Intraoperative Predictors of Long-term Outcomes After Radiofrequency Endometrial Ablation

Clinical analysis of 2152 cases of abnormal uterine bleeding treated by NovaSure endometrial ablation

OBJECTIVE

To evaluate the efficiency, postoperative hysterectomy rate, and influencing factors for therapeutic effect of the NovaSure endometrial ablation procedure in abnormal uterine bleeding (AUB).

METHODS

We conducted a retrospective cohort study of 2152 patients from the Department of Gynecology at the Third Xiangya Hospital, CSU from October 2010 to December 2018.

RESULTS

From the first year to the eighth year after operation, annual effective rate was above 95.24%, and the differences were not statistically significant. There are statistically significant differences between the effective and ineffective groups with regard to age, intrauterine polyps, total length of the uterus, systemic coagulation disorder, and preoperative hemoglobin. A multivariate logistic regression analysis showed that the risk factors associated with systemic coagulation disorders (P = 0.027) and high total uterine length (P = 0.003) affected NovaSure efficacy in the treatment of AUB. By December 2019, the postoperative hysterectomy rate was 1.86% (40/2152) and the complication rate was 1.67% (36/2152).

CONCLUSION

NovaSure is a reliable treatment for AUB and serious medical complications because of its simple operation, low amount of bleeding, quick postoperative recovery, and safe and effective short-term and long-term efficacy. However, it should be carefully selected for patients with a total uterus length exceeding 10 cm.

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.

Evaluation and Management of Abnormal Uterine Bleeding

Abnormal uterine bleeding (AUB) is a common condition that leads to increased health care costs and decreased quality of life. A systematic approach to AUB evaluation can simplify management and enhance women's well-being. Abnormal uterine bleeding describes any variation from normal bleeding patterns in nonpregnant, reproductive-aged women beyond menarche lasting for at least 6 months. Ambiguous and inconsistent use of terminology and definitions to characterize AUB in the past decades necessitated a new, consensus-based approach to nomenclature and AUB evaluation. This led to the International Federation of Gynecology and Obstetrics (FIGO) System 1 in 2007, which standardized nomenclature, set parameters, and defined normal and abnormal bleeding based on the 5th to 95th percentile data from available large-scale epidemiologic studies. FIGO System 1, endorsed by several national and international societies, improved worldwide communication among educators, clinicians, and researchers. FIGO System 2, published in 2011, focused on classifications of AUB etiology into structural and nonstructural entities using the PALM-COEIN (polyp[s], adenomyosis, leiomyoma, malignancy, coagulopathy, ovulatory dysfunction, endometrial disorders, iatrogenic, and not yet classified) classification system. The PALM-COEIN classification is facilitated by a complete patient history combined with appropriate imaging, histopathologic analysis, or laboratory evaluation to ensure accurate diagnostic and treatment approaches to AUB. Herein we present the systematic evaluation of AUB.

Pain is an Independent Risk Factor for Failed Global Endometrial Ablation

STUDY OBJECTIVE

To determine whether pain, as part of an indication for global endometrial ablation, is an independent risk factor for failure.

DESIGN

Retrospective cohort study (Canadian Task Force classification II-2).

SETTING

Academic-affiliated community hospital.

PATIENTS

Women undergoing global endometrial ablation with radiofrequency ablation (RFA), hydrothermablation (HTA), or uterine balloon ablation (UBA) between January 2003 and December 2015.

INTERVENTIONS

Procedure failure was defined as subsequent hysterectomy after the index ablation.

MEASUREMENTS AND MAIN RESULTS

A total of 5818 women who underwent an endometrial ablation were identified, including 3706 with RFA (63.7%), 1786 with HTA (30.7%), and 326 with UBA (5.6%). Of the 5818 ablations, 437 (7.5%) involved pain (i.e., pelvic pain, dysmenorrhea, dyspareunia, lower abdominal pain, endometriosis, or adenomyosis) before ablation, along with abnormal uterine bleeding. Pain as part of the preoperative diagnoses before endometrial ablation was a significant risk factor for subsequent hysterectomy compared with all other diagnoses (19.2% vs 13.5%; p = .001). Consistent with previous studies, women who underwent ablation at an older age were less likely to fail, which held true even when one of the indications for ablation was related to pain (odds ratio, 0.96/year; 95% confidence interval, 0.95-0.97). When the pathology reports of women who underwent a hysterectomy were examined, women in the pain group had lower rates of adenomyosis than women without pain (38.1% vs 50.1%; p = .04). However, there was a trend toward a higher rate of endometriosis on pathology reports (14.3% vs 8.7%; p = .09) and even higher rates of visualized endometriosis identified by operative reports in women who had pain before their ablation (42.9% vs 15.8%; p < .001). Patients who had pain before their ablation were less likely to have myomas/polyps (p = .01).

CONCLUSION

Pelvic pain before global endometrial ablation is an independent risk factor for failure.

Management considerations for patients with uterine fibroids and concurrent venous thromboembolism

PURPOSE OF REVIEW

The purpose is to provide an update on management strategies for uterine fibroids in the setting of venous thromboembolism (VTE).

RECENT FINDINGS

Uterine fibroids and VTE are independently associated with morbidity and increasing healthcare costs. Women with large uterine fibroids have a higher likelihood of VTE. Current strategies for stratifying patients with VTE take into account the nature of the VTE (i.e., truly provoked or unprovoked) and many patients may only require short-term anticoagulation. In those patients with risk factors for recurrent VTE, longer term anticoagulation may be required.

SUMMARY

In women with large uterine fibroids, the likelihood of concurrent VTE increases. Peri and postoperative management should be determined based on patient-specific risk stratification, with the majority of patients requiring short-term anticoagulation. Further risk stratification may be required for patients with essentially an unprovoked VTE, and consultation with a thrombosis specialist is recommended.

Late-onset endometrial ablation failure

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.

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Over 500,000 endometrial ablations (EAs) are performed in the U. S. each year.

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Late-onset endometrial ablation failures (LOEAFs) are the most common complication of EA.

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25% of women who undergo EA will require hysterectomy within 5 years.

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Reducing the incidence of LOEAFs requires improved patient selection for EA.

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Ultrasound-guided reoperative hysteroscopic surgery (UGRHS) reduces the need hysterectomy following LOEAF.