The long-term effectiveness of endometrial laser ablation: a survival analysis

Rates of subsequent surgery following endometrial ablation among English women with menorrhagia: population-based cohort study

OBJECTIVE

To assess the risk of further surgery amongst women who had an initial endometrial ablation (EA) for the treatment of heavy menstrual bleeding (HMB).

DESIGN

A retrospective cohort study using a national administrative database.

SETTING

Population-based study of hospital care in the English National Health Service.

POPULATION

A cohort of 114,910 women who had EA for HMB between January 2000 and December 2011.

METHODS

Multiple Cox regressions were performed to identify the risks of a further procedure, adjusted for age, social deprivation, year and type of initial EA, and presence of fibroids/polyps.

MAIN OUTCOME MEASURES

Time to repeat EA or hysterectomy after initial surgery.

RESULTS

Of 114,910 women undergoing EA, 16.7% had at least one subsequent procedure within 5 years. Higher rates of subsequent surgery were associated with younger age at initial EA, with women aged under 35 years having an adjusted hazard ratio of 2.83 (95% CI 2.67-2.99), compared with women aged over 45 years. Women who had radiofrequency ablation were less likely to have subsequent surgery as compared with first-generation techniques (HR 0.69, 95% CI 0.63-0.76). The rate of a subsequent hysterectomy within 5 years was 13.5%. Younger women (OR 0.59, 95% CI 0.51-0.69) and those who had balloon, microwave, or radiofrequency ablation were less likely to have a second EA procedure, rather than a hysterectomy.

CONCLUSIONS

One in six women have further surgery after EA for HMB, which is a higher rate than reported in clinical trials. This risk of further surgery decreases with age.

First-generation endometrial ablation: roller-ball vs loop vs laser

Hysteroscopic guided or first generation endometrial ablation methods include transcervical endometrial resection, and rollerball and laser ablation. These techniques have been shown to be effective and safe alternatives to hysterectomy for dysfunctional uterine bleeding resulting in reduction in menstrual blood loss and dysmenorrhoea, correction of anaemia and improvement in quality of life. Compared with hysterectomy, treatment is associated with lower morbidity, shorter hospitalisation and faster recovery, and reduced treatment costs. As a result, the 1st generation ablation techniques are recognized as the "gold standard" ablation methods. There are many similarities between the three techniques with respect to surgical principles and effectiveness. Certainly, menstrual improvement and patient satisfaction are similar with all three methods. In contrast, the complication profile of the three techniques is different, but surgical experience is arguably a much more important arbiter of patient safety than the technique itself.

Factors affecting the outcome of endometrial ablation using Cavaterm plus

OBJECTIVE

To study treatment outcome using the modified technique: Cavaterm plus.

STUDY DESIGN

Retrospective postal questionnaire, in a large teaching hospital. One hundred and twenty-eight women with menorrhagia were treated between February 2001 and April 2003. Data were collected prospectively for the duration of the procedure and alternatives offered. Follow up questionnaire was distributed during November 2003 to assess menstrual status. Multiple binary logistic regression was performed to assess factors influencing success.

RESULTS

The mean follow up was 72 weeks, 103 patients (80.5%) completed the questionnaire. In 26 (25.2%) cases, there were one or more important deviations from recommended procedure. Twenty (19.4%) women had procedure-related amenorrhoea, 6 (5.8%) had spotting, 35 (34%) had light, and 26 (25.2%) had moderate bleeding. Eleven (10.7%) had a hysterectomy. The risk of failure was inversely related to age (OR 0.778, 95% CI 0.669-0.905), was higher in women who prior to surgery had longer duration of bleeding (OR 1.29, 95% CI 1.1-1.52), and when recommended selection or operative procedures were not followed (OR 5.056, 95% CI 1.097-23.3).

CONCLUSION

Cavaterm plus is associated with high patient satisfaction. The technique remains a good choice for women wishing to avoid hysterectomy, but there is a need to observe determinants of poor outcome.

Endometrial ablation

PURPOSE OF REVIEW

Although endometrial ablation has now been accepted practice for more than 20 years, it continues to be a source of research, controversy and speculation. This is illustrated by the 175 articles found in PubMed between the years 2000 and 2003 under the search term 'endometrial ablation' commissioned as part of the preparation for this article.

RECENT FINDINGS

The so-called first-generation methods (laser, resection, rollerball) have now got long-term follow-up data of up to 20 years. A few of the second-generation devices have published long-term follow-up data of 5 years. All of the second-generation devices assessed in randomized trials with the first-generation methods compare favourably; however, there are few data on cost effectiveness. Similarly, there are few data comparing endometrial ablation with the Mirena intrauterine device.

SUMMARY

Conventional endometrial ablation has been extensively validated; however, many of the newer techniques have inadequate patient numbers or lengths of follow-up on which to evaluate their long-term efficacy, safety or cost effectiveness fully. The anticipated decline in hysterectomy rates with the advent of endometrial destruction methods has not occurred, and this may indicate a lower threshold for surgical management.