Emergency endometrial ablation for life-threatening uterine bleeding as a result of a coagulopathy

The Patient with Non-Pregnancy-Associated Vaginal Bleeding

Abnormal uterine bleeding (AUB) unrelated to pregnancy affects 20% to 30% of women at some point in life and is a common emergency department (ED) and urgent care (UC) presentation. AUB is a complex condition with extensive terminology, broad differential diagnosis, and numerous treatment options, yet few published evidence-based guidelines. In the ED or UC setting most affected patients are often more frustrated than acutely ill. These factors can make for a challenging patient encounter in the EC/UC setting. This article reviews acute and chronic AUB in the nonpregnant patient and suggests a simplified approach for its evaluation and management.

Endometrial Ablation

The destruction of the endometrium in women with heavy menstrual bleeding has been used for well over a century, and the various techniques of delivering forms of thermal energy have been modified over the years to ensure a safe and effective treatment approach. Today, 6 nonresectoscopic devices are approved for use in the United States in addition to resectoscopic techniques that rely on the skillful use of the operative hysteroscope. Regardless of the technique used, endometrial ablation uniformly reduces menstrual blood loss, improves general and menstrual-related quality of life, and prevents hysterectomy in 4 of 5 women who undergo the procedure. When patients are appropriately selected, outcomes are optimized, and risks of serious complications are minimized. This article reviews the literature with singular reference to nonresectoscopic endometrial ablation procedures including historical background, appropriate patient selection, clinical outcomes data, complications, and special or unique considerations.

Acute uterine bleeding unrelated to pregnancy: a Southern California Permanente Medical Group practice guideline

Acute uterine bleeding unrelated to pregnancy has been defined as bleeding "sufficient in volume as to, in the opinion of the treating clinician, require urgent or emergent intervention." The Southern California Permanente Medical Group updated its guidelines for the management of this condition on the basis of the best available evidence, as identified in a systematic review of the available literature. Given the paucity of studies evaluating this condition, the guidelines, by necessity, include recommendations largely based on opinion or other sources such as case series that are, in general, categorized as low-quality evidence. Medical interventions with single or combined gonadal steroidal agents administered parenterally or orally show promise, but more high-quality studies are needed to better define the appropriate drugs, dose, and administrative scheduling. There is also some evidence that intrauterine tamponade may be useful in at least selected cases. Special attention must be paid to both diagnosing and treating inherited disorders of hemostasis, such as von Willebrand disease, that may otherwise be underdiagnosed in both adolescent and adult women.

Nonresectoscopic endometrial ablation in high-risk surgical patients: a cohort study

STUDY OBJECTIVE

To evaluate the use of nonresectoscopic endometrial ablation in women with high anesthetic and surgical risk compared with low-risk women based on the American Society of Anesthesia (ASA) physical status stratification.

DESIGN

This is a cohort study of women who were classified as high-risk (HR) or low-risk (LR) cohorts based on ASA physical status stratification. The ASA classification includes 6 grades: ASAP1, a normal healthy person; ASAP2, mild systemic disease; ASAP3, severe systemic disease; ASAP4, severe systemic disease that is a constant threat to life; ASAP5, a critically ill patient who is not expected to survive without the operation; and ASAP6, declared brain-dead patient whose organs are being removed for donor purposes. Baseline characteristics including comorbidities were obtained. Outcome measures included amenorrhea, treatment failure, and operative complications. The time to treatment failure was compared using Kaplan-Meier analysis. Risk adjustments were performed using regression models.

SETTING

Academic medical center in the Upper Midwest.

PATIENTS

Seven-hundred eleven women underwent nonresectoscopic endometrial ablation at our institution between January 1998 and December 2005.

INTERVENTIONS

Bipolar radiofrequency was used in 448 women and thermal balloon ablation in 263 women.

MEASUREMENTS AND MAIN RESULTS

The HR cohort had a higher proportion of women with cardiac disease (27.1% vs. 6.7%, p < .001) and more women with nongynecologic cancer (12.3% vs. 2.9%, Fisher exact test, p < .001). Nonetheless, endometrial ablation had comparable efficacy in both the HR and LR cohorts with 5-year failure rates of 11.7% and 14.8% (p = .659), respectively. Amenorrhea rates were also similar in both cohorts (29.7% vs. 27.2%, p = .645). After adjusting for known confounders including age, parity, dysmenorrhea, previous tubal ligation, uterine length, and the type of the procedure, the calculated hazard ratio for failure in the HR cohort was 0.80 (95% confidence interval; 0.31-1.74, p = .607), and the adjusted odds ratio for amenorrhea was 1.27 (95% confidence interval, 0.71-2.20; p = .411). Complications were rare in both groups. The mortality rate in the HR cohort was significantly higher compared with the LR cohort (7.9% vs. <1%, p < .001), but this was not related to the ablation procedures.

CONCLUSION

For women who are high anesthetic and surgical risks because of serious underlying comorbidities, nonresectoscopic endometrial ablation can provide minimally invasive, safe, and effective therapy for menorrhagia.

Health-related quality of life and patient satisfaction after global endometrial ablation for menorrhagia in women with bleeding disorders: a follow-up survey and systematic review

OBJECTIVE

The purpose of this study was to describe health-related quality of life and satisfaction after global endometrial ablation in women with bleeding disorders and a systematic review of the literature.

STUDY DESIGN

A follow-up survey was mailed to 36 patients with bleeding disorders and 110 reference patients (no coagulopathies) who underwent global endometrial ablation for menorrhagia. The survey included a generic (SF-12) and menorrhagia multi-attribute utility scale questionnaires.

RESULTS

Ninety-six women (66%) responded. The total menorrhagia multiattribute utility scale score increased from 35-100 in bleeding disorder cohort (P = .03) and from 48-100 in the reference cohort (P < .001). Although postablation SF-12 mental domain scores were comparable in both cohorts (55 vs 55; P = .67), physical domain scores were lower in the bleeding disorder cohort (50 vs 56; P < .001). High satisfaction was reported by both cohorts (95% vs 84%; P = .60).

CONCLUSION

Global endometrial ablation improved health-related quality of life for women with bleeding disorders and had high satisfaction rates.

Global Endometrial Ablation for Menorrhagia in Women With Bleeding Disorders

OBJECTIVE

To evaluate the efficacy of global endometrial ablation in women with bleeding disorders who presented with menorrhagia.

METHODS

A records-linkage system was used to construct a retrospective cohort of 41 women with bleeding disorders (coagulopathy) and a reference group of 111 randomly selected women without bleeding disorders from a pool of 943 women who underwent global endometrial ablation (with thermal balloon ablation technology or bipolar radiofrequency ablation technology) for menorrhagia at Mayo Clinic (Rochester, Minnesota) from January 1995 through December 2005. Demographic data, type of global endometrial ablation therapy and reablation, and hysterectomy data were extracted from the database.

RESULTS

There was no significant difference in baseline age, parity, body mass index, uterine size, type of global endometrial ablation therapy, or duration of follow-up between the groups. Two women (5%) in the coagulopathy group had hysterectomy or reablation, compared with 8 (7%) in the reference group (Fisher exact test, P=.728). A Kaplan-Meier plot showed no difference in the time to treatment failure between the groups (log-rank test, P=.534). Procedural-related complications were generally minor and infrequent (9 of 152 [6%]). Complications were equally distributed in the coagulopathy (4 of 41) and reference groups (6 of 111) (Fisher exact test, P=.267).

CONCLUSION

Global endometrial ablation is an effective treatment choice for women with coagulopathy presenting with menorrhagia.

Oral Medroxyprogesterone Acetate and Combination Oral Contraceptives for Acute Uterine Bleeding

OBJECTIVE

To compare the efficacy of multidose medroxyprogesterone acetate and a multidose monophasic combined oral contraceptive (OC) for hemodynamically stable women with nongestational, acute uterine bleeding.

METHODS

Hemodynamically stable patients with acute uterine bleeding sufficient to justify immediate medical or surgical intervention were enrolled in an open-label, randomized trial comparing oral medroxyprogesterone acetate 20 mg and a monophasic combination OC containing 1 mg norethindrone and 35 mug of ethinyl estradiol, each administered three times per day. Doses were reduced after 1 week to 20 mg per day and one tablet per day for the next 3 weeks for the medroxyprogesterone acetate and OC groups, respectively. Following baseline assessment, patients completed daily treatment and symptom logs collected at 14 and 28 days after initiation of therapy.

RESULTS

Forty patients were randomly assigned, 20 in each group; 33 were evaluated at the 14-day visit. Emergency surgical procedures were avoided in 100% of those women taking medroxyprogesterone acetate and 95% of the OC group. Cessation of bleeding had occurred in 88% of the OC group and 76% of those receiving medroxyprogesterone acetate, with a median time to bleeding cessation of 3 days for both groups. Compliance with therapy was higher in the medroxyprogesterone acetate group than the OC group, but there was no overall difference in the incidence of treatment-related nausea and bloating.

CONCLUSION

This randomized trial is limited by sample size but suggests that both regimens may be effective and reasonably well tolerated.

CLINICAL TRIAL REGISTRATION

Current Clinical Trials (clinicaltrials.gov, www.clinicaltrials.gov) Identifier: NCT00350480

LEVEL OF EVIDENCE

II-1.

A randomized prospective comparative study of general versus epidural anesthesia for transcervical hysteroscopic endometrial resection

OBJECTIVE

This study was undertaken to compare general versus epidural anesthesia during hysteroscopic endometrial resection for dysfunctional uterine bleeding.

STUDY DESIGN

In a prospective comparative study, 24 women with abnormal uterine bleeding that was unresponsive to conservative medical management were randomly assigned to undergo hysteroscopic endometrial resection with either general or epidural anesthesia.

RESULTS

The durations of the endometrial resection procedure were similar for women who had general and epidural anesthesia (28.3 +/- 4.2 minutes vs 27.5 +/- 5.4 minutes, respectively). However, there was a statistically significantly lower absorption of distention fluid in women who underwent the procedure with general rather than epidural anesthesia (380.8 +/- 158.2 mL vs 648.3 +/- 157.1 mL, respectively; P < .0005).

CONCLUSION

A significantly lower amount of glycine distention fluid was absorbed during endometrial resection in women who underwent the procedure with general rather than epidural anesthesia.

Severe menorrhagia due to Glanzmann thrombasthenia treated with hydrothermal ablation

Glanzmann thrombasthenia is a rare platelet disorder inherited as an autosomal recessive trait. Abnormal uterine bleeding is a common problem in women with the disease. Medical management may not always be effective and further treatment may be necessary. Two women underwent endometrial ablation with a continuous-flow circulating hydrothermal ablator. After follow-up of 12 and 18 months, both women remained without abnormal uterine bleeding.

The effect of increasing age on the outcome of hysteroscopic endometrial resection for management of dysfunctional uterine bleeding

STUDY OBJECTIVE

To determine the outcome of hysteroscopic endometrial resection for dysfunctional uterine bleeding according to women's age.

DESIGN

Long-term follow-up by telephone interview (Canadian Task Force classification II-2).

SETTING

University-affiliated medical center. Patients. One hundred sixty-nine women with abnormal uterine bleeding unresponsive to conservative medical management.

INTERVENTION

Hysteroscopic endometrial resection.

MEASUREMENTS AND MAIN RESULTS

Questionnaires were completed for 162 (95.9%) patients with mean +/- SD follow-up of 32 +/- 17 months. The frequency of postoperative complications was not related to age. After ablation, the rate of amenorrhea was significantly higher in 31 women age 50 years or older than in younger women (p <0.001), and also in 72 women age 45 to 49 than in 59 age 44 or less (p <0.05). Complete relief of dysmenorrhea was achieved significantly more often in women age 45 to 49 (p <0.005) and 50 or older (p <0.05) than in those age 44 or younger. Dissatisfaction with the outcome of endometrial resection was uncommon, but most frequent among women age 44 or younger (p <0.10). There was no difference in the proportion of women requiring second ablation or hysterectomy in any age group.

CONCLUSION

Significantly higher rates of amenorrhea and complete relief of dysmenorrhea after endometrial resection are achieved in older than in younger women.