NovaSure impedance controlled endometrial ablation: Long-term follow-up results

Risk of Hysterectomy After Endometrial Ablation: A Systematic Review and Meta-analysis

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.

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.

Long-term outcome of endometrial ablation therapy with Cavaterm Thermal Balloon in patients with abnormal uterine bleeding

Objective

The purpose of this study was to evaluate the long-term outcome of endometrial ablation (EA) therapy with Cavaterm Thermal Balloon in patients with abnormal uterine bleeding (AUB).

Material and Methods

The retrospective cross-sectional study was performed on 209 patients who referred to Shahid Sadoughi Hospital in Yazd, Iran between March 2010 and September 2017 with AUB undergoing EA therapy. The data was collected by a questionnaire from the medical records of patients and phone call. The primary and secondary outcomes post EA therapy (from six months to seven years post-operatively) were assessed in patients.

Results

The mean age of participants was 45.9±5.9 years and the mean follow-up duration was 21.2±13.2 months. The rate of treatment response was 95% in the first six months and 92.1% thereafter. The prevalence of amenorrhea was 41.2%. The patient satisfaction rate at the end of follow-up duration was 81.3%. Dysmenorrhea completely resolved in 32.6%. Moreover, 1.4% of patients became pregnant during follow-up. By the end of follow-up, four (1.9%) patients had a hysterectomy due directly to treatment failure.

Conclusion

This study showed that EA surgery with Cavaterm Thermal Balloon was an effective treatment for AUB. The procedure was safe and was associated with a very low rate of postoperative adverse events. The patient satisfaction rate was favorable.

Effectiveness of bipolar impedance controlled radiofrequency (NovaSure) endometrial ablation for the treatment of menorrhagia in Hong Kong Chinese women☆

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.

The evidence for laser treatments to the vulvo-vagina: Making sure we do not repeat past mistakes

Following menopause, up to 49% of women will experience genitourinary symptoms such as vaginal itching, dryness, dyspareunia and incontinence as a result of oestrogen deficiency. Treatments such as vaginal lubricants and moisturisers only temporarily relieve symptoms, while local oestrogen treatments are often unacceptable or unsafe for many women. Recently, a novel laser treatment has been proposed as a non-invasive, long-term solution to vulvo-vaginal and urinary symptoms. While preliminary histological results have been promising, its therapeutic, clinical effect has yet to be determined. However, despite the scarcity of evidence for its safety and long-term benefit, laser treatments are widely marketed for a range of genitourinary symptoms, with high uptake by both clinicians and women alike. This review aims to examine the evidence for laser treatments to the vulvo-vagina and to evaluate its safety and efficacy. Our results include 17 studies investigating the effect of laser therapy for vulvo-vaginal symptoms, seven for its effects on urinary incontinence and four for histology. These are limited to non-randomised, observational data with small sample sizes between 15 to 175 women and follow-up duration from none to two years. As such, strong evidence for laser efficacy and safety is limited and warrants more robust, placebo-controlled, randomised trials before widespread implementation.

Endometrial ablation

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.

Endometrial ablation for heavy menstrual bleeding

Endometrial ablation can be described as one of the great gynecological success stories. It has changed the management of heavy menstrual bleeding dramatically. The development of newer (second generation) endometrial ablative techniques has enabled clinicians to set up comprehensive 'one stop clinics' based on an outpatient service to treat heavy menstrual bleeding effectively without the need for general anesthetic or conscious sedation. This article describes the rationale and evidence for use of different endometrial auto-ablative systems along with relevant technical and clinical aspects. It also addresses the essentials of a successful approach to outpatient endometrial ablation along with discussion on risks, complications and contraindications of the procedure.

Radiofrequency endometrial ablation for the treatment of heavy menstrual bleeding among women at high surgical risk

OBJECTIVE

To evaluate quality of life (QoL) after radiofrequency endometrial ablation (RFEA) for heavy menstrual bleeding among women at high surgical risk.

METHODS

An observational study was undertaken among women aged at least 18 years who underwent RFEA at Hanover Medical School, Germany, between June 2010 and November 2012. A validated menorrhagia outcomes questionnaire (MOQ) was used to evaluate QoL and global outcomes among patients at high risk and low risk of complications after major surgery. The high-risk group included women with anemia, coagulopathy, anticoagulation, thromboembolism, transplantation, malignancy, severe cardiovascular or pulmonary disease, and obesity.

RESULTS

Overall, 235 women underwent RFEA during the study period. Median follow-up was 13 months (range 3-30). Questionnaire responses were received from 202 (86.0%) women, including 132 (65.3%) high-risk patients. The MOQ total outcome (mean difference 2.0; P = 0.166) and QoL/satisfaction (mean difference 0.8; P = 0.601) scores were similar in the two groups. Success (i.e. symptom relief and no further surgery) was recorded for 119 (90.2%) patients in the high-risk group and 67 (95.7%) patients in the low-risk group (P = 0.155).

CONCLUSION

RFEA improved QoL and achieved a high rate of satisfaction for both high- and low-risk patients. RFEA offers a less invasive alternative to hysterectomy and its associated perioperative risks, particularly among high-risk patients.

Cost effectiveness of endometrial ablation with the NovaSure(®) system versus other global ablation modalities and hysterectomy for treatment of abnormal uterine bleeding: US commercial and Medicaid payer perspectives

OBJECTIVES

Abnormal uterine bleeding (AUB) interferes with physical, emotional, and social well-being, impacting the quality of life of more than 10 million women in the USA. Hysterectomy, the most common surgical treatment of AUB, has significant morbidity, low mortality, long recovery, and high associated health care costs. Global endometrial ablation (GEA) provides a surgical alternative with reduced morbidity, cost, and recovery time. The NovaSure(®) system utilizes unique radiofrequency impedance-based GEA technology. This study evaluated cost effectiveness of AUB treatment with NovaSure ablation versus other GEA modalities and versus hysterectomy from the US commercial and Medicaid payer perspectives.

METHODS

A health state transition (semi-Markov) model was developed using epidemiologic, clinical, and economic data from commercial and Medicaid claims database analyses, supplemented by published literature. Three hypothetical cohorts of women receiving AUB interventions were simulated over 1-, 3-, and 5-year horizons to evaluate clinical and economic outcomes for NovaSure, other GEA modalities, and hysterectomy.

RESULTS

Model analyses show lower costs for NovaSure-treated patients than for those treated with other GEA modalities or hysterectomy over all time frames under commercial payer and Medicaid perspectives. By Year 3, cost savings versus other GEA were $930 (commercial) and $3,000 (Medicaid); cost savings versus hysterectomy were $6,500 (commercial) and $8,900 (Medicaid). Coinciding with a 43%-71% reduction in need for re-ablation, there were 69%-88% fewer intervention/reintervention complications for NovaSure-treated patients versus other GEA modalities, and 82%-91% fewer versus hysterectomy. Furthermore, NovaSure-treated patients had fewer days of work absence and short-term disability. Cost-effectiveness metrics showed NovaSure treatment as economically dominant over other GEA modalities in all circumstances. With few exceptions, similar results were shown for NovaSure treatment versus hysterectomy.

CONCLUSION

Model results demonstrate strong financial favorability for NovaSure ablation versus other GEA modalities and hysterectomy from commercial and Medicaid payer perspectives. Results will interest clinicians, health care payers, and self-insured employers striving for cost-effective AUB treatments.

The long-term outcomes of endometrial ablation in the treatment of heavy menstrual bleeding

PURPOSE OF REVIEW

Long-term data from the studies of various endometrial ablation techniques are beginning to emerge. This review appraises the current literature on endometrial ablation for heavy menstrual bleeding, with particular emphasis on second-generation techniques, and their effectiveness, rates of repeat and further interventions and adverse events occurring 1 year or more after the procedure.

RECENT FINDINGS

Second-generation, nonhysteroscopic techniques are marginally superior to hysteroscopic approaches, in terms of amenorrhoea, refractory menorrhagia and satisfaction rates. Hysterectomy rates are around 20% at 2 years, with a further 3-5% having repeat ablations. Bipolar radiofrequency and microwave ablation give rise to higher amenorrhoea rates than thermal balloon ablation, and are less likely to require repeat or further intervention.

SUMMARY

Endometrial ablation is a well tolerated and effective procedure for the treatment of heavy menstrual bleeding. Second-generation techniques provide greater benefit than hysteroscopic techniques, with shorter procedural times and the possibility of outpatient treatment. Chronic pelvic pain frequently resolves after ablation, but can also develop de novo. Pregnancy outcomes are poor and continuing contraception is recommended.

[Does repeated endometrial destruction procedure decrease abnormal uterine bleeding, and does it reduce the number of hysterectomies in this indication?]

OBJECTIVE

Hysteroscopic endometrial resection or destruction in the indication of abnormal uterine bleeding or post-menopausal bleeding represents an alternative to hysterectomy, as it carries a lower morbidity rate. In case of failure of such procedure though, hysterectomy will most often be proposed as a second line of treatment. The place of the repetition of an endometrial destruction procedure has not yet been evaluated. The aim of our study is to evaluate the efficiency and the satisfaction after two consecutive techniques of endometrial destruction in case of abnormal uterine bleeding or post-menopausal bleeding.

MATERIAL AND METHODS

Nineteen patients presenting with recurring abnormal uterine bleeding after one procedure of endometrial destruction, underwent in our department, between 2004 and 2011, a second conservative endometrial procedure.

RESULTS

No complication occurred during the repeated procedure. Sixteen of the nineteen patients (84.2 %) included answered a questionnaire. The mean delay since the second procedure was 27 months [25; 29]. Eight patients (i.e. 50 %) later underwent a hysterectomy, with 5 of them (31.25 % of all 16 patients) being directly attributed to treatment failure. Patients said to be satisfied with the management of their condition in 68.75 % of cases, and 93.75 % of them would recommend it to a friend.

CONCLUSION

Our results suggest that a second conservative management in case of recurrence of AUB is effective. Hysterectomy could be avoided in 50 % of cases. A second conservative treatment could be an interesting option for patients with medical contra-indication for heavier surgery, as well as for patients willing to keep their uterus.

Endometrial ablation with the NovaSure system in Iran

OBJECTIVE

To evaluate the rate of response to treatment with the NovaSure endometrial ablation device among Iranian women with menorrhagia.

METHODS

Twenty 35-50-year-old women with menorrhagia who were referred to Arash Hospital, Tehran, Iran, in 2008 were enrolled. They underwent endometrial ablation via the NovaSure system and were followed-up for 2 years.

RESULTS

The incidence of amenorrhea was 30.0% at the end of the 2-year follow-up period. Hypomenorrhea was reported by 40.0% of women. The mean number of days of bleeding per month decreased significantly, from 30.0 ± 6.4 days before treatment to 3.1 ± 2.6 days after 2 years (P < 0.001). The severity of bleeding decreased significantly within 2 years after treatment (P < 0.001). In total, 85.0% of women were satisfied and 90.0% had responded to treatment-as defined by amenorrhea, hypomenorrhea, or return to normal menstruation.

CONCLUSION

The NovaSure system is effective and should be considered by gynecologists for the treatment of menorrhagia.

Success rate, quality of life, and descriptive analysis after generalized endometrial ablation in an obese population

OBJECTIVE

To describe the success rate of and the quality of life after global endometrial ablation in an obese population.

METHODS

A follow-up survey was mailed to 72 women who had undergone global endometrial ablation. The survey included a menorrhagia-specific NovaSure endometrial ablation questionnaire. The mean follow-up time was 2.5years.

RESULTS

Forty-four women (61%) responded, with a mean body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) of 30.5. Overall, patients reported a decrease in missed social activities, in inability to perform activities of daily living, in missed work days, in bleeding tendencies, and in pain. The amenorrhea rate was 37%, and the success rate (those not requiring any further therapeutic treatment) was 86%. Patient satisfaction was 93%.

CONCLUSION

Global endometrial ablation improved quality of life for obese women with menorrhagia and had a high rate of satisfaction, even for patients not achieving amenorrhea. Patients with a BMI of more than 34 showed a trend toward failure and a higher rate of hysterectomy.

Does the radiofrequency impedance-controlled endometrial ablation have any morphologic effects on uterine leiomyomata? Report of 3 cases

A variety of novel endometrial ablation technologies are now in routine use. A subset of uteri that had previously undergone these treatments will ultimately be evaluated by the pathologist. However, the full spectrum of histologic changes that may result from these treatments has received only sporadic attention. The NovaSure™ [Hologic Corporation, Marlborough, MA, USA] endometrial ablation system is one of several available second-generation technologies and its particular endometrial ablative power is based on the delivery of radiofrequency energy. The present analysis was designed to decipher any histologic changes (if any) associated with the NovaSure™ endometrial ablation system relative to benign smooth muscle tumors of the uterine corpus. Over a one-year period, 3 uteri that had previously undergone the NovaSure™ endometrial ablation and which also had leiomyomatous mass lesions were evaluated. The leiomyomatous mass lesions were extensively sampled and were evaluated for cellular shapes (epithelioid change, cellular rounding, extraordinary cytoplasmic eosinophilia, clear cell change, cytoplasmic vacuolation), nuclear changes (nucleomegaly, nucleolomegaly, multinucleation, hyperchromasia, symplastic changes), necrosis (coagulative and/or infarct), mitotic activity, apoptotic bodies or pyknotic cells, myxoid change, hyalinization. The three uteri were resected 61, 47 and 74 (mean 60.7) days post-ablation. After a detailed evaluation of multiple submucosal, intramural and subserosal leiomyomata from these 3 uteri, no noteworthy histologic changes were identified in the tumors. Since the presence or absence of tumor necrosis is one histologic criterion by which malignant potential is assigned to uterine smooth muscle neoplasms, defining any extrinsic processes that may establish, or contribute to this finding is clinically relevant. The findings reported herein suggests that if a leiomyoma that was obtained from a patient that had recently undergone the NovaSure™ endometrial ablation displays any degenerative changes such as necrosis, the changes are probably not attributable to the ablation.