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Oderkerk TJ, Beelen P, Bukkems ALA, Van Kuijk SMJ, Sluijter HMM, van de Kar MRD, Herman MC, Bongers MY, Geomini PMAJ. Risk of Hysterectomy After Endometrial Ablation: A Systematic Review and Meta-analysis. Obstet Gynecol 2023; 142:51-60. [PMID: 37290114 DOI: 10.1097/aog.0000000000005223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/30/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To assess the risk of hysterectomy after nonresectoscopic endometrial ablation in patients with heavy menstrual bleeding. DATA SOURCES The EMBASE, MEDLINE, ClinicalTrials.gov and Cochrane databases were searched for eligible articles from inception until June 13, 2022. We used combinations of search terms for endometrial ablation and hysterectomy. METHODS OF STUDY SELECTION Articles included in the review described the incidence of hysterectomy at a specific point in time after ablation with a minimum follow-up duration of 12 months. TABULATION, INTEGRATION, AND RESULTS The literature search yielded a total of 3,022 hits. A total of 53 studies met our inclusion and exclusion criteria, including six retrospective studies, 24 randomized controlled trials, and 23 prospective studies. A total of 48,071 patients underwent endometrial ablation between 1992 and 2017. Follow-up duration varied between 12 and 120 months. Analyses per follow-up moment showed 4.3% hysterectomy rate at 12 months of follow-up (n=29 studies), 11.1% at 18 months (n=1 study), 8.0% at 24 months (n=11 studies), 10.2% at 36 months (n=12 studies), 7.6% at 48 months (n=2 studies), and 12.4% at 60 months (n=6 studies). Two studies reported a mean hysterectomy rate at 10 years after ablation of 21.3%. Minimal clinically relevant differences in hysterectomy rates were observed among the different study designs. Furthermore, we found no significant differences in hysterectomy rate among the different nonresectoscopic endometrial ablation devices. CONCLUSION The risk of hysterectomy after endometrial ablation seems to increase from 4.3% after 1 year to 12.4% after 5 years. Clinicians can use the results of this review to counsel patients about the 12% risk of hysterectomy 5 years after endometrial ablation. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42020156281.
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Affiliation(s)
- Tamara J Oderkerk
- Department of Obstetrics and Gynecology, Máxima Medical Centre, Veldhoven, the Department of Obstetrics and Gynecology, Grow-school of Oncology and Reproduction, Maastricht University, and the Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre+, Maastricht, the Community Health Service, GGD Noord Brabant, North Brabant, and the Department of Obstetrics and Gynecology, Jeroen Bosch Hospital's-Hertogenbosch, Hertogenbosch, the Netherlands
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Samala M, Pasupula SS, Mudigonda S, Tadikonda RR. Endometrial ablation techniques in treating menorrhagia. Minerva Obstet Gynecol 2023; 75:279-287. [PMID: 35912462 DOI: 10.23736/s2724-606x.22.05101-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Menorrhagia is a frequent gynecological problem that is clinically described as excessive blood loss of 80 mL per menstrual cycle. It has the potential to lower their quality of life and to induce anemia. Medical therapy has typically been the first line of treatment; however, it is frequently ineffectual. Hysterectomy, on the other hand, is clearly 100 percent effective in stopping bleeding, but it is more expensive and can cause serious problems. So, the endometrial ablation is preferred when the endometrial layer is destroyed or removed during the procedure. To "ablate" (remove) the endometrial lining, a variety of procedures has been devised. The gold standard resectoscopic procedures (laser, transcervical endometrial resection, and rollerball) require hysteroscopic visualization of the uterus and while safe, necessitate expert surgeons. Several innovative procedures have lately been developed, the majority of which may be conducted blindly and take less time. Many nonresectoscopic procedures are still in the process of being developed, refined, and investigated. This article discusses the various techniques and procedures used in endometrial ablation, the importance of the physician using endometrial thinning agents because success rates are higher when thinning agents are used, and the importance of women understanding the complications mainly related to pregnancy. Women should be helped to make informed management decisions by discussing the risks and benefits of each treatment with their consultant. Since there are many treatment options available, with no one option being superior in all respects, patient preference and treatment preferences should be considered when deciding on management.
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Vitale SG, Della Corte L, Ciebiera M, Carugno J, Riemma G, Lasmar RB, Lasmar BP, Kahramanoglu I, Urman B, Mikuš M, De Angelis C, Török P, Angioni S. Hysteroscopic Endometrial Ablation: From Indications to Instrumentation and Techniques-A Call to Action. Diagnostics (Basel) 2023; 13:diagnostics13030339. [PMID: 36766443 PMCID: PMC9914843 DOI: 10.3390/diagnostics13030339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 01/15/2023] [Accepted: 01/16/2023] [Indexed: 01/19/2023] Open
Abstract
The development of minimally invasive techniques has led to the creation of innovative alternatives in cases where traditional methods are not applicable. In modern gynecology, hysteroscopy has become the gold standard for the evaluation and treatment of intrauterine pathology. Endometrial ablation (EA) is a procedure that uses different types of energy to destroy the endometrium and is currently used as an alternative technique in cases of heavy menstrual bleeding when medical treatment has failed and uterine preservation is desired. The aim of this review was to evaluate the feasibility, safety, and clinical outcomes of hysteroscopic EA as an alternative in patients with abnormal uterine bleeding. A detailed computerized search of the literature was performed in the main electronic databases (MEDLINE, EMBASE, Web of Science, PubMed, and Cochrane Library), from 1994 to June 2022, to evaluate the outcomes in patients with abnormal uterine bleeding (AUB) undergoing EA using hysteroscopic and non-hysteroscopic techniques. Only scientific publications in English were included. Twelve articles on the current use of endometrial ablation were included. Data on patient symptoms, tools used for EA, primary outcomes, and adverse events were recorded. EA should be considered an effective and safe approach in the management of patients with abnormal uterine bleeding caused by benign pathology, in whom medical treatment has failed or is contraindicated. Due to the lack of evidence, it would be interesting to determine whether EA would also have a role in the treatment of women with premalignant lesions, avoiding invasive surgical procedures or medical treatment in those patients for whom hysterectomy or the use of hormonal treatment is contraindicated.
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Affiliation(s)
- Salvatore Giovanni Vitale
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy
- Correspondence: ; Tel.: +39-3479354575
| | - Luigi Della Corte
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy
| | - Michał Ciebiera
- Second Department of Obstetrics and Gynecology, Center of Postgraduate Medical Education, 00189 Warsaw, Poland
| | - Josè Carugno
- Minimally Invasive Gynecology Unit, Obstetrics, Gynecology and Reproductive Sciences Department, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | - Gaetano Riemma
- Obstetrics and Gynecology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80128 Naples, Italy
| | - Ricardo Bassil Lasmar
- Department of Surgery and Specialities, Federal Fluminense University, Rio de Janeiro 24020-140, Brazil
| | - Bernardo Portugal Lasmar
- Department of Surgery and Specialities, Federal Fluminense University, Rio de Janeiro 24020-140, Brazil
| | - Ilker Kahramanoglu
- Department of Gynecologic Oncology, Emsey Hospital, 34912 Istanbul, Turkey
| | - Bulent Urman
- Department of Obstetrics and Gynecology, Koc University School of Medicine, 34010 Istanbul, Turkey
| | - Mislav Mikuš
- Department of Obstetrics and Gynecology, University Hospital Centre Zagreb, Petrova 13, 10000 Zagreb, Croatia
| | - Carlo De Angelis
- Department of Maternal and Child Health and Urological Sciences, “Sapienza“ University of Rome, 00185 Rome, Italy
| | - Péter Török
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Debrecen, H-4032 Debrecen, Hungary
| | - Stefano Angioni
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy
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Beelen P, van der Velde MGAM, Herman MC, Geomini PM, van den Brink MJ, Duijnhoven RG, Bongers MY. Treatment of women with heavy menstrual bleeding: Results of a prospective cohort study alongside a randomised controlled trial. Eur J Obstet Gynecol Reprod Biol 2020; 257:1-5. [PMID: 33309849 DOI: 10.1016/j.ejogrb.2020.11.071] [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: 08/30/2020] [Revised: 11/08/2020] [Accepted: 11/30/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The objective of this study was to compare the reintervention rate of women who opted for treatment with the levonorgestrel-releasing intrauterine system (LNG-IUS) to women who opted for endometrial ablation. Furthermore, the difference in reintervention rate between women in this observational cohort and women who were randomised was compared, with the hypothesis that women who actively decide on treatment have lower reintervention rates compared to women in a RCT. STUDY DESIGN An observational cohort study alongside a multicentre randomised controlled trial (RCT) was conducted between April 2012 and January 2016, with a follow-up time of 24 months, in 26 hospitals and nearby general practices in the Netherlands. Women suffering from heavy menstrual bleeding, aged 34 years and older, without intracavitary pathology and without a future fertility desire, were eligible for this trial. Women who declined randomisation were asked to participate in the observational cohort. The outcome measure was reintervention rate at 24 months of follow-up. RESULTS 276 women were followed in the observational cohort of which 87 women preferred an initial treatment with LNG-IUS and 189 women preferred an initial treatment with endometrial ablation. At 24 months of follow-up women in the LNG-IUS-group were more likely to receive a reintervention compared to the women in the ablation group, 28/81 (35 %) versus 25/178 (14 %) (aRR 2.42, CI 1.47-3.98, p-value 0.001). No differences in reintervention rates were found between women in the observational cohort and women in the RCT. CONCLUSIONS Women who receive an LNG-IUS are more likely to undergo an additional intervention compared to women who receive endometrial ablation. Reintervention rates of women in the cohort and RCT population were comparable. The results of this study endorse the findings of the RCT and will contribute to shared decision making in women with heavy menstrual bleeding.
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Affiliation(s)
- Pleun Beelen
- Department of Obstetrics and Gynaecology, Máxima MC, Veldhoven, the Netherlands; Department of General Practice, University of Maastricht, Maastricht, the Netherlands.
| | | | - Malou C Herman
- Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital's Hertogenbosch, the Netherlands
| | - Peggy M Geomini
- Department of Obstetrics and Gynaecology, Máxima MC, Veldhoven, the Netherlands
| | - Marian J van den Brink
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Ruben G Duijnhoven
- Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Marlies Y Bongers
- Department of Obstetrics and Gynaecology, Máxima MC, Veldhoven, the Netherlands; Maastricht University, Grow Research School of Oncology and Developmental Biology, Maastricht, the Netherlands
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Lee EJ, Kang H, Kwon HJ, Chung YJ, Kim JH, Lee SH. Radiofrequency endometrial ablation with a novel endometrial tip for the management of heavy menstrual bleeding and abnormal uterine bleeding: a prospective study. Int J Hyperthermia 2020; 37:772-776. [PMID: 32619371 DOI: 10.1080/02656736.2020.1778196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Aim: To evaluate the safety and efficacy of a radiofrequency ablation system with a novel endometrial tip (RFA-EMT) for the management of heavy menstrual bleeding (HMB) or abnormal uterine bleeding (AUB).Methods: This is a prospective study including a total of 38 premenopausal women with heavy menstrual bleeding (HMB) or abnormal uterine bleeding (AUB) that failed to respond to medical therapy. Hysteroscopic evaluation and curettage biopsy were performed just before the procedure. The procedure was timed to occur during the early proliferative phase (cycle days 4-10). RFA-EMT procedures were performed by a single surgeon with the patient under general anesthesia with a laryngeal mask airway. Primary outcome was reduction in bleeding, reported as amenorrhea, hypomenorrhea, and eumenorrhea, which were measured via hemoglobin level and pictorial blood assessment chart (PBAC) score. Secondary outcomes were adverse events, dysmenorrhea with numeric rating scale (NRS) score, and endometrial thickening in the early proliferative phase, as assessed by transvaginal ultrasonography.Results: There were no peri- or post-procedural complications. Combined amenorrhea, hypomenorrhea, and eumenorrhea rates at 3 and 6 months were 97.4% and 100%, respectively. The hemoglobin level was significantly increased, and the PBAC score, NRS score, and endometrial thickening were significantly decreased after 3 months. These trends were maintained for 6 months after the procedure.Conclusion: RFA-EMT, a new technique, is safe and effective for women with HMB or AUB for which medical therapy has failed.
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Affiliation(s)
- Eun-Ju Lee
- Department of Obstetrics and Gynecology, Chung-Ang University School of Medicine, Seoul, South Korea
| | - Hyun Kang
- Department of Anesthesiology, Chung-Ang University School of Medicine, Seoul, South Korea
| | - Hyoung Joon Kwon
- Department of Obstetrics and Gynecology, Chung-Ang University School of Medicine, Seoul, South Korea
| | - Yun Jae Chung
- Department of Internal Medicine, Chung-Ang University School of Medicine, Seoul, South Korea
| | - Ji-Hye Kim
- Department of Obstetrics and Gynecology, Chung-Ang University School of Medicine, Seoul, South Korea
| | - Sang Hoon Lee
- Department of Obstetrics and Gynecology, Chung-Ang University School of Medicine, Seoul, South Korea
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Zhao H, Yang B, Feng L, Li H, Shang H, Zhao Z, Dai Y. Comparison of Combined Bipolar Radiofrequency Impedance-Controlled Endometrial Ablation with Levonorgestrel Intrauterine System versus Bipolar Radiofrequency Endometrial Ablation Alone in Women with Abnormal Uterine Bleeding. J Minim Invasive Gynecol 2020; 27:774-780. [DOI: 10.1016/j.jmig.2019.05.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 05/26/2019] [Accepted: 05/29/2019] [Indexed: 12/30/2022]
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Beelen P, Reinders IMA, Scheepers WFW, Herman MC, Geomini PMAJ, van Kuijk SMJ, Bongers MY. Prognostic Factors for the Failure of Endometrial Ablation: A Systematic Review and Meta-analysis. Obstet Gynecol 2019; 134:1269-1281. [PMID: 31764738 DOI: 10.1097/aog.0000000000003556] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To provide an overview of prognostic factors predicting failure of second-generation endometrial ablation. DATA SOURCES MEDLINE, EMBASE, the Cochrane Library, and ClinicalTrials.gov were systematically searched from 1988 until February 2019. The search was conducted without language restrictions using the following search terms: "endometrial ablation," "prognosis," "predict," "long term," "late onset," "outcome." METHODS OF STUDY SELECTION The literature search provided a total of 990 studies. All types of studies reporting about prognostic factors of second-generation endometrial ablation failure were included. TABULATION, INTEGRATION, AND RESULTS After screening for eligibility, 56 studies were included in this review, of which 21 were included in the meta-analysis. In these 56 studies, 157,830 women were included. We evaluated 10 prognostic factors: age, myomas, history of tubal ligation, body mass index, parity, preexisting dysmenorrhea, caesarean delivery, bleeding pattern, uterus position, and uterus length. Meta-analysis was performed for the primary outcome (surgical reintervention) to estimate summary treatment effects. Younger age (aged 35 years or younger, odds ratio [OR] 1.68, 95% CI 1.19-2.36; aged 40 years or younger, OR 1.58, 95% CI 1.30-1.93; aged 45 years or younger OR 1.63, 95% CI 1.28-2.07), prior tubal ligation (OR 1.46, 95% CI 1.23-1.73), and preexisting dysmenorrhea (OR 2.12, 95% CI 1.41-3.19) were associated with an increased risk of surgical reintervention. Studies investigating the prognostic factors myomas and obesity showed conflicting results. CONCLUSION Younger age, prior tubal ligation and preexisting dysmenorrhea were found to be associated with failure of endometrial ablation. Obesity and the presence of large submucous myomas may be associated with failure, as well, though more research is necessary to estimate the influence of these factors. It is important to take the results of this review into account when counselling women with heavy menstrual bleeding. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42019126247.
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Affiliation(s)
- Pleun Beelen
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, the Departments of Obstetrics and Gynaecology and Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, and the Department of General Practice and the Research School Grow, University of Maastricht, Maastricht, the Netherlands
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8
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The case against endometrial ablation for treatment of heavy menstrual bleeding. Curr Opin Obstet Gynecol 2018; 30:287-292. [DOI: 10.1097/gco.0000000000000463] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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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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10
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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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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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Munro MG. Endometrial ablation. Best Pract Res Clin Obstet Gynaecol 2017; 46:120-139. [PMID: 29128205 DOI: 10.1016/j.bpobgyn.2017.10.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 10/06/2017] [Indexed: 10/18/2022]
Abstract
Endometrial ablation (EA) includes a spectrum of procedures performed with or without hysteroscopic direction, designed to destroy the endometrium for the treatment of the symptom of heavy menstrual bleeding (HMB) secondary to a spectrum of causes, but most commonly those that are endometrial in origin (AUB-E) or ovulatory disorders (AUB-O). Resectoscopic endometrial ablation (REA) is often mistakenly referred to as the "first generation" technique, while proprietary devices that do not use the resectoscope (nonresectoscopic EA or NREA) are often misperceived as "second generation" devices. Indeed, the origins of NREA date back to the late 19th century with the use of steam, and the early and mid 20th century, when radiofrequency and cryotherapy based NREA techniques were published - long before the resectoscope was used and reported. The NREA devices have also been mislabeled as "global", a misleading term borrowed from the marketing departments of device manufacturers - there is no device that predictably treats the entire endometrium. Consequently, none can be construed as being "global". Instead, EA is a procedure designed for women as an alternative to hysterectomy, or, perhaps, medical therapy, when future fertility is no longer desired. Women who select EA should anticipate a relatively low risk procedure that will likely reduce their HMB to normal levels or less. This paper will review the spectrum of EA techniques and devices, their clinical outcomes and adverse events, and explore their value compared to hysterectomy and selected medical therapies.
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Affiliation(s)
- Malcolm G Munro
- Department of Obstetrics & Gynecology, David Geffen School of Medicine at UCLA, Director of Gynecologic Services, Kaiser Permanente, Los Angeles Medical Center, Los Angeles, CA, United States.
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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: 10] [Impact Index Per Article: 1.4] [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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Wyatt SN, Banahan T, Tang Y, Nadendla K, Szychowski JM, Jenkins TR. Effect of Radiofrequency Endometrial Ablation on Dysmenorrhea. J Minim Invasive Gynecol 2016; 23:1163-1166. [PMID: 27590567 DOI: 10.1016/j.jmig.2016.08.825] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 08/18/2016] [Accepted: 08/19/2016] [Indexed: 10/21/2022]
Abstract
STUDY OBJECTIVE To examine rates of dysmenorrhea after radiofrequency endometrial ablation in patients with and without known dysmenorrhea symptoms prior to the procedure in a diverse population. DESIGN Retrospective cohort study (Canadian Task Force classification II-2). SETTING Academic gynecology practice. PATIENTS A total of 307 women underwent endometrial ablation between 2007 and 2013 at our institution. Patients who had preoperative and postoperative pain symptom assessments as well as a description of pain timing recorded were included in our analysis. Exclusion criteria were age <19 years and operative biopsy findings consistent with complex atypical hyperplasia. INTERVENTIONS The difference in preoperative and postoperative rates of dysmenorrhea was evaluated. Demographic information and other outcome variables were used to evaluate factors associated with resolution of dysmenorrhea. MEASUREMENTS AND MAIN RESULTS A total of 307 patients who underwent radiofrequency endometrial ablation were identified. After exclusions, 296 charts were examined, and 144 patients met our enrollment criteria. The mean age of the study cohort was 45.4 ± 6.2 years; 57 patients (40%) were African American, 16 (11%) had a body mass index (BMI) > 40, and 41 (29%) were of normal weight. Preoperative dysmenorrhea was reported by 100 patients (69%); 48 of these patients (48%) experienced resolution of symptoms postoperatively. Only 3 of the 44 patients (7%) without preoperative dysmenorrhea reported new-onset dysmenorrhea postoperatively. Significantly fewer patients had dysmenorrhea after compared to before radiofrequency ablation (55 of 144 [38%] vs 100 of 144 [69%]; p < .001). Resolution of dysmenorrhea after ablation was associated with reduction in bleeding volume (p = .048) but not with a reduction in frequency of bleeding (p = .12). CONCLUSIONS Approximately one-half of women who undergo radiofrequency endometrial ablation to treat heavy menstrual bleeding who also have preoperative dysmenorrhea exhibit documented pain resolution after the procedure. Resolution of dysmenorrhea is more likely if menstrual flow volume is decreased postprocedure.
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Affiliation(s)
- Sabrina N Wyatt
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, OK.
| | - Taylor Banahan
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Ying Tang
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL
| | - Kavita Nadendla
- School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Jeff M Szychowski
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL; Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL
| | - Todd R Jenkins
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
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Nelson AL, Vasquez L, Tabatabai R, Im SS. The yield of endometrial aspiration in women with various risk factors and bleeding abnormalities. Contracept Reprod Med 2016; 1:9. [PMID: 29201398 PMCID: PMC5693553 DOI: 10.1186/s40834-016-0020-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 04/23/2016] [Indexed: 12/27/2022] Open
Abstract
Background Even in the face of a substantial increase in the numbers of endometrial cancer cases and in the numbers of women who have risk factors, there is no clear agreement about the indications for assessing the endometria of women with abnormal bleeding or about the tools to use in that assessment. This study sought to determine in a group of high risk women with abnormal uterine bleeding, the probability that an outpatient endometrial aspiration would identify significant pathology. Methods Retrospective cohort study of the histology from endometrial aspirations performed from 2001 to 2008 for abnormal uterine bleeding at Harbor-UCLA Medical Center and its satellite public health clinics. Medical records were reviewed in detail to assess risk factors, descriptions of bleeding abnormalities and histologic results. Results The charts of 1601 women who underwent 1636 endometrial biopsies for a wide variety of abnormal uterine bleeding patterns yielded 73 (4.6 %) cases of endometrial carcinoma, 43 cases of atypical endometrial hyperplasia (2.7 %), for an overall yield of significant pathology of 7.2 %. Hyperplasia without atypia was found in another 83 cases (5.2 %). Obesity, diabetes and postmenopausal age are associated with an increased risk of significant pathology. Bleeding patterns were so poorly documented that analysis of yield by this factor should be viewed with caution. Conclusions The probability of detecting significant uterine pathology is greatest among obese, diabetic postmenopausal women with diabetes (26.3 %). Conversely, the probability of identifying significant pathology in younger women without risk factors is less than 2 %. For women who perceive their individualized risk estimate to be too small to justify an endometrial biopsy, it may be possible to offer oral higher dose progestin therapy on the condition that persistent abnormal bleeding will require more intensive evaluation. These estimates of absolute risk of being diagnosed with significant pathology on endometrial biopsy may be helpful to patients as they consider giving informed consent for the procedure.
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Affiliation(s)
- Anita L Nelson
- Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA USA.,1457 3rd Street, Manhattan Beach, CA 90266 USA
| | - Lisa Vasquez
- Department Obstetrics and Gynecology, Healthcare Partners, Montebello, CA USA
| | - Roya Tabatabai
- Department of Hematology and Oncology, Olive View-UCLA Medical Center, Sylmar, CA USA
| | - Samuel S Im
- Department of Obstetrics and Gynecology, Harbor-UCLA Medical Center, Torrance, CA USA
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Obesity Education Strategies for Cancer Prevention in Women's Health. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2015; 4:249-258. [PMID: 26877893 DOI: 10.1007/s13669-015-0129-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Obesity is the cause of up to one-third of all cancers affecting women today, most notably endometrial, colon and breast cancer. Women's health providers are poised to advise women on obesity's link to cancer development, but often lack resources or training to provide appropriate counseling. Here, we review obesity's role in increasing the risk of several common reproductive system conditions faced by women, including polycystic ovarian syndrome, infertility, gynecologic surgical complications, and pregnancy complications. These events can be used as teachable moments to help frame the discussion of weight management and promote cancer prevention. We also review national guidelines and existing tangible weight-loss strategies that can be employed within the outpatient women's health setting to help women achieve weight loss goals and affect cancer prevention.
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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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