Late-onset endometrial ablation failure

A 52-mg levonorgestrel-releasing intrauterine system vs bipolar radiofrequency nonresectoscopic endometrial ablation in women with heavy menstrual bleeding: long-term follow-up of a multicenter randomized controlled trial

BACKGROUND

The symptom of heavy menstrual bleeding has a substantial impact on professional, physical, and social functioning. In 2021, results from a randomized controlled trial comparing a 52-mg levonorgestrel-releasing intrauterine system and radiofrequency nonresectoscopic endometrial ablation as treatments for women with heavy menstrual bleeding were published. Both treatment strategies were equally effective in treating heavy menstrual bleeding during 2-year follow-up. However, long-term results are also relevant for both patients and healthcare providers.

OBJECTIVE

This study aimed to assess long-term differences in reintervention risk and menstrual blood loss in women with the symptom of heavy menstrual bleeding treated according to a strategy starting with a 52-mg levonorgestrel-releasing intrauterine system or radiofrequency nonresectoscopic endometrial ablation.

STUDY DESIGN

This study was a long-term follow-up study of a multicenter randomized controlled trial (MIRA trial), in which women were allocated to either a 52-mg levonorgestrel-releasing intrauterine device (n=132) or radiofrequency nonresectoscopic endometrial ablation (n=138). Women from the original trial were contacted to fill out 6 questionnaires. The primary outcome was the reintervention rate after allocated treatment. Secondary outcomes included surgical reintervention rate, menstrual bleeding measured by the Pictorial Blood Loss Assessment Chart, (disease-specific) quality of life, sexual function, and patient satisfaction.

RESULTS

From the 270 women who were randomized in the original trial, 196 (52-mg levonorgestrel-releasing intrauterine system group: n=94; radiofrequency nonresectoscopic endometrial ablation group: n=102) participated in this long-term follow-up study. Mean follow-up duration was 7.4 years (range, 6-9 years). The cumulative reintervention rate (including both medical and surgical reinterventions) was 40.0% (34/85) in the 52-mg levonorgestrel-releasing intrauterine system group and 28.7% (27/94) in the radiofrequency nonresectoscopic endometrial ablation group (relative risk, 1.39; 95% confidence interval, 0.92-2.10). The cumulative rate of surgical reinterventions only was significantly higher among patients with a treatment strategy starting with a 52-mg levonorgestrel-releasing intrauterine system compared with radiofrequency nonresectoscopic endometrial ablation (35.3% [30/85] vs 19.1% [18/94]; relative risk, 1.84; 95% confidence interval, 1.11-3.10). However, the hysterectomy rate was similar (11.8% [10/94] in the 52-mg levonorgestrel-releasing intrauterine system group and 18.1% [17/102] in the radiofrequency nonresectoscopic endometrial ablation group; relative risk, 0.65; 95% confidence interval, 0.32-1.34). Most reinterventions occurred during the first 24 months of follow-up. A total of 171 Pictorial Blood Loss Assessment Chart scores showed a median bleeding score of 0.0. No clinically relevant differences were found regarding quality of life, sexual function, and patient satisfaction.

CONCLUSION

The overall risk of reintervention after long-term follow-up was not different between women treated according to a treatment strategy starting with a 52-mg levonorgestrel-releasing intrauterine system and those treated using a strategy starting with radiofrequency nonresectoscopic endometrial ablation. However, women allocated to a treatment strategy starting with a 52-mg levonorgestrel-releasing intrauterine system had a higher risk of surgical reintervention, which was driven by an increase in subsequent endometrial ablation. Both treatment strategies were effective in lowering menstrual blood loss over the long term. The results of this long-term follow-up study can support physicians in optimizing the counseling of women with heavy menstrual bleeding, thus promoting informed decision-making regarding choice of treatment.

Evaluation of Radiofrequency Endometrial Ablation: A 17-year Canadian Experience

STUDY OBJECTIVE

The purpose of this study was to better elucidate radiofrequency endometrial ablation (REA) durability by assessing the probability of failure as defined by need for postablation hysterectomy. Age at index REA, duration from REA until hysterectomy, and REA failure (REAF) risk factors were analyzed.

DESIGN

A retrospective cohort study was conducted using patient data between April 1, 2002, and March 31, 2019. REAF cases were identified using operative procedure codes. Cox proportional hazard regression assessed the effect of age at index REA on time to postablation hysterectomy. Kaplan-Meier survival curve evaluated timing of postablation hysterectomy, stratified by age at index REA.

SETTING

This study was conducted at Regina General Hospital in Regina, Saskatchewan, Canada.

PATIENTS

Patient population included those who were 21 years of age or older, were premenopausal, and had a history of heavy menstrual bleeding at the time of REA.

INTERVENTIONS

The intervention under investigation was REA.

MEASUREMENTS AND MAIN RESULTS

The overall probability of postablation hysterectomy was 22.6%. The probabilities of postablation hysterectomy were 36.1% for women younger than 30 years (n = 128), 28% for women 30 to 34.9 years old (n = 528), 29.6% for women 35 to 39.9 years old (n = 1152), and 17.6% for women 40 years and older (n = 2221). Characteristics associated with REAF included tubal occlusion, cesarean section, dysmenorrhea, and chronic pelvic pain (p <.01) among women younger than 40 years. Leiomyomas accounted for higher failure rates in women 40 years and older (p <.01).

CONCLUSION

Postablation hysterectomy is more likely to occur in women younger than 40 years. REA can be considered in women aged 30 to 39.9 years old, who have no known REAF risk factors. Women younger than 40 years with REAF risk factors will experience higher rates of hysterectomy. Thus, the decision to proceed with REA should be individualized with careful consideration for the underlying causes of abnormal uterine bleeding, while respecting patient autonomy.

Endometrial ablation techniques in treating menorrhagia

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.

Endometrial Cryoablation for the Treatment of Heavy Menstrual Bleeding: 36-Month Outcomes from the CLARITY Study

Study Objective

To examine long-term outcomes from the pivotal study that evaluated the safety and effectiveness of the Cerene^® Cryotherapy Device (Channel Medsystems, Berkeley, CA) in premenopausal women with heavy menstrual bleeding due to benign causes who have completed childbearing.

Methods

The prospective, multicenter, single-arm, open-label study had eight sites in the USA, one in Mexico, and two in Canada. Inclusion criteria included uterine sound ≤10 cm, endometrial cavity length 2.5 to 6.5 cm, age 25 to 50 years, a pictorial blood loss assessment chart score of ≥150, no submucosal myomata and/or uterine obstruction, distortion, or abnormality. A total of 242 subjects underwent a 2.5-minute cryoablation. Long-term follow-up visits were conducted at Month 24 and Month 36. Data collected included gynecological adverse events, description of last menstrual period, contraception status, self-report of pregnancy, medical or surgical interventions to treat abnormal uterine bleeding, satisfaction, recommendation, and quality of life (QoL). QoL outcomes were measured with the Menorrhagia Impact Questionnaire (MIQ) and the Premenstrual Symptoms Impact Survey (PMSIS™).

Results

201 subjects completed their Month 36 final study visit. Subject outcomes were comparable to those at Month 12. Eighty-nine percent of subjects reported amenorrhea, a lighter-than-normal, or normal period, 91% of subjects had no or slight limitations in MIQ measured activities, and 85% reported premenstrual symptoms at a low frequency. Eighty-five percent of the subjects were satisfied or very satisfied. The cumulative incidence of hysterectomy was 5% and reintervention was 8.7%. Forty-nine gynecologic adverse events (AE) were reported; one non-serious AE, postcoital bleeding, was reported as related to the procedure. No serious device-related or procedure-related AEs were reported.

Conclusion

Study data demonstrate that the positive effects of Cerene Cryotherapy Device treatment are sustained through Month 36 and that the risks associated with the device and procedure are low (ClinicalTrials.gov; NCT02842736).

Modified thermal balloon endometrial ablation for treatment of heavy menstrual bleeding

Objectives:

The objective of this study was to determine the efficacy of modified thermal balloon ablation using Foley's catheter in the treatment of heavy menstrual bleeding (HMB).

Materials and Methods:

Twelve patients with HMB aged 35–55 years underwent modified thermal balloon ablation using Foley's catheter. Patients were selected after complete clinical evaluation and investigations. The procedure was undertaken in the operation theater under general anesthesia/intravenous sedation. Three cycles of modified thermal balloon ablation using Foley's catheter were performed to ablate the endometrium. The time given to each cycle was 7 min. All the cycles were performed in the same setting. The main outcome measures that were studied were reduction in the menstrual flow, the need for further treatment, and relief of dysmenorrhea if present. Outcome measure regarding reduction in menstrual flow was statistically analyzed using Fisher's exact test. Statistical significance was determined at a level of P < 0.05.

Results:

Eighty-two percent of patients experienced a reasonable reduction in menstrual blood flow at 3-month follow-up. Eighteen percent observed no change in bleeding pattern and needed further treatment after failure of the procedure. Forty-two percent of patients complained of minor side effects such as cramp lower abdominal pain and fever. Rupture of balloon during the procedure occurred in only one case (8%).

Conclusion:

Modified thermal balloon ablation with Foley's catheter can be a promising management of HMB in resource-poor settings. It is a cost-effective alternative to the original endometrial ablation techniques.

Hysteroscopic Access and Uterine Cavity Evaluation 12 Months Post-Endometrial Ablation with the Cerene® Cryotherapy Device

STUDY OBJECTIVE

To evaluate if physical access and the ability to systematically assess the post-ablation uterine cavity were preserved at 12 months after endometrial ablation with the Cerene® Cryotherapy Device (Channel Medsystems®, Emeryville, CA).

DESIGN

A prospective, multi-center, single-arm study.

SETTING

In the clinic at 8 US sites and outpatient hospital setting at 2 sites in Canada and 1 site in Mexico.

PATIENTS OR PARTICIPANTS

230 of 242 subjects post-ablation continued in the study at the Month 12 visit. 223 subjects were available for a diagnostic hysteroscopic evaluation.

INTERVENTIONS

Subjects who had previously been treated with a 2.5-minute cryoablation of the endometrium utilizing the Cerene® Device underwent a diagnostic hysteroscopy at the Month 12 follow-up visit.

MEASUREMENTS AND MAIN RESULTS

The uterine cavity was accessible in 220 of 223 subjects (98.7%) and not accessible in 3 (1.3%), due to pain (n=2) and cervical stenosis (n=1). Visualization of the uterine cavity was possible in 204 of 220 subjects (92.7%) with one or both tubal ostia identified in 89.2% (182/204) of subjects. Both tubal ostia were visible in 160 of 204 subjects (78.4%) and one ostium in 22 of 204 subjects (10.8%). The cavity was not visualized in the remaining 16 of 220 subjects (7.2%) due to intrauterine adhesions (n=14), technical difficulties (n=1), or menstruation (n=1). In 95.6% (195/204) of subjects where the cavity was visualized, the hysteroscopic view was judged adequate to evaluate the uterine cavity for pathologic change. No significant complications occurred during the hysteroscopic evaluations.

CONCLUSION

This is the largest study to date conducted to hysteroscopically evaluate the post-ablation uterine cavity. Uterine cavity assessment with in-office hysteroscopy one year after the use of the Cerene® Cryotherapy Device is attainable, enabling both diagnostic and therapeutic procedures within the endometrial cavity.

A Prospective, Multicenter, Clinical Trial Evaluating the Safety and Effectiveness of the Cerene Device to Treat Heavy Menstrual Bleeding

STUDY OBJECTIVE

To evaluate the safety and effectiveness of a novel cryoablation device (Cerene Cryotherapy Device, Channel Medsystems, Emeryville, CA) in premenopausal women with heavy menstrual bleeding owing to benign causes.

DESIGN

A prospective, multi-center, single-arm, open label, non-randomized study.

SETTING

At 11 academic and private practices in North America: 8 clinic sites in the United States, and 3 outpatient hospital sites (1 in Mexico and 2 in Canada).

PATIENTS

A total of 242 subjects comprise the intent-to-treat population. Subject demographics were similar to other published endometrial ablation studies performed.

INTERVENTIONS

Subjects were treated with a single-use disposable cryoablation device (Cerene) which delivers a 2.5-minute treatment to the endometrium. Analgesia and local anesthesia were administered per investigator discretion; intravenous sedation was used in only 3% of subjects and no general anesthesia was used.

MEASUREMENTS AND MAIN RESULTS

There were no device or procedure-related serious adverse events, nor unanticipated adverse device effects. Cerene cryoablation was effective in reducing menstrual blood loss, which was measured by pictorial blood loss assessment chart (PBLAC) score. Mean score dropped from 360.6 at pretreatment (±332.1) to 51 at 12 months posttreatment (±64.1), with 81% of 230 evaluable subjects reporting a PBLAC score of ≤75 and 85% of evaluable subjects reporting a PBLAC score of ≤ 100. The median pain rating was ≤2 (mild) throughout the treatment. Of 223 subjects that underwent hysteroscopic evaluation at 12 months, the uterine cavity was visualized in 220 subjects. Quality of life improved with 90% of reporting subjects indicating satisfied or very satisfied at month 12.

CONCLUSION

This study demonstrated that Cerene cryoablation is safe and effective, offering the benefits of reduced menstrual blood loss with limited use of pain medication, high patient tolerability, quality of life improvement, and preserved access to the uterine cavity.

Radiofrequency endometrial ablation with a novel endometrial tip for the management of heavy menstrual bleeding and abnormal uterine bleeding: a prospective study

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.

Invasive Procedural Treatments for Symptomatic Uterine Fibroids: A Cost Analysis

PURPOSE

The aim of this study was to evaluate the contemporary use of procedural interventions to treat symptomatic uterine fibroids and assess associated health care system costs.

METHODS

Using the IBM Watson MarketScan Commercial Claims and Encounters database for 2009 to 2015 and relevant International Classification of Diseases diagnosis codes, women aged 18 to 55 years with clinically significant uterine fibroids were identified. Using Current Procedural Terminology codes, relevant procedural interventions were identified (hysterectomy, endometrial ablation, myomectomy, and uterine fibroid embolization [UFE]). Costs were defined as total actual payments by insurers and patients (per procedure and per episode of care) and were adjusted and compared using generalized linear models.

RESULTS

Of 241,757 invasive procedures for fibroids, hysterectomy was most common (76.5%), followed by endometrial ablation (14.5%), myomectomy (4.7%), and UFE (4.3%). Hysterectomy was more common in older women and those in rural areas (65.2% of patients <40 years of age, 77.6% of those 40-49 years of age, and 83.6% of those 50-55 years of age; 83.9% of patients outside versus 75.3% within metropolitan statistical areas). Per procedure, adjusted mean costs were $3,188 (95% confidence interval [CI], $3,114-$3,264) for hysterectomy, $2,781 (95% CI, $2,695-$2,870) for ablation, $4,436 (95% CI, $4,256-$4,623) for myomectomy, and $6,161 (95% CI, $5,736-$6,617) for UFE. Adjusted mean costs for entire episodes of care were $14,676 (95% CI, $14,496-$14,858) for hysterectomy, $6,702 (95% CI, $6,534-$6,875) for endometrial ablation, $14,791 (95% CI, $14,465-$15,125) for myomectomy, and $13,873 (95% CI, $13,182-$14,599) for UFE.

CONCLUSIONS

Of invasive procedures for symptomatic uterine fibroids, hysterectomy was used more frequently than endometrial ablation, myomectomy, and UFE combined. Per procedure and per episode, ablation was least costly. Costs per episode were similar for hysterectomy, myomectomy, and UFE.

Prognostic Factors for the Failure of Endometrial Ablation: A Systematic Review and Meta-analysis

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.