insufficient to determine appropriateness of endometrial ablation. The following must be established:

Clinical Symptoms

• Is the patient experiencing abnormal uterine bleeding (heavy menstrual bleeding, menorrhagia)? Endometrial ablation is specifically indicated for treatment of heavy menstrual bleeding refractory to medical therapy, not for incidental imaging findings 1, 2, 3.
• Is the patient experiencing bulk symptoms (pressure, pain, fullness, bowel or bladder symptoms)? These would suggest fibroids as the primary issue, not an endometrial problem 1.
• Is the patient asymptomatic? If so, no intervention is warranted 1.

Menopausal Status

• Is the patient premenopausal or postmenopausal? This fundamentally changes the diagnostic and treatment approach 1, 4.
• In postmenopausal women, an endometrium measuring 2 mm is well below the 4-5 mm threshold that would trigger concern for malignancy 4, 5.

Fertility Desires

• Does the patient desire future pregnancy? Endometrial ablation is absolutely contraindicated in women who desire future fertility, as it irreversibly destroys the endometrial lining and is associated with high risk of pregnancy complications including extrauterine pregnancy, preterm delivery, and stillbirth 1, 2.

Why Endometrial Ablation is Likely NOT Appropriate Here

The Endometrium is Too Thin

• A 2 mm endometrium suggests minimal endometrial tissue present, which is not consistent with the typical pathology requiring ablation 4, 5.
• Endometrial ablation is designed to destroy proliferative or hyperplastic endometrium causing heavy menstrual bleeding 2, 3.
• In postmenopausal women, 2 mm endometrial thickness has a nearly 100% negative predictive value for endometrial cancer and requires no intervention if asymptomatic 4, 5.

No Structural Pathology Identified

• The imaging shows no focal lesions, no fibroids, and homogenous myometrium [@question context].
• Endometrial ablation may be considered when small submucosal fibroids are present, but has a 23% failure rate with submucosal fibroids compared to 4% in normal cavities [@2@, 1].
• The absence of pathology suggests either the patient is asymptomatic (no treatment needed) or the bleeding has another etiology requiring different investigation 1.

Proper Indications for Endometrial Ablation

Endometrial ablation should only be considered when ALL of the following criteria are met:

Absolute Requirements

• Completed childbearing with permanent contraception in place or planned, as pregnancy after ablation carries severe risks [@5@, 1,2].
• Documented heavy menstrual bleeding (menorrhagia) causing significant impact on quality of life [@11@, @12@, 3].
• Failure of or intolerance to medical therapy (hormonal contraceptives, NSAIDs, tranexamic acid, levonorgestrel IUD) [1, @6@, 2].
• Benign etiology confirmed through endometrial sampling to exclude hyperplasia or malignancy [@1@, @11@, @12@].
• Normal or near-normal uterine cavity size (most devices accommodate cavities up to 10 cm) [@2@, 1].

Relative Contraindications to Consider

• History of tubal ligation and dysmenorrhea are associated with higher rates of postablation pain and treatment failure; these patients should consider alternative treatments [@10@].
• Presence of adenomyosis or multiple fibroids increases failure rates and need for subsequent hysterectomy [@2@, 1, @13@].
• Age under 40 years may be associated with higher long-term failure rates due to longer follow-up time [@3@].

Critical Next Steps Before Any Treatment

If Premenopausal with Bleeding Symptoms

1. Endometrial sampling is mandatory to exclude hyperplasia or malignancy before considering ablation [@1@, 2, @12@].
2. Trial of medical therapy first: levonorgestrel IUD is cost-effective with higher quality of life and fewer complications than ablation 6.
3. Hysteroscopy to visualize the cavity and confirm no focal lesions were missed by imaging 1, 2.

If Postmenopausal

1. With a 2 mm endometrium and no bleeding, no intervention is needed 4, 5.
2. If bleeding is present despite thin endometrium, endometrial sampling is mandatory to exclude malignancy, as cancer can present with minimal endometrial thickening [@7@, 4].
3. Endometrial ablation is NOT appropriate for postmenopausal bleeding—diagnosis and treatment of the underlying cause (cancer, atrophy, polyps) is required [@5@, @8@].

Important Caveats and Pitfalls

• The levonorgestrel IUD should be offered as first-line therapy before ablation, as it is more cost-effective with higher quality of life and fewer long-term complications 6.
• Endometrial ablation does not provide contraception and carries serious pregnancy risks if contraception fails [@6@, 2].
• Long-term complications of ablation include postablation syndrome with cyclic pelvic pain, hematometra, cervical stenosis, and potential delayed diagnosis of endometrial cancer [@1@, @10@].
• Hysterectomy, while more invasive initially, provides definitive treatment with higher long-term quality of life and satisfaction compared to ablation, and should be discussed as an alternative [@6@, @10@].
• Patients with history of cesarean section or uterine surgery may have higher perforation risk during ablation [@11