Endometrial ablation: normal appearance and complications

Global endometrial ablation is a commonly performed, minimally invasive technique aimed at improving/resolving abnormal uterine bleeding and menorrhagia in women. As non-resectoscopic techniques have come into existence, endometrial ablation performance continues to increase due to accessibility and decreased requirements for operating room time and advanced technical training. The increased utilization of this method translates into increased imaging of patients who have undergone the procedure. An understanding of the expected imaging appearances of endometrial ablation using different modalities is important for the abdominal radiologist. In addition, the frequent usage of the technique naturally comes with complications requiring appropriate imaging work-up. We review the expected appearance of the post-endometrial ablated uterus on multiple imaging modalities and demonstrate the more common and rare complications seen in the immediate post-procedural time period and remotely.

Cost-utility of levonorgestrel intrauterine system compared with hysterectomy and second generation endometrial ablative techniques in managing patients with menorrhagia in the UK

OBJECTIVE

To estimate the cost-utility of levonorgestrel intrauterine system (LNG-IUS; Mirena) compared to second generation endometrial ablative techniques [i.e. microwave endometrial ablation (MEA) and thermal balloon endometrial ablation (TBEA)) and hysterectomy in the UK.

METHODS

Clinical and utility data from a 5-year randomised controlled trial comparing LNG-IUS with hysterectomy were combined with further data from published studies to construct a state-transition (Markov) model. The model depicted the movement of patients between health states over 5 years following treatment for menorrhagia. The model was used to estimate the cost-utility of LNG-IUS followed by ablation (L-A); LNG-IUS followed by hysterectomy (L-H); immediate ablation (MEA or TBEA) and immediate hysterectomy in the UK at 2004/2005 prices, from the perspective of the UK's National Health Service (NHS).

MAIN OUTCOME MEASURES AND RESULTS

The expected 5-yearly cost of treating menorrhagia with L-A, L-H, TBEA, MEA and hysterectomy was estimated to be 828 pounds sterling, 1355 pounds sterling, 1679 pounds sterling, 1812 pounds sterling and 2983 pounds sterling per patient respectively and the expected level of health gain to be 4.14, 4.12, 4.13, 4.13 and 4.01 QALYs per patient respectively. LNG-IUS followed by ablation dominated all the alternative treatments. Hysterectomy was dominated by the alternative treatments. Sensitivity analysis found the model to be sensitive to the quality of life data used.

CONCLUSION

Within the model's limitations, LNGIUS followed by ablation appears to offer the NHS a cost-effective treatment for menorrhagia, when compared to immediate surgery, affording the NHS a less expensive treatment modality without detrimental effects on resulting health gain.

Clinical and health service implications of second generation endometrial ablation devices

PURPOSE OF REVIEW

This review evaluates the current evidence on the efficacy, safety and cost-effectiveness of the ever-increasing number of second-generation endometrial ablation devices.

RECENT FINDINGS

The literature covered by this review includes (1) evidence on long-term benefit, avoidance of hysterectomy and improvement in quality of life, (2) applicability of these techniques in the outpatient environment under local or no anaesthesia, (3) frequency and nature of early and delayed complications associated with these devices, (4) impact on clinical practice and the health service, and (5) implications for research.

SUMMARY

Where appropriate, second-generation devices are rapidly becoming the first-line surgical choice for the management of heavy menstrual bleeding. This has both cost-savings and negative implications for the health service. There is also emerging evidence that improvement in quality of life is more relevant to women than amenorrhoea rates. What has come to light from this review is the lack of accurate data on adverse events rate, and the urgent need for a better appreciation of the frequency and nature of complications.

Thermal ablation performed in a primary care setting: the South Warwickshire Experience

OBJECTIVE

To assess the feasibility of performing outpatient thermal ablation in a primary care setting.

DESIGN

Prospective study.

SETTING

A small peripheral hospital in the UK used by local general practitioners and visiting hospital practitioners for its outpatient facilities.

POPULATION

The area of South Warwickshire serves a population of 270,000.

METHODS

Two general practitioners were trained to perform outpatient thermal ablation using the Thermachoice thermal ablation system (Thermachoice II). The unit functioned autonomously with support from a local gynaecologist and radiologist, accepting referrals from hospital consultants and general practitioners.

MAIN OUTCOME MEASURES

Severity of menstrual loss, premenstrual symptoms, dysmenorrhoea and quality of life assessed by visual analogue scales before treatment and at one month, two months, one year and two years.

RESULTS

Eighty-seven women were treated. No major complications were encountered from the procedure. Reduction of menstrual loss or cure was reported by over 94% of women. Premenstrual syndrome (PMS) and symptoms of dysmenorrhoea were also improved by treatment. The majority of women were satisfied with the operation at one month (96%), two months (93%), one year (92%) and two years (94%).

CONCLUSIONS

Thermal ablation is a simple procedure well suited to an outpatient setting. There are few complications as a result of the use of the thermal ablation catheters, and this study has shown that the procedure can be undertaken in a primary care setting with excellent results.

A cost-utility analysis of microwave and thermal balloon endometrial ablation techniques for the treatment of heavy menstrual bleeding

OBJECTIVE

To assess the cost effectiveness of the second-generation surgical treatments for heavy menstrual bleeding (microwave and thermal balloon endometrial ablation) compared with existing endometrial ablation techniques (transcervical resection and rollerball, alone or in combination) and hysterectomy.

DESIGN

A state transition (Markov) cost-utility economic model.

POPULATION

Women with heavy menstrual bleeding.

METHODS

A Markov model was developed using spreadsheet software. Transition probabilities, costs and quality of life data were obtained from a systematic review of effectiveness undertaken by the authors, from published sources, and expert opinion. Cost data were obtained from the literature and from a NHS trust hospital. Indirect comparison of thermal balloon endometrial ablation versus microwave endometrial ablation or either second-generation endometrial ablation method versus hysterectomy, and comparison of second-generation versus first-generation techniques were carried out from the perspective of health service payers. The effects of uncertainty were explored through extensive one-way sensitivity analyses and Monte Carlo simulation.

MAIN OUTCOME MEASURES

Incremental cost effectiveness ratios based on cost per quality adjusted life year (QALY) gained, and cost effectiveness acceptability curves.

RESULTS

Compared with first-generation techniques, both microwave and thermal balloon endometrial ablation cost less and accrued more QALYs. Hysterectomy was more expensive, but accrued more QALYs than all endometrial ablation methods. Baseline results showed that differences between microwave endometrial ablation and thermal balloon endometrial ablation were slight. Sensitivity analyses showed that small changes in values may have a marked effect on cost effectiveness. Probabilistic simulation highlighted the uncertainty in comparisons between different endometrial ablation options, particularly between second-generation techniques.

CONCLUSIONS

Despite limitations in available data, the analysis suggests that second-generation techniques are likely to be more cost effective than first-generation techniques in most cases. Hysterectomy, where a woman finds this option acceptable, continues to be a very cost effective procedure compared with all endometrial ablation methods.