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Marchand GJ, Masoud A, Grover S, King A, Brazil G, Ulibarri H, Parise J, Arroyo A, Coriell C, Moir C, Govindan M. First and second-generation endometrial ablation devices: A network meta-analysis. BMJ Open 2024; 14:e065966. [PMID: 38806429 PMCID: PMC11138282 DOI: 10.1136/bmjopen-2022-065966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 09/06/2023] [Indexed: 05/30/2024] Open
Abstract
OBJECTIVE First-generation and second-generation endometrial ablation (EA) techniques, along with medical treatment and invasive surgery, are considered successful lines of management for abnormal uterine bleeding (AUB). We set out to determine the efficacy of first and second-generation ablation techniques compared with medical treatment, invasive surgery and different modalities of the EA techniques themselves. DESIGN Systematic review and network meta-analysis using a frequentist network. DATA SOURCES We searched Medline (Ovid), PubMed, ClinicalTrials.gov, Cochrane CENTRAL, Web of Science, EBSCO and Scopus for all published studies up to 1 March 2021 using relevant keywords. ELIGIBILITY CRITERIA We included all randomised controlled trials (RCTs) that compared premenopausal women with AUB receiving the intervention of second-generation EA techniques. DATA EXTRACTION AND SYNTHESIS 49 high-quality RCTs with 8038 women were included. We extracted and pooled the data and then analysed to estimate the network meta-analysis models within a frequentist framework. We used the random-effects model of the netmeta package in R (V.3.6.1) and the 'Meta-Insight' website. RESULTS Our network meta-analysis showed many varying results according to specific outcomes. The uterine balloon ablation had significantly higher amenorrhoea rates than other techniques in both short (hydrothermal ablation (risk ratio (RR)=0.51, 95% CI 0.37; 0.72), microwave ablation (RR=0.43, 95% CI 0.31; 0.59), first-generation techniques (RR=0.44, 95% CI 0.33; 0.59), endometrial laser intrauterine therapy (RR=0.18, 95% CI 0.10; 0.32) and bipolar radio frequency treatments (RR=0.22, 95% CI 0.15; 0.31)) and long-term follow-up (microwave ablation (RR=0.11, 95% CI 0.01; 0.86), bipolar radio frequency ablation (RR=0.12, 95% CI 0.02; 0.90), first generation (RR=0.12, 95% CI 0.02; 0.90) and endometrial laser intrauterine thermal therapy (RR=0.04, 95% CI 0.01; 0.36)). When calculating efficacy based only on calculated bleeding scores, the highest scores were achieved by cryoablation systems (p-score=0.98). CONCLUSION Most second-generation EA systems were superior to first-generation systems, and statistical superiority between devices depended on which characteristic was measured (secondary amenorrhoea rate, treatment of AUB, patient satisfaction or treatment of dysmenorrhoea). Although our study was limited by a paucity of data comparing large numbers of devices, we conclude that there is no evidence at this time that any one of the examined second-generation systems is clearly superior to all others.
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Affiliation(s)
- Greg J Marchand
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Ahmed Masoud
- Fayoum University Faculty of Medicine, Fayoum, Egypt
| | | | - Alexa King
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Giovanna Brazil
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Hollie Ulibarri
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Julia Parise
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Amanda Arroyo
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Catherine Coriell
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Carmen Moir
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Malini Govindan
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
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Impact of combined endometrial resection or ablation and levonorgestrel intrauterine device on postoperative bleeding pattern. Arch Gynecol Obstet 2023; 307:493-499. [PMID: 36129518 DOI: 10.1007/s00404-022-06790-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/07/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE The aim of this study was to describe the rate of amenorrhea in women treated with transcervical endometrial resection (TCER) or radiofrequency endometrial ablation combined with levonorgestrel intrauterine contraceptive device (LNG-IUD) six months post-operatively. METHODS The study was performed as a prospective cohort study. All patients were included at four gynecological centers in Region of Southern Denmark. In total, 162 women referred due to menorrhagia, metrorrhagia or menometrorrhagia and offered TCER or radiofrequency endometrial ablation in combination with or without LNG-IUD included during November 2018 to June 2021 at the women's own discretion and without any cost (covered by the hospital). Data were analyzed using a multivariate regression model. RESULTS In total, 58 women were offered TCER and 31 (53.4%) combined treatment with TCER + LNG-IUD. Among 104 women who received radiofrequency endometrial ablation, 46 (44.2%) underwent combined treatment with LNG-IUD. The incidence of amenorrhea was 26% among women who underwent treatment with TCRE and 52% when treated with TCER + LNG-IUD (adjusted OR 5.16; 95% CI 1.35-19.6; P < 0.016). Radiofrequency endometrial ablation was followed by a 41% incidence of amenorrhea, and when radiofrequency endometrial ablation was combined with LNG-IUD, the incidence of amenorrhea was 63% (adjusted OR 2.15; 95% CI 0.86-5.37; P < 0.1). We observed no statistically significant differences when comparing the groups across. CONCLUSION Our study suggests that the combination of TCER or radiofrequency endometrial ablation with LNG-IUD was superior to TCER. However, the combined treatment of radiofrequency endometrial ablation with LNG-IUD did not reach statistical significance. Further studies are needed to evaluate the effects of different ablation techniques on the amenorrhea rate.
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Geary RS, Gurol-Urganci I, Kiran A, Cromwell DA, Bansi-Matharu L, Shakespeare J, Mahmood T, van der Meulen J. Factors associated with receiving surgical treatment for menorrhagia in England and Wales: findings from a cohort study of the National Heavy Menstrual Bleeding Audit. BMJ Open 2019; 9:e024260. [PMID: 30782899 PMCID: PMC6377553 DOI: 10.1136/bmjopen-2018-024260] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 11/23/2018] [Accepted: 11/23/2018] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To examine the factors associated with receiving surgery for heavy menstrual bleeding (HMB) in England and Wales. DESIGN National cohort study. SETTING National Health Service hospitals. PARTICIPANTS Women with HMB aged 18-60 who had a new referral to secondary care. METHODS Patient-reported data linked to administrative hospital data. Risk ratios (RR) estimated using multivariable Poisson regression. PRIMARY OUTCOME MEASURE Surgery within 1 year of first outpatient clinic visit. RESULTS 14 545 women were included. At their first clinic visit, mean age was 42 years, mean symptom severity score was 62 (scale ranging from 0 (least) to 100 (most severe)), 73.9% of women reported having symptoms for >1 year and 30.4% reported no prior treatment in primary care. One year later, 42.6% had received surgery. Of these, 57.8% had endometrial ablation and 37.2% hysterectomy. Women with more severe symptoms were more likely to have received surgery (most vs least severe quintile, 33.1% vs 56.0%; RR 1.6, 95% CI 1.5 to 1.7). Surgery was more likely among those who reported prior primary care treatment compared with those who did not (48.0% vs 31.1%; RR 1.5, 95% CI 1.4 to 1.6). Surgery was less likely among Asian and more likely among black women, compared with white women. Surgery was not associated with socioeconomic deprivation. CONCLUSIONS Receipt of surgery for HMB depends on symptom severity and prior treatment in primary care. Referral pathways should be locally audited to ensure women with HMB receive care that addresses their individual needs and preferences, especially for those who do not receive treatment in primary care.
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Affiliation(s)
- Rebecca Sally Geary
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Ipek Gurol-Urganci
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Amit Kiran
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
| | - David A Cromwell
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
| | | | | | - Tahir Mahmood
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
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Abstract
Global endometrial ablation is a commonly performed, minimally invasive technique aimed at improving/resolving abnormal uterine bleeding and menorrhagia in women. As non-resectoscopic techniques have come into existence, endometrial ablation performance continues to increase due to accessibility and decreased requirements for operating room time and advanced technical training. The increased utilization of this method translates into increased imaging of patients who have undergone the procedure. An understanding of the expected imaging appearances of endometrial ablation using different modalities is important for the abdominal radiologist. In addition, the frequent usage of the technique naturally comes with complications requiring appropriate imaging work-up. We review the expected appearance of the post-endometrial ablated uterus on multiple imaging modalities and demonstrate the more common and rare complications seen in the immediate post-procedural time period and remotely.
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Lee MHM. Effectiveness of bipolar impedance controlled radiofrequency (NovaSure) endometrial ablation for the treatment of menorrhagia in Hong Kong Chinese women ☆. Gynecol Minim Invasive Ther 2018; 6:186-190. [PMID: 30254911 PMCID: PMC6135189 DOI: 10.1016/j.gmit.2017.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 06/12/2017] [Accepted: 06/14/2017] [Indexed: 11/25/2022] Open
Abstract
Objective: Bipolar impedance controlled radiofrequency endometrial ablation is a valuable treatment options for menorrhagia. We examined the short term outcomes of Hong Kong Chinese women undergone this procedure. Material: All patients who underwent this procedure at Queen Elizabeth Hospital, Hong Kong during January 2013 to August 2016. Method this is a prospective cohort study where the menstruation status among the selected patients was questioned at each 6 monthly follow-up after the procedure. A validated MIQ (menorrhagia impact questionnaire) was sent to assess quality of life before and after the procedure. Result: 44 patients underwent the procedure. 77.4% had reduced or minimal bleeding with 19.4% achieving amenorrhoea. 96.77% were found to have reduced bleeding or amenorrhoeic at 3 months; 96.3% at 6 months, 95.83% at 12 months; 95.45% at 18 months; 100% at 24 and 36 months of follow up. Endometritis occurred in 9.7%. No case required blood transfusion or other surgical management post-operatively. Improvement in all aspects of MIQ was seen when compared post-operative scores to preoperative scores (p < 0.01). 100% claimed improvement in menstruation and 87.1% suggested they would recommend the procedure to family and friends. Conclusions: Bipolar impedance controlled radiofrequency endometrial ablation appears to be an effective method for managing menorrhagia amongst Chinese women in Hong Kong.
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Bardawil E, Kohn J, Blazek K, Chohan L, Zurawin R, Guan X. Endometrial Ablation—Current Evidence for Patient Optimization and Long-Term Outcomes. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2018. [DOI: 10.1007/s13669-018-0237-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Scordalakes C, delRosario R, Shimer A, Stankiewicz R. Efficacy and patient satisfaction after NovaSure and Minerva endometrial ablation for treating abnormal uterine bleeding: a retrospective comparative study. Int J Womens Health 2018; 10:137-145. [PMID: 29713204 PMCID: PMC5912370 DOI: 10.2147/ijwh.s153699] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective Compare amenorrhea rate, menstrual symptoms, patient satisfaction, and adverse events in women who underwent endometrial ablation with the NovaSure versus the Minerva radiofrequency ablation systems. Methods We surveyed 189 premenopausal women (mean 40.8±6.2 years old) who underwent endometrial ablation for abnormal uterine bleeding using the NovaSure (n=97) or Minerva (n=92) systems, at four private US gynecology clinics, and whose procedure date was after July 2015 with follow-up ≥3 months. Women were surveyed an average of 11.3±3.9 months (range 137–532 days) after ablation. Results The subject-reported amenorrhea rate was 52% higher in NovaSure subjects than Minerva subjects (64% and 42%, respectively; p=0.004). Age and bleeding cyclicity did not affect amenorrhea rate in either group. Normal-to-no bleeding was reported by >90% of subjects after either treatment. NovaSure was significantly more effective than Minerva at reducing pad/tampon use in women with any residual bleeding (2.4±5.2 items/day versus 4.7±5.5 items/day, p=0.049). NovaSure was significantly more effective than Minerva at reducing premenstrual syndrome (PMS) symptoms (p=0.019) and menstrual pain (p=0.003), and more NovaSure subjects (94%) than Minerva subjects (78%) were satisfied with clinical outcomes (p=0.003). Adverse events did not differ by treatment; three women in each group progressed to hysterectomy. Conclusion While overall bleeding reduction in premenopausal women with abnormal uterine bleeding was excellent with either endometrial ablation system, NovaSure treatment resulted in a higher patient-reported 1-year amenorrhea rate, and women with residual bleeding used fewer pads and tampons than Minerva-treated women. Additionally, NovaSure subjects reported better menstrual-related life quality and PMS symptom alleviation, and greater satisfaction with outcomes than Minerva-treated women.
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Cooper K, McCormack K, Breeman S, Wood J, Scott NW, Clark J, Hawe J, Hawthorn R, Phillips K, Hyde A, McDonald A, Forrest M, Wileman S, Scotland G, Norrie J, Bhattacharya S. HEALTH: laparoscopic supracervical hysterectomy versus second-generation endometrial ablation for the treatment of heavy menstrual bleeding: study protocol for a randomised controlled trial. Trials 2018; 19:63. [PMID: 29368658 PMCID: PMC5784594 DOI: 10.1186/s13063-017-2374-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 12/04/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Heavy menstrual bleeding (HMB) is a common problem affecting approximately 1.5 million women in England and Wales with a major impact on their physical, emotional, social and material quality of life. It is the fourth most common reason why women attend gynaecology outpatient clinics and accounts for one-fifth of all gynaecology outpatient referrals. Initial treatment in primary care is medical - either by means of oral or injected medication or the levonorgestrel-intrauterine system (Mirena®). If medical treatment fails then surgical treatment can be offered, either endometrial ablation (EA), which destroys the lining of the cavity of the uterus (endometrium), or hysterectomy, i.e. surgical removal of the uterus. While effective, conventional hysterectomy is invasive and carries a risk of complications due to injury to other pelvic structures. The procedure can be simplified and complications minimised by undertaking a 'supracervical' hysterectomy where the cervix is left in situ and only the body of the uterus removed. Recent advances in endoscopic technologies have facilitated increased use of laparoscopic supracervical hysterectomy (LASH) which can be performed as a day-case procedure and is relatively easy for the surgeon to learn. HEALTH (Hysterectomy or Endometrial AbLation Trial for Heavy menstrual bleeding) aims to address the question 'Is LASH superior to second generation EA for the treatment of HMB in terms of clinical and cost effectiveness?' METHODS/DESIGN Women aged < 50 years, with HMB, in whom medical treatment has failed and who are eligible for EA will be considered for trial entry. We aim to recruit women from approximately 30 active secondary care centres in the UK NHS who carry out both surgical procedures. All women who consent will complete a diary of pain symptoms from day 1 to day 14 after surgery, postal questionnaires at six weeks and six months after surgery and 15 months post randomisation. Healthcare utilisation questions will also be completed at the six-week, six-month and 15-month time-points. DISCUSSION Measuring the comparative effectiveness of LASH vs EA will provide the robust evidence required to determine whether the new technique should be adopted widely in the NHS. TRIAL REGISTRATION International Standard Randomised Controlled Trials, ISRCTN49013893 . Registered on 28 January 2014.
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Affiliation(s)
- Kevin Cooper
- NHS Grampian, Aberdeen Royal Infirmary, Foresterhill Road, Aberdeen, AB25 2ZN UK
| | - Kirsty McCormack
- Centre for Healthcare Randomised Trials, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD UK
| | - Suzanne Breeman
- Centre for Healthcare Randomised Trials, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD UK
| | - Jessica Wood
- Centre for Healthcare Randomised Trials, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD UK
| | - Neil W. Scott
- Medical Statistics Team, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD UK
| | - Justin Clark
- Birmingham Women’s NHS Foundation Trust, Birmingham Women’s Hospital, Mindelsohn Way, Birmingham, B15 2TG UK
| | - Jed Hawe
- Countess of Chester Hospital NHS Foundation Trust, Countess of Chester Health Park, Liverpool Road, Chester, CH2 1UL UK
| | - Robert Hawthorn
- NHS Greater Glasgow and Clyde, Southern General Hospital, 1345 Govan Road, Glasgow, G51 4TF UK
| | - Kevin Phillips
- Hull and East Yorkshire Hospitals NHS Trust, Castle Hill Hospital, Castle Road, Cottingham, HU16 5JQ UK
| | - Angela Hyde
- Royal College of Obstetricians and Gynaecologists Women’s Network, Regent’s Park, London, NW1 4RG UK
| | - Alison McDonald
- Centre for Healthcare Randomised Trials, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD UK
| | - Mark Forrest
- Centre for Healthcare Randomised Trials, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD UK
| | - Samantha Wileman
- Centre for Healthcare Randomised Trials, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD UK
| | - Graham Scotland
- Health Economics Research Unit, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD UK
| | - John Norrie
- Medical Statistics and Trial Methodology, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Little France Road, Edinburgh, EH16 4UX UK
| | - Siladitya Bhattacharya
- NHS Grampian, Aberdeen Royal Infirmary, Foresterhill Road, Aberdeen, AB25 2ZN UK
- Institute of Applied Health Sciences, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD UK
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Klebanoff J, Makai GE, Patel NR, Hoffman MK. Incidence and predictors of failed second-generation endometrial ablation. GYNECOLOGICAL SURGERY 2017; 14:26. [PMID: 29263716 PMCID: PMC5732311 DOI: 10.1186/s10397-017-1030-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 11/28/2017] [Indexed: 11/10/2022]
Abstract
Background The need for any treatment following an endometrial ablation is frequently cited as “failed therapy,” with the two most common secondary interventions being repeat ablation and hysterectomy. Since second-generation devices have become standard of care, no large cohort study has assessed treatment outcomes with regard to only these newer devices. We sought to determine the incidence and predictors of failed second-generation endometrial ablation, defined as the need for surgical re-intervention. We performed a retrospective cohort study at a single academic-affiliated community hospital. Subjects included women undergoing second-generation endometrial ablation for benign indications between October 2003 and March 2016. Second-generation devices utilized during the study period included the radiofrequency ablation device (RFA), hydrothermal ablation device (HTA), and the uterine balloon ablation system (UBA). Results Five thousand nine hundred thirty-six women underwent endometrial ablation at a single institution (3757 RFA (63.3%), 1848 HTA (31.1%), and 331 UBA (5.6%)). The primary outcome assessed was surgical re-intervention, defined as hysterectomy or repeat endometrial ablation. Of the total 927 (15.6%) women who required re-intervention, 822 (13.9%) underwent hysterectomy and 105 (1.8%) underwent repeat endometrial ablation. Women who underwent re-intervention were younger (41.6 versus 42.9 years, p < .001), were more often African-American (21.8% versus 16.2%, p < .001), and were more likely to have had a primary radiofrequency ablation procedure (hazard ratio 1.37; 95%CI 1.01 to 1.86). Older age was associated with decreased risk for treatment failure with women older than 45 years of age having the lowest risk for failure (p < .001). Age between 35 and 40 years conferred the highest risk of treatment failure (HR 1.59, 95% CI 1.32–1.92). Indications for re-intervention following ablation included menorrhagia (81.8%), abnormal uterine bleeding (27.8%), polyps/fibroids (18.7%), and pain (9.5%). Conclusion Surgical re-intervention was required in 15.6% of women who underwent second-generation endometrial ablation. Age, ethnicity, and radiofrequency ablation were significant risk factors for failed endometrial ablation, and menorrhagia was the leading indication for re-intervention.
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Affiliation(s)
- Jordan Klebanoff
- Department of Obstetrics & Gynecology, Christiana Care Health System, 4755 Ogletown-Stanton Road, Suite 1905, Newark, DE 19718 USA
| | - Gretchen E Makai
- Division of Minimally Invasive Gynecology, Christiana Care Health System, Newark, DE USA
| | - Nima R Patel
- Division of Minimally Invasive Gynecology, Christiana Care Health System, Newark, DE USA
| | - Matthew K Hoffman
- Department of Obstetrics & Gynecology, Christiana Care Health System, 4755 Ogletown-Stanton Road, Suite 1905, Newark, DE 19718 USA
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Update on the management of abnormal uterine bleeding. J Gynecol Obstet Hum Reprod 2017; 46:613-622. [DOI: 10.1016/j.jogoh.2017.07.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 07/10/2017] [Accepted: 07/11/2017] [Indexed: 01/29/2023]
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Wortman M. Late-onset endometrial ablation failure. Case Rep Womens Health 2017; 15:11-28. [PMID: 29593995 PMCID: PMC5842972 DOI: 10.1016/j.crwh.2017.07.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 07/05/2017] [Indexed: 11/26/2022] Open
Abstract
Endometrial ablation, first reported in the 19th century, has gained wide acceptance in the gynecologic community as an important tool for the management of abnormal uterine bleeding when medical management has been unsuccessful or contraindicated. The introduction of global endometrial ablation (GEA) devices beginning in 1997 has provided unsurpassed safety addressing many of the concerns associated with their resectoscopic predecessors. As of this writing the GEA market has surpassed a half-million devices in the United States per annum and has an expected compound annual growth rate (CAGR) projected to be 5.5% from 2016 to 2024. While the short term safety and efficacy of these devices has been reported in numerous clinical trials we only recently are becoming aware of the high incidence of late-onset endometrial ablation failures (LOEAFs) associated with these procedures. Currently, about a quarter of women who undergo a GEA procedure will eventually require a hysterectomy while an unknown number have less than satisfactory results. In order to reduce these suboptimal outcomes physicians must better understand the etiology and risk factors that predispose a patient toward the development of LOEAF as well as current knowledge of patient and procedure selection for EA as well as treatment options for these delayed complications. Over 500,000 endometrial ablations (EAs) are performed in the U. S. each year. Late-onset endometrial ablation failures (LOEAFs) are the most common complication of EA. 25% of women who undergo EA will require hysterectomy within 5 years. Reducing the incidence of LOEAFs requires improved patient selection for EA. Ultrasound-guided reoperative hysteroscopic surgery (UGRHS) reduces the need hysterectomy following LOEAF.
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Affiliation(s)
- Morris Wortman
- Center for Menstrual Disorders, 2020 South Clinton Avenue, Rochester, NY 14618, United States
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Busca A, Parra-Herran C. The role of pathologic evaluation of endometrial ablation resections in predicting ablation failure and adenomyosis in hysterectomy. Pathol Res Pract 2016; 212:778-82. [PMID: 27461823 DOI: 10.1016/j.prp.2016.06.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 06/09/2016] [Accepted: 06/21/2016] [Indexed: 11/26/2022]
Abstract
Endometrial ablation is commonly performed to manage heavy menstrual bleeding. However, failure in symptom control eventually requiring hysterectomy is frequent. Adenomyosis is common in such failure cases. Ablations using a resectoscope will produce an Endo-Myometrial Resection (EMR) specimen. The value of histopathologic examination of EMRs in predicting treatment failure and adenomyosis has not been addressed. We retrieved histologic material from subjects with failed ablation (persistent symptoms requiring hysterectomy) and subjects with ablation followed by clinical improvement and no hysterectomy (control group). Material was evaluated for features of an abnormal endometrial distribution suggestive of adenomyosis: myometrial fragments with endometrium on opposite edges, myometrium with endometrium in ≥3 edges and areas of endometrium completely surrounded by myometrium (endometrial islands). Hysterectomy specimens from the study group were evaluated for the presence of adenomyosis and its distribution (superficial/deep). Both study and control groups consisted of 18 patients each. The number of fragments with endometrium on opposite sides was significantly higher in the study group: 2.11 vs 0.94 in the control group (p=0.005). Conversely, maximum aggregate dimension (2.3cm vs 2.79cm), number of fragments with endometrium on three sides (4.5 vs 2.78) and number of fragments with endometrial islands (4.5 vs 4.11) did not significantly differ between groups. Adenomyosis was seen in 72.2% hysterectomies from the study group; 27.8% involved deep myometrium. None of the EMR features were statistically associated with adenomyosis. Certain endomyometrial distribution patterns in EMR specimens correlate with future ablation failure and need for definitive surgery. This may be explained by residual endometrial tissue not resected due to a markedly irregular endomyometrial interface. Adenomyosis is frequent in cases of ablation failure. However, a significant association between EMR patterns studied and adenomyosis was not observed.
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Affiliation(s)
- Aurelia Busca
- Department of Pathology and Laboratory Medicine, University of Ottawa and The Ottawa Hospital, Ottawa ON, Canada
| | - Carlos Parra-Herran
- Department of Laboratory Medicine and Pathobiology, University of Toronto and Sunnybrook Health Sciences Centre, Toronto ON, Canada.
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Abstract
BACKGROUND Heavy menstrual bleeding significantly impairs the quality of life of many otherwise healthy women. Perception of heavy menstrual bleeding is subjective and management usually depends upon what symptoms are acceptable to the individual. Surgical options include conservative surgery (uterine resection or ablation) and hysterectomy. Medical treatment options include oral medication and a hormone-releasing intrauterine device (LNG-IUS). OBJECTIVES To compare the effectiveness, safety and acceptability of surgery versus medical therapy for heavy menstrual bleeding. SEARCH METHODS We searched the following databases from inception to January 2016: Cochrane Gynaecology and Fertility Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO and clinical trials registers (clinical trials.gov and ICTRP). We also searched the reference lists of retrieved articles. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing conservative surgery or hysterectomy versus medical therapy (oral or intrauterine) for heavy menstrual bleeding. DATA COLLECTION AND ANALYSIS Two review authors independently selected the studies, assessed their risk of bias and extracted the data. Our primary outcomes were menstrual bleeding, satisfaction rate and adverse events. Where appropriate we pooled the data to calculate pooled risk ratios (RRs) or mean differences, with 95% confidence intervals (CIs), using a fixed-effect model. We assessed heterogeneity with the I(2) statistic and evaluated the quality of the evidence using GRADE methods. MAIN RESULTS We included 15 parallel-group RCTs (1289 women). Surgical interventions included hysterectomy and endometrial resection or ablation. Medical interventions included oral medication and the levonorgestrel-releasing intrauterine device (LNG-IUS). The overall quality of the evidence for different comparisons ranged from very low to moderate. The main limitations were lack of blinding, attrition and imprecision. Moreover, it was difficult to interpret long-term study findings as many women randomised to medical interventions subsequently underwent surgery. Surgery versus oral medicationSurgery (endometrial resection) was more effective in controlling bleeding at four months (RR 2.66, 95% CI 1.94 to 3.64, one RCT, 186 women, moderate quality evidence) and also at two years (RR 1.29, 95% CI 1.06 to 1.57, one RCT, 173 women, low quality evidence). There was no evidence of a difference between the groups at five years (RR 1.14, 95% CI 0.97 to 1.34, one RCT, 140 women, very low quality evidence).Satisfaction with treatment was higher in the surgical group at two years (RR 1.40, 95% CI 1.13 to 1.74, one RCT, 173 women, moderate quality evidence), but there was no evidence of a difference between the groups at five years (RR 1.13, 95% CI 0.94 to 1.37, one RCT, 114 women, very low quality evidence). There were fewer adverse events in the surgical group at four months (RR 0.26, 95 CI 0.15 to 0.46, one RCT, 186 women). These findings require cautious interpretation, as 59% of women randomised to the oral medication group had had surgery within two years and 77% within five years. Surgery versus LNG-IUSWhen hysterectomy was compared with LNG-IUS, the hysterectomy group were more likely to have objective control of bleeding at one year (RR 1.11, 95% CI 1.05 to 1.19, one RCT, 223 women, moderate quality evidence). There was no evidence of a difference in quality of life between the groups at five or 10 years, but by 10 years 46% of women originally assigned to LNG-IUS had undergone hysterectomy. Adverse effects associated with hysterectomy included surgical complications such as bladder or bowel perforation and vesicovaginal fistula. Adverse effects associated with LNG-IUS were ongoing bleeding and hormonal symptoms.When conservative surgery was compared with LNG-IUS, at one year the surgical group were more likely to have subjective control of bleeding (RR 1.19, 95% CI 1.07 to 1.32, five RCTs, 281 women, low quality evidence, I(2) = 15%). Satisfaction rates were higher in the surgical group at one year (RR 1.16, 95% CI 1.04, to 1.28, six RCTs, 442 women, I(2) = 27%), but this finding was sensitive to the choice of statistical model and use of a random-effects model showed no conclusive evidence of a difference between the groups. There was no evidence of a difference between the groups in satisfaction rates at two years (RR 0.93, 95% CI 0.81 to 1.08, two RCTs, 117 women, I(2) = 1%).At one year there were fewer adverse events (such as bleeding and spotting) in the surgical group (RR 0.36, 95% CI 0.15 to 0.82, three RCTs, moderate quality evidence). It was unclear what proportion of women assigned to LNG-IUS underwent surgery over long-term follow-up, as there were few data beyond one year. AUTHORS' CONCLUSIONS Surgery, especially hysterectomy, reduces menstrual bleeding more than medical treatment at one year. There is no conclusive evidence of a difference in satisfaction rates between surgery and LNG-IUS, though adverse effects such as bleeding and spotting are more likely to occur with LNG-IUS. Oral medication suits a minority of women in the long term, and the LNG-IUS device provides a better alternative to surgery in most cases. Although hysterectomy is a definitive treatment for heavy menstrual bleeding, it can cause serious complications for a minority of women. Most women may be well advised to try a less radical treatment as first-line therapy. Both LNG-IUS and conservative surgery appear to be safe, acceptable and effective.
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Affiliation(s)
- Jane Marjoribanks
- University of AucklandDepartment of Obstetrics and GynaecologyPark RdGraftonAucklandNew Zealand1003
| | - Anne Lethaby
- University of AucklandDepartment of Obstetrics and GynaecologyPark RdGraftonAucklandNew Zealand1003
| | - Cindy Farquhar
- University of AucklandDepartment of Obstetrics and GynaecologyPark RdGraftonAucklandNew Zealand1003
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Bischoff-Everding C, Soeder R, Neukirch B. Economic and clinical benefits of endometrial radiofrequency ablation compared with other ablation techniques in women with menorrhagia: a retrospective analysis with German health claims data. Int J Womens Health 2016; 8:23-9. [PMID: 26848277 PMCID: PMC4723096 DOI: 10.2147/ijwh.s89468] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To evaluate the economic and clinical benefits of endometrial radiofrequency ablation (RFA) compared with other ablation techniques for the treatment of menorrhagia. METHODS Using German health claims data, women meeting defined inclusion criteria for the intervention group (RFA) were selected. A comparable control group (other endometrial ablations) was established using propensity score matching. These two groups were compared during the quarter of treatment (QoT) and a follow-up of 2 years for the following outcomes: costs during QoT and during follow-up, repeated menorrhagia diagnoses during follow-up and necessary retreatments during follow-up. RESULTS After performing propensity score matching, 50 cases could be allocated to the intervention group, while 38 were identified as control cases. Patients in the RFA group had 5% fewer repeat menorrhagia diagnoses (40% vs 45%; not significant) and 5% fewer treatments associated with recurrent menorrhagia (6% vs 11%; not significant) than cases in the control group. During the QoT, the RFA group incurred €578 additional costs (€2,068 vs €1,490; ns). However, during follow-up, the control group incurred €1,254 additional costs (€4,561 vs €5,815; ns), with medication, outpatient physician consultations, and hospitals costs being the main cost drivers. However, none of the results were statistically significant. CONCLUSION Although RFA was more cost-intensive in the QoT compared with other endometrial ablation techniques, an average total savings of €676 was generated during the follow-up period. While having evidence that RFA is clinically equivalent to other endometrial ablation procedures, we generated indications that RFA is non-inferior and favorable with regard to economic outcomes.
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Affiliation(s)
| | | | - Benno Neukirch
- Faculty of Health Care, Hochschule Niederrhein - University of Applied Sciences, Krefeld, Germany
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Di Spiezio Sardo A, Spinelli M, Zizolfi B, Nappi C. Ambulatory management of heavy menstrual bleeding. ACTA ACUST UNITED AC 2015; 12:35-43. [PMID: 26696502 DOI: 10.2217/whe.15.80] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Heavy menstrual bleeding (HMB) has significant adverse effects on the quality of life of many women, placing an economic burden on both health services and society at large. Thus, it is essential that all women with HMB have easy access to the proper diagnostic and therapeutic work-up in an outpatient fashion, avoiding the more time-consuming inpatient management. This new outpatient approach for HMB is one of the latest development of gynecological practice and can offer both diagnostic and therapeutic procedures. This manuscript aims to show the current possibilities of the modern management of HMB, which can be safely and effectively accomplished in the outpatient setting: global and directed endometrial biopsy, levonorgestrel intrauterine system insertion as well as minimally invasive surgical procedures (encompassing a variety of operative hysteroscopic procedures and second-generation endometrial ablation) are described below.
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Affiliation(s)
- Attilio Di Spiezio Sardo
- Department of Neurosciences & Reproductive Sciences, University of Naples Federico II, Naples, Italy
| | - Marialuigia Spinelli
- Department of Neurosciences & Reproductive Sciences, University of Naples Federico II, Naples, Italy
| | - Brunella Zizolfi
- Department of Neurosciences & Reproductive Sciences, University of Naples Federico II, Naples, Italy
| | - Carmine Nappi
- Department of Neurosciences & Reproductive Sciences, University of Naples Federico II, Naples, Italy
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16
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Bongers M. Hysteroscopy and heavy menstrual bleeding (to cover TCRE and second-generation endometrial ablation). Best Pract Res Clin Obstet Gynaecol 2015; 29:930-9. [DOI: 10.1016/j.bpobgyn.2015.03.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 03/18/2015] [Indexed: 11/24/2022]
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Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2015; 2015:CD003677. [PMID: 26264829 PMCID: PMC6984437 DOI: 10.1002/14651858.cd003677.pub5] [Citation(s) in RCA: 261] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The four approaches to hysterectomy for benign disease are abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH) and robotic-assisted hysterectomy (RH). OBJECTIVES To assess the effectiveness and safety of different surgical approaches to hysterectomy for women with benign gynaecological conditions. SEARCH METHODS We searched the following databases (from inception to 14 August 2014) using the Ovid platform: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. We also searched relevant citation lists. We used both indexed and free-text terms. SELECTION CRITERIA We included randomised controlled trials (RCTs) in which clinical outcomes were compared between one surgical approach to hysterectomy and another. DATA COLLECTION AND ANALYSIS At least two review authors independently selected trials, assessed risk of bias and performed data extraction. Our primary outcomes were return to normal activities, satisfaction, quality of life, intraoperative visceral injury and major long-term complications (i.e. fistula, pelvi-abdominal pain, urinary dysfunction, bowel dysfunction, pelvic floor condition and sexual dysfunction). MAIN RESULTS We included 47 studies with 5102 women. The evidence for most comparisons was of low or moderate quality. The main limitations were poor reporting and imprecision. Vaginal hysterectomy (VH) versus abdominal hysterectomy (AH) (nine RCTs, 762 women)Return to normal activities was shorter in the VH group (mean difference (MD) -9.5 days, 95% confidence interval (CI) -12.6 to -6.4, three RCTs, 176 women, I(2) = 75%, moderate quality evidence). There was no evidence of a difference between the groups for the other primary outcomes. Laparoscopic hysterectomy (LH) versus AH (25 RCTs, 2983 women)Return to normal activities was shorter in the LH group (MD -13.6 days, 95% CI -15.4 to -11.8; six RCTs, 520 women, I(2) = 71%, low quality evidence), but there were more urinary tract injuries in the LH group (odds ratio (OR) 2.4, 95% CI 1.2 to 4.8, 13 RCTs, 2140 women, I(2) = 0%, low quality evidence). There was no evidence of a difference between the groups for the other primary outcomes. LH versus VH (16 RCTs, 1440 women)There was no evidence of a difference between the groups for any primary outcomes. Robotic-assisted hysterectomy (RH) versus LH (two RCTs, 152 women)There was no evidence of a difference between the groups for any primary outcomes. Neither of the studies reported satisfaction rates or quality of life.Overall, the number of adverse events was low in the included studies. AUTHORS' CONCLUSIONS Among women undergoing hysterectomy for benign disease, VH appears to be superior to LH and AH, as it is associated with faster return to normal activities. When technically feasible, VH should be performed in preference to AH because of more rapid recovery and fewer febrile episodes postoperatively. Where VH is not possible, LH has some advantages over AH (including more rapid recovery and fewer febrile episodes and wound or abdominal wall infections), but these are offset by a longer operating time. No advantages of LH over VH could be found; LH had a longer operation time, and total laparoscopic hysterectomy (TLH) had more urinary tract injuries. Of the three subcategories of LH, there are more RCT data for laparoscopic-assisted vaginal hysterectomy and LH than for TLH. Single-port laparoscopic hysterectomy and RH should either be abandoned or further evaluated since there is a lack of evidence of any benefit over conventional LH. Overall, the evidence in this review has to be interpreted with caution as adverse event rates were low, resulting in low power for these comparisons. The surgical approach to hysterectomy should be discussed and decided in the light of the relative benefits and hazards. These benefits and hazards seem to be dependent on surgical expertise and this may influence the decision. In conclusion, when VH is not feasible, LH may avoid the need for AH, but LH is associated with more urinary tract injuries. There is no evidence that RH is of benefit in this population. Preferably, the surgical approach to hysterectomy should be decided by the woman in discussion with her surgeon.
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Affiliation(s)
- Johanna WM Aarts
- Radboud University Nijmegen Medical CenterDepartment of Obstetrics and GynaecologyGeert Grooteplein 10NijmegenNetherlands6500HB
| | - Theodoor E Nieboer
- Radboud University Nijmegen Medical CenterDepartment of Obstetrics and GynaecologyGeert Grooteplein 10NijmegenNetherlands6500HB
| | - Neil Johnson
- University of AdelaideRobinson Research InstituteNorwich Centre Ground Floor, 55 King William RoadNorth AdelaideAdelaideSouth AustraliaAustralia5006
| | - Emma Tavender
- Monash UniversityAustralian Satellite of the Cochrane EPOC Group, Department of SurgeryLevel 6, 99 Commercial RoadMelbourneVictoriaAustraliaVIC 3004
| | - Ray Garry
- University of Teeside and South Cleveland Hospital, MiddlesbroughGynaecological Surgery94 WestgateGuisboroughYorkshireUKTS14 6AP
| | - Ben Willem J Mol
- The University of AdelaideThe Robinson Institute, School of Paediatrics and Reproductive HealthLevel 3, Medical School South BuildingFrome RoadAdelaideSouth AustraliaAustraliaSA 5005
| | - Kirsten B Kluivers
- Radboud University Nijmegen Medical CenterDepartment of Obstetrics and GynaecologyGeert Grooteplein 10NijmegenNetherlands6500HB
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Laberge P, Leyland N, Murji A, Fortin C, Martyn P, Vilos G, Leyland N, Wolfman W, Allaire C, Awadalla A, Dunn S, Heywood M, Lemyre M, Marcoux V, Potestio F, Rittenberg D, Singh S, Yeung G. Endometrial Ablation in the Management of Abnormal Uterine Bleeding. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2015; 37:362-79. [DOI: 10.1016/s1701-2163(15)30288-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
Abnormal uterine bleeding is a common medical condition with several causes. The International Federation of Gynecology and Obstetrics published guidelines in 2011 to develop universally accepted nomenclature and a classification system. In addition, the American College of Obstetrics and Gynecology recently updated recommendations on evaluation of abnormal uterine bleeding and indications for endometrial biopsies. This article reviews both medical and surgical treatments, including meta-analysis reviews of the most effective treatment options.
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Affiliation(s)
- Michelle L Matthews
- Reproductive Endocrinology, Carolinas HealthCare System, 1025 Morehead Medical Drive, Suite 500, Charlotte, NC 28204, USA.
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20
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Abstract
Hysteroscopic surgery is pivotal in management of many gynecological pathologies. The skills required for performing advanced hysteroscopic surgery (AHS), eg, transcervical hysteroscopic endometrial resection (TCRE), hysteroscopic polypectomy and myomectomy in the management of menorrhagia, hysteroscopic septulysis in fertility-related gynecological problems and hysteroscopic removal of chronically retained products of conception and excision of intramural ectopic pregnancy ought to be practiced by contemporary gynecological surgeons in their day-to-day clinical practice. AHS is a minimally invasive procedure that preserves the uterus in most cases. Whilst the outcome is of paramount importance, proper training should be adopted and followed through so that doctors, nurses, and institutions may deliver the highest standard of patient care.
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Affiliation(s)
- Mark M Erian
- Teaching and Research Department, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Glenda R McLaren
- University of Queensland and Mater Mothers Hospital, Brisbane, Australia
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