Advances in endometrial ablation

Sonographic findings in two cases of complicated pregnancy in women previously treated with endometrial ablation

When medical therapy fails for menorrhagia in a premenopausal woman, minimally invasive endometrial ablation can be used as a conservative management alternative to hysterectomy. Endometrial ablation alone is not considered effective contraception, and women of reproductive age can become pregnant after ablative therapy. We now present two cases of pregnancy after endometrial ablation and associated imaging where both cases required cesarean hysterectomy due to post-partum hemorrhage. Pregnancy after endometrial ablation incurs increased morbidity and diagnostic dilemmas.

Analysis of uterine and ovarian arterial blood flow and ovarian hormone levels prior to and after hysteroscopic endometrial resection

The objective of this study was to evaluate the effect of hysteroscopic endometrial ablation on the ovarian and uterine artery blood flow and on follicle stimulating hormone (FSH) and oestradiol (E2) levels. A total of 26 consecutive women with abnormal uterine bleeding refractory to medical treatment had undergone hysteroscopic electrosurgical transcervical resection of the endometrium (TCRE). Ultrasonographic measurement of ovarian volumes and colour Doppler flow assessment of the uterine and ovarian arteries were performed on all patients before surgery (group 1) and 1 week (group 2) and 6 months (group 3) after surgery. Blood samples were also collected for determination of FSH and E2 levels, 4 weeks before and 1 month after surgery. No statistically significant change was observed between preoperative and postoperative (1st week and 3rd month) volumes of the ovaries. The mean pulsatility index (PI) of the uterine and ovarian artery did not show statistically significant differences between postoperative 1st week and 3rd month measurements of uterine and ovarian artery PI. The increase in serum levels of FSH and E2 after endometrial resection did not reach statistical significance. Although, women may present with climacteric complaints of hot flushes and nocturnal sweating after endometrial resection, this is probably a psychological response to hypomenorrhoea and amenorrhoea, as no statistically significant changes in FSH and E2 levels and uterine/ovarian blood flow were demonstrated in the early postoperative period.

Endometrial ablation: postoperative complications

Endometrial ablation as a treatment for abnormal uterine bleeding has evolved considerably over the past several decades. Postoperative complications include the following: (1) pregnancy after endometrial ablation; (2) pain-related obstructed menses (hematometra, postablation tubal sterilization syndrome); (3) failure to control menses (repeat ablation, hysterectomy); (4) risk from preexisting conditions (endometrial neoplasia, cesarean section); and (5) infection. Physicians performing endometrial ablation should be aware of postoperative complications and be able to diagnose and provide treatment for these conditions.

Modified thermal balloon endometrial ablation in low resource settings: a cost-effective method using Foley's catheter

OBJECTIVE

To assess the efficacy of a modified Foley's catheter endometrial ablation in the treatment of abnormal uterine bleeding in low resource settings.

METHODS

Four hundred and thirty premenopausal women with abnormal uterine bleeding were subjected to thermal balloon endometrial ablation using modified Foley's catheter. The primary outcome measure was patient satisfaction regarding menstrual blood loss. Secondary measures included improvement in quality of life scores and failure rates.

RESULTS

Three hundred and three patients were available for evaluation at 3-year follow up. 270/303 (89.1%) reported their satisfaction as indicated by reduction in days of menstrual flow per cycle (4.2 vs. 8.8 days, p < 0.0001). There was a significant improvement in quality of life scores (p < 0.0001). The rate of failure varies according to the interval of follow up from 15.6% at 6 months to 10.9% at 3 years.

CONCLUSION

Modified Foley's catheter endometrial ablation is a cost effective alternative to other thermal endometrial ablation techniques in the treatment of abnormal uterine bleeding in low resource settings.

Pregnancy following endometrial ablation: a review article

This review summarises the 70 pregnancies reported following endometrial ablation by various techniques, including a those in a case report from the authors' own experience. Thirty-one viable pregnancies resulted, with a high proportion of complications. These included a perinatal mortality rate of 12.9% (4 cases), and an overall prematurity rate of 42%, which reduced to 31% after excluding iatrogenic deliveries performed for other complications. Eight (26%) cases had a morbidly adherent placenta and a further two cases required a manual removal of placenta. Seven (39%) of the term births were reported as having malpresentations and 71% of the total births were by caesarean section. The complications are discussed and a comparison is made with Asherman's Syndrome. In addition, the various factors that may be relevant to fertility after endometrial ablation are discussed.

Long-term complications of endometrial ablation: Cause, diagnosis, treatment, and prevention

At first, total endometrial ablation seemed extremely safe in the short term. However, as time passed, certain unique long-term complications became evident. The problem is that after this procedure, intrauterine scarring and contracture can occur. Any bleeding from persistent or regenerating endometrium behind the scar may be obstructed and cause problems such as central hematometra, cornual hematometra, postablation tubal sterilization syndrome, retrograde menstruation, and potential delay in the diagnosis of endometrial cancer. The incidence of these complications is probably understated because most radiologists and pathologists have not been educated about the findings to make the appropriate diagnosis of cornual hematometra and postablation tubal sterilization syndrome. This review will thoroughly discuss how to diagnose and treat these problems. Possible ways of preventing these long-term complications will also be discussed.

Indications and options for endometrial ablation

Endometrial ablation is an effective therapeutic option for the management of menorrhagia in properly selected patients. Hysteroscopic and non-hysteroscopic techniques offer similar rates of symptom relief and patient satisfaction.

The occurrence and outcome of 39 pregnancies after 1621 cases of transcervical resection of endometrium

BACKGROUND

To evaluate the outcomes and management of pregnancy after transcervical resection of the endometrium (TCRE).

METHODS

Retrospective study of 39 pregnancies after 1621 procedures of TCRE.

RESULTS

Among 1621 women who were successfully followed up after TCRE, there were 39 pregnancies in 32 women, including five ectopic pregnancies (12.8%) and 34 intrauterine pregnancies (87.2%). The majority of pregnancies (84.6%) occurred within the first 2 years. In the first year after TCRE, the incidence of pregnancy was 1.5%. In women who had amenorrhoea after TCRE, the chances of conception (2/676; 0.3%) were significantly (P < 0.001) lower than for those who continued to have period (30/945; 3.2%). Thirty-two cases with intrauterine pregnancy were terminated under ultrasound guidance with two difficult procedures. Only one pregnancy in our study resulted in spontaneous miscarriage which was managed by suction curettage. One term pregnancy had placenta increta resulting in Caesarean hysterectomy.

CONCLUSIONS

Pregnancies after TCRE are associated with increased risk, and clinicians should be aware of the various complications of pregnancy that may occur after TCRE, including an increased risk of ectopic pregnancy. Surgical termination of pregnancy after TCRE is potentially a difficult procedure and should be carried out under ultrasound guidance.

Hysteroscopic and nonhysteroscopic endometrial ablation

Endometrial ablation is defined as the elimination of the endometrium by thermal energy or resection. It was introduced in the 1980s as an alternative to hysterectomy to those patients with abnormal uterine bleeding and benign pathology who are unable or unwilling to tolerate traditional therapies. This article explores various endometrial ablation techniques.

Management of menstrual problems and contraception in adolescents with mental retardation: a medical, legal, and ethical review with new suggested guidelines

The controversial history of the reproductive rights of the mentally retarded has led to the formulation of laws in the past century designed to protect women from forced sterilization. Significantly, however, in their official ethical guidelines, The American College of Obstetricians and Gynecologists states that "sterilization should not be denied to individuals simply because they also may be vulnerable to coercion" (Int J Gynaecol Obstet 1999; 65:317). Recent advances in medical and surgical methods of contraception and control of menstrual abnormalities have led to a re-evaluation of the management of adolescents with special needs. Physicians, the courts, parents, and caretakers need to be aware of the latest medical and surgical options available, the current applicable laws in each state if such exist, and the ethical guidelines to determine what treatment option is in the best interests of the patient. This review examines the history of the sterilization of the mentally retarded, the latest surgical and pharmacologic treatments available, and the current legal environment and proposes an algorithm to facilitate the management of menstrual hygiene and contraception.