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Eising HP, Punt MC, Schermer T, Leemans JC, Bongers MY. The ISTH-BAT score and outcomes after endometrial ablation in women with heavy menstrual bleeding. Haemophilia 2023; 29:1573-1579. [PMID: 37758646 DOI: 10.1111/hae.14872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/11/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND The International Society on Thrombosis and Haemostasis bleeding assessment tool (ISTH-BAT), is used during the diagnostic workup of bleeding disorders. Data on ISTH-BAT scores in women with heavy menstrual bleeding (HMB) undergoing endometrial ablation (EA) could be essential in optimizing HMB counselling. OBJECTIVE To investigate the postsurgical incidence of amenorrhea, dysmenorrhea, quality of life, re-intervention after EA, and ISTH-BAT score. METHODS This study included women who have undergone EA because of HMB. During a follow-up of 2 to 5 years, ISTH-BAT, pictorial blood assessment chart (PBAC), and Short Form-36 survey (SF-36) were administered. At 10 years of follow-up surgical re-interventions were evaluated. RESULTS Seventy-one women were included of whom 77% (n = 55) had an ISTH-BAT score < 6, versus 23% (n = 16) ISTH-BAT score ≥6 (mean age 46.3 versus 42.3, p = 0.004). In the ISTH-BAT ≥6 group versus < 6 group, amenorrhea occurred in 63% (10/16) versus 82% (45/55) (p = 0.111), dysmenorrhea in 38% (6/16) versus 18% (10/55) (p = 0.111), and surgical re-intervention in 19% (3/16) versus 25% (14/55) (p = 0.582). SF-36 item (Bodily) pain was lower in the ISTH-BAT ≥6 group versus < 6 (median score 58.7 vs. 80.0, p = 0.104). CONCLUSIONS An ISTH-BAT score ≥6 may be related to a lower amenorrhea incidence and higher dysmenorrhea rate after EA.
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Affiliation(s)
- Heleen P Eising
- Department of Gynaecology and Obstetrics, Gelre Hospital, Apeldoorn, The Netherlands
- Grow Research School Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Marieke C Punt
- Department of Gynaecology and Obstetrics, Gelre Hospital, Apeldoorn, The Netherlands
| | - Tjard Schermer
- Gelre Leerhuis, Department of Epidemiology, Gelre Hospitals, Apeldoorn, The Netherlands
| | - Jaklien C Leemans
- Department of Gynaecology and Obstetrics, Máxima Medical Center, Veldhoven, The Netherlands
| | - Marlies Y Bongers
- Grow Research School Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
- Department of Gynaecology and Obstetrics, Máxima Medical Center, Veldhoven, The Netherlands
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van den Brink MJ, Beelen P, Herman MC, Geomini PM, Dekker JH, Vermeulen KM, Bongers MY, Berger MY. The levonorgestrel intrauterine system versus endometrial ablation for heavy menstrual bleeding: a cost-effectiveness analysis. BJOG 2021; 128:2003-2011. [PMID: 34245652 PMCID: PMC8518490 DOI: 10.1111/1471-0528.16836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2021] [Indexed: 11/30/2022]
Abstract
Objective To evaluate the costs and non‐inferiority of a strategy starting with the levonorgestrel intrauterine system (LNG‐IUS) compared with endometrial ablation (EA) in the treatment of heavy menstrual bleeding (HMB). Design Cost‐effectiveness analysis from a societal perspective alongside a multicentre randomised non‐inferiority trial. Setting General practices and gynaecology departments in the Netherlands. Population In all, 270 women with HMB, aged ≥34 years old, without intracavitary pathology or wish for a future child. Methods Randomisation to a strategy starting with the LNG‐IUS (n = 132) or EA (n = 138). The incremental cost‐effectiveness ratio was estimated. Main outcome measures Direct medical costs and (in)direct non‐medical costs were calculated. The primary outcome was menstrual blood loss after 24 months, measured with the mean Pictorial Blood Assessment Chart (PBAC)‐score (non‐inferiority margin 25 points). A secondary outcome was successful blood loss reduction (PBAC‐score ≤75 points). Results Total costs per patient were €2,285 in the LNG‐IUS strategy and €3,465 in the EA strategy (difference: €1,180). At 24 months, mean PBAC‐scores were 64.8 in the LNG‐IUS group (n = 115) and 14.2 in the EA group (n = 132); difference 50.5 points (95% CI 4.3–96.7). In the LNG‐IUS group, 87% of women had a PBAC‐score ≤75 points versus 94% in the EA group (relative risk [RR] 0.93, 95% CI 0.85–1.01). The ICER was €23 (95% CI €5–111) per PBAC‐point. Conclusions A strategy starting with the LNG‐IUS was cheaper than starting with EA, but non‐inferiority could not be demonstrated. The LNG‐IUS is reversible and less invasive and can be a cost‐effective treatment option, depending on the success rate women are willing to accept. Tweetable abstract Treatment of heavy menstrual bleeding starting with LNG‐IUS is cheaper but slightly less effective than endometrial ablation. Treatment of heavy menstrual bleeding starting with LNG‐IUS is cheaper but slightly less effective than endometrial ablation.
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Affiliation(s)
- M J van den Brink
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - P Beelen
- Department of General Practice, University of Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, The Netherlands
| | - M C Herman
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, The Netherlands
| | - P M Geomini
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, The Netherlands
| | - J H Dekker
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - K M Vermeulen
- Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - M Y Bongers
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, The Netherlands.,Department of Obstetrics and Gynaecology, Grow Research School for Oncology and Developmental Biology, University of Maastricht, Maastricht, The Netherlands
| | - M Y Berger
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
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Levonorgestrel-releasing intrauterine system versus endometrial ablation for heavy menstrual bleeding. Am J Obstet Gynecol 2021; 224:187.e1-187.e10. [PMID: 32795428 DOI: 10.1016/j.ajog.2020.08.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/30/2020] [Accepted: 08/10/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Heavy menstrual bleeding affects the physical functioning and social well-being of many women. The levonorgestrel-releasing intrauterine system and endometrial ablation are 2 frequently applied treatments in women with heavy menstrual bleeding. OBJECTIVE This study aimed to compare the effectiveness of the levonorgestrel-releasing intrauterine system with endometrial ablation in women with heavy menstrual bleeding. STUDY DESIGN This multicenter, randomized controlled, noninferiority trial was performed in 26 hospitals and in a network of general practices in the Netherlands. Women with heavy menstrual bleeding, aged 34 years and older, without a pregnancy wish or intracavitary pathology were randomly allocated to treatment with either the levonorgestrel-releasing intrauterine system (Mirena) or endometrial ablation, performed with a bipolar radiofrequency device (NovaSure). The primary outcome was blood loss at 24 months, measured with a Pictorial Blood Loss Assessment Chart score. Secondary outcomes included reintervention rates, patient satisfaction, quality of life, and sexual function. RESULTS We registered 645 women as eligible, of whom 270 women provided informed consent. Of these, 132 women were allocated to the levonorgestrel-releasing intrauterine system (baseline Pictorial Blood Loss Assessment Chart score, 616) and 138 women to endometrial ablation (baseline Pictorial Blood Loss Assessment Chart score, 630). At 24 months, mean Pictorial Blood Loss Assessment Chart scores were 64.8 in the levonorgestrel-releasing intrauterine system group and 14.2 in the endometrial ablation group (difference, 50.5 points; 95% confidence interval, 4.3-96.7; noninferiority, P=.87 [25 Pictorial Blood Loss Assessment Chart point margin]). Compared with 14 women (10%) in the endometrial ablation group, 34 women (27%) underwent a surgical reintervention in the levonorgestrel-releasing intrauterine system group (relative risk, 2.64; 95% confidence interval, 1.49-4.68). There was no significant difference in patient satisfaction and quality of life between the groups. CONCLUSION Both the levonorgestrel-releasing intrauterine system and endometrial ablation strategies lead to a large decrease in menstrual blood loss in women with heavy menstrual bleeding, with comparable quality of life scores after treatment. Nevertheless, there was a significant difference in menstrual blood loss in favor of endometrial ablation, and we could not demonstrate noninferiority of starting with the levonorgestrel-releasing intrauterine system. Women who start with the levonorgestrel-releasing intrauterine system, a reversible and less invasive treatment, are at an increased risk of needing additional treatment compared with women who start with endometrial ablation. The results of this study will enable physicians to provide women with heavy menstrual bleeding with the evidence to make a well-informed decision between the 2 treatments.
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Beelen P, van der Velde MGAM, Herman MC, Geomini PM, van den Brink MJ, Duijnhoven RG, Bongers MY. Treatment of women with heavy menstrual bleeding: Results of a prospective cohort study alongside a randomised controlled trial. Eur J Obstet Gynecol Reprod Biol 2020; 257:1-5. [PMID: 33309849 DOI: 10.1016/j.ejogrb.2020.11.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 11/08/2020] [Accepted: 11/30/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The objective of this study was to compare the reintervention rate of women who opted for treatment with the levonorgestrel-releasing intrauterine system (LNG-IUS) to women who opted for endometrial ablation. Furthermore, the difference in reintervention rate between women in this observational cohort and women who were randomised was compared, with the hypothesis that women who actively decide on treatment have lower reintervention rates compared to women in a RCT. STUDY DESIGN An observational cohort study alongside a multicentre randomised controlled trial (RCT) was conducted between April 2012 and January 2016, with a follow-up time of 24 months, in 26 hospitals and nearby general practices in the Netherlands. Women suffering from heavy menstrual bleeding, aged 34 years and older, without intracavitary pathology and without a future fertility desire, were eligible for this trial. Women who declined randomisation were asked to participate in the observational cohort. The outcome measure was reintervention rate at 24 months of follow-up. RESULTS 276 women were followed in the observational cohort of which 87 women preferred an initial treatment with LNG-IUS and 189 women preferred an initial treatment with endometrial ablation. At 24 months of follow-up women in the LNG-IUS-group were more likely to receive a reintervention compared to the women in the ablation group, 28/81 (35 %) versus 25/178 (14 %) (aRR 2.42, CI 1.47-3.98, p-value 0.001). No differences in reintervention rates were found between women in the observational cohort and women in the RCT. CONCLUSIONS Women who receive an LNG-IUS are more likely to undergo an additional intervention compared to women who receive endometrial ablation. Reintervention rates of women in the cohort and RCT population were comparable. The results of this study endorse the findings of the RCT and will contribute to shared decision making in women with heavy menstrual bleeding.
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Affiliation(s)
- Pleun Beelen
- Department of Obstetrics and Gynaecology, Máxima MC, Veldhoven, the Netherlands; Department of General Practice, University of Maastricht, Maastricht, the Netherlands.
| | | | - Malou C Herman
- Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital's Hertogenbosch, the Netherlands
| | - Peggy M Geomini
- Department of Obstetrics and Gynaecology, Máxima MC, Veldhoven, the Netherlands
| | - Marian J van den Brink
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Ruben G Duijnhoven
- Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Marlies Y Bongers
- Department of Obstetrics and Gynaecology, Máxima MC, Veldhoven, the Netherlands; Maastricht University, Grow Research School of Oncology and Developmental Biology, Maastricht, the Netherlands
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Beelen P, Reinders IMA, Scheepers WFW, Herman MC, Geomini PMAJ, van Kuijk SMJ, Bongers MY. Prognostic Factors for the Failure of Endometrial Ablation: A Systematic Review and Meta-analysis. Obstet Gynecol 2019; 134:1269-1281. [PMID: 31764738 DOI: 10.1097/aog.0000000000003556] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Pleun Beelen
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, the Departments of Obstetrics and Gynaecology and Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, and the Department of General Practice and the Research School Grow, University of Maastricht, Maastricht, the Netherlands
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Bofill Rodriguez M, Lethaby A, Grigore M, Brown J, Hickey M, Farquhar C. Endometrial resection and ablation techniques for heavy menstrual bleeding. Cochrane Database Syst Rev 2019; 1:CD001501. [PMID: 30667064 PMCID: PMC7057272 DOI: 10.1002/14651858.cd001501.pub5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Heavy menstrual bleeding (HMB) is a significant health problem in premenopausal women; it can reduce their quality of life and can cause social disruption and physical problems such as iron deficiency anaemia. First-line treatment has traditionally consisted of medical therapy (hormonal and non-hormonal), but this is not always successful in reducing menstrual bleeding to acceptable levels. Hysterectomy is a definitive treatment, but it is more costly and carries some risk. Endometrial ablation may be an alternative to hysterectomy that preserves the uterus. Many techniques have been developed to 'ablate' (remove) the lining of the endometrium. First-generation techniques require visualisation of the uterus with a hysteroscope during the procedure; although it is safe, this procedure requires specific technical skills. Newer techniques for endometrial ablation (second- and third-generation techniques) have been developed that are quicker than previous approaches because they do not require hysteroscopic visualisation during the procedure. OBJECTIVES To compare the efficacy, safety, and acceptability of endometrial destruction techniques to reduce heavy menstrual bleeding (HMB) in premenopausal women. SEARCH METHODS We searched the Cochrane Gynaecology and Fertility Group Specialised Register of controlled trials, the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE, Embase, CINAHL, and PsycInfo (from inception to May 2018). We also searched trials registers, other sources of unpublished or grey literature, and reference lists of retrieved studies, and we made contact with experts in the field and with pharmaceutical companies that manufacture ablation devices. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing different endometrial ablation or resection techniques for women reporting HMB without known uterine pathology, other than fibroids outside the uterine cavity and smaller than 3 centimetres, were eligible. Outcomes included improvement in HMB and in quality of life, patient satisfaction, operative outcomes, complications, and the need for further surgery, including hysterectomy. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion, assessed trials for risk of bias, and extracted data. We contacted study authors for clarification of methods or for additional data. We assessed adverse events only if they were separately measured in the included trials. We undertook comparisons with individual techniques as well as an overall comparison of first- and second-generation ablation methods. MAIN RESULTS We included in this update 28 studies (4287 women) with sample sizes ranging from 20 to 372. Most studies had low risk of bias for randomisation, attrition, and selective reporting. Less than half of these studies had adequate allocation concealment, and most were unblinded. Using GRADE, we determined that the quality of evidence ranged from moderate to very low. We downgraded evidence for risk of bias, imprecision, and inconsistency.Overall comparison of second-generation versus first-generation (i.e. gold standard hysteroscopic ablative) techniques revealed no evidence of differences in amenorrhoea at 1 year and 2 to 5 years' follow-up (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.78 to 1.27; 12 studies; 2145 women; I² = 77%; and RR 1.16, 95% CI 0.78 to 1.72; 672 women; 4 studies; I² = 80%; very low-quality evidence) and showed subjective improvement at 1 year follow-up based on a Pictorial Blood Assessment Chart (PBAC) (< 75 or acceptable improvement) (RR 1.03, 95% CI 0.98 to 1.09; 5 studies; 1282 women; I² = 0%; and RR 1.12, 95% CI 0.97 to 1.28; 236 women; 1 study; low-quality evidence). Study results showed no difference in patient satisfaction between second- and first-generation techniques at 1 year follow-up (RR 1.01, 95% CI 0.98 to 1.04; 11 studies; 1750 women; I² = 36%; low-quality evidence) nor at 2 to 5 years' follow-up (RR 1.02, 95% CI 0.93 to 1.13; 672 women; 4 studies; I² = 81%).Compared with first-generation techniques, second-generation endometrial ablation techniques were associated with shorter operating times (mean difference (MD) -13.52 minutes, 95% CI -16.90 to -10.13; 9 studies; 1822 women; low-quality evidence) and more often were performed under local rather than general anaesthesia (RR 2.8, 95% CI 1.8 to 4.4; 6 studies; 1434 women; low-quality evidence).We are uncertain whether perforation rates differed between second- and first-generation techniques (RR 0.32, 95% CI 0.10 to 1.01; 1885 women; 8 studies; I² = 0%).Trials reported little or no difference between second- and first-generation techniques in requirement for additional surgery (ablation or hysterectomy) at 1 year follow-up (RR 0.72, 95% CI 0.41 to 1.26; 6 studies: 935 women; low-quality evidence). At 5 years, results showed probably little or no difference between groups in the requirement for hysterectomy (RR 0.85, 95% CI 0.59 to 1.22; 4 studies; 758 women; moderate-quality evidence). AUTHORS' CONCLUSIONS Approaches to endometrial ablation have evolved from first-generation techniques to newer second- and third-generation approaches. Current evidence suggests that compared to first-generation techniques (endometrial laser ablation, transcervical resection of the endometrium, rollerball endometrial ablation), second-generation approaches (thermal balloon endometrial ablation, microwave endometrial ablation, hydrothermal ablation, bipolar radiofrequency endometrial ablation, endometrial cryotherapy) are of equivalent efficacy for heavy menstrual bleeding, with comparable rates of amenorrhoea and improvement on the PBAC. Second-generation techniques are associated with shorter operating times and are performed more often under local rather than general anaesthesia. It is uncertain whether perforation rates differed between second- and first-generation techniques. Evidence was insufficient to show which second-generation approaches were superior to others and to reveal the efficacy and safety of third-generation approaches versus first- and second-generation techniques.
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Affiliation(s)
| | - Anne Lethaby
- University of AucklandDepartment of Obstetrics and GynaecologyPark RdGraftonAucklandNew Zealand1142
| | - Mihaela Grigore
- Grigore T. Popa University of Medicine and PharmacyStr.Universitatii nr.16IasiRomania700115
| | | | - Martha Hickey
- The Royal Women's HospitalThe University of MelbourneLevel 7, Research PrecinctMelbourneVictoriaAustraliaParkville 3052
| | - Cindy Farquhar
- University of AucklandDepartment of Obstetrics and GynaecologyPark RdGraftonAucklandNew Zealand1142
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van den Brink MJ, Beelen P, Herman MC, Claassen NJ, Bongers MY, Geomini PM, van der Steeg JW, van den Wijngaard L, van Wely M. Women’s preferences for the levonorgestrel intrauterine system versus endometrial ablation for heavy menstrual bleeding. Eur J Obstet Gynecol Reprod Biol 2018; 228:143-147. [DOI: 10.1016/j.ejogrb.2018.06.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 05/28/2018] [Accepted: 06/11/2018] [Indexed: 11/26/2022]
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Cramer MS, Klebanoff JS, Hoffman MK. Pain is an Independent Risk Factor for Failed Global Endometrial Ablation. J Minim Invasive Gynecol 2018; 25:1018-1023. [PMID: 29374620 DOI: 10.1016/j.jmig.2018.01.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 01/17/2018] [Accepted: 01/18/2018] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Meagan S Cramer
- Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, Delaware.
| | - Jordan S Klebanoff
- Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, Delaware
| | - Matthew K Hoffman
- Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, Delaware
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Klebanoff J, Makai GE, Patel NR, Hoffman MK. Incidence and predictors of failed second-generation endometrial ablation. GYNECOLOGICAL SURGERY 2017; 14:26. [PMID: 29263716 PMCID: PMC5732311 DOI: 10.1186/s10397-017-1030-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 11/28/2017] [Indexed: 11/10/2022]
Abstract
Background The need for any treatment following an endometrial ablation is frequently cited as “failed therapy,” with the two most common secondary interventions being repeat ablation and hysterectomy. Since second-generation devices have become standard of care, no large cohort study has assessed treatment outcomes with regard to only these newer devices. We sought to determine the incidence and predictors of failed second-generation endometrial ablation, defined as the need for surgical re-intervention. We performed a retrospective cohort study at a single academic-affiliated community hospital. Subjects included women undergoing second-generation endometrial ablation for benign indications between October 2003 and March 2016. Second-generation devices utilized during the study period included the radiofrequency ablation device (RFA), hydrothermal ablation device (HTA), and the uterine balloon ablation system (UBA). Results Five thousand nine hundred thirty-six women underwent endometrial ablation at a single institution (3757 RFA (63.3%), 1848 HTA (31.1%), and 331 UBA (5.6%)). The primary outcome assessed was surgical re-intervention, defined as hysterectomy or repeat endometrial ablation. Of the total 927 (15.6%) women who required re-intervention, 822 (13.9%) underwent hysterectomy and 105 (1.8%) underwent repeat endometrial ablation. Women who underwent re-intervention were younger (41.6 versus 42.9 years, p < .001), were more often African-American (21.8% versus 16.2%, p < .001), and were more likely to have had a primary radiofrequency ablation procedure (hazard ratio 1.37; 95%CI 1.01 to 1.86). Older age was associated with decreased risk for treatment failure with women older than 45 years of age having the lowest risk for failure (p < .001). Age between 35 and 40 years conferred the highest risk of treatment failure (HR 1.59, 95% CI 1.32–1.92). Indications for re-intervention following ablation included menorrhagia (81.8%), abnormal uterine bleeding (27.8%), polyps/fibroids (18.7%), and pain (9.5%). Conclusion Surgical re-intervention was required in 15.6% of women who underwent second-generation endometrial ablation. Age, ethnicity, and radiofrequency ablation were significant risk factors for failed endometrial ablation, and menorrhagia was the leading indication for re-intervention.
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Affiliation(s)
- Jordan Klebanoff
- Department of Obstetrics & Gynecology, Christiana Care Health System, 4755 Ogletown-Stanton Road, Suite 1905, Newark, DE 19718 USA
| | - Gretchen E Makai
- Division of Minimally Invasive Gynecology, Christiana Care Health System, Newark, DE USA
| | - Nima R Patel
- Division of Minimally Invasive Gynecology, Christiana Care Health System, Newark, DE USA
| | - Matthew K Hoffman
- Department of Obstetrics & Gynecology, Christiana Care Health System, 4755 Ogletown-Stanton Road, Suite 1905, Newark, DE 19718 USA
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Munro MG. Endometrial ablation. Best Pract Res Clin Obstet Gynaecol 2017; 46:120-139. [PMID: 29128205 DOI: 10.1016/j.bpobgyn.2017.10.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 10/06/2017] [Indexed: 10/18/2022]
Abstract
Endometrial ablation (EA) includes a spectrum of procedures performed with or without hysteroscopic direction, designed to destroy the endometrium for the treatment of the symptom of heavy menstrual bleeding (HMB) secondary to a spectrum of causes, but most commonly those that are endometrial in origin (AUB-E) or ovulatory disorders (AUB-O). Resectoscopic endometrial ablation (REA) is often mistakenly referred to as the "first generation" technique, while proprietary devices that do not use the resectoscope (nonresectoscopic EA or NREA) are often misperceived as "second generation" devices. Indeed, the origins of NREA date back to the late 19th century with the use of steam, and the early and mid 20th century, when radiofrequency and cryotherapy based NREA techniques were published - long before the resectoscope was used and reported. The NREA devices have also been mislabeled as "global", a misleading term borrowed from the marketing departments of device manufacturers - there is no device that predictably treats the entire endometrium. Consequently, none can be construed as being "global". Instead, EA is a procedure designed for women as an alternative to hysterectomy, or, perhaps, medical therapy, when future fertility is no longer desired. Women who select EA should anticipate a relatively low risk procedure that will likely reduce their HMB to normal levels or less. This paper will review the spectrum of EA techniques and devices, their clinical outcomes and adverse events, and explore their value compared to hysterectomy and selected medical therapies.
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Affiliation(s)
- Malcolm G Munro
- Department of Obstetrics & Gynecology, David Geffen School of Medicine at UCLA, Director of Gynecologic Services, Kaiser Permanente, Los Angeles Medical Center, Los Angeles, CA, United States.
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Zhai Y, Zhang Z, Wang W, Zheng T, Zhang H. Meta-analysis of bipolar radiofrequency endometrial ablation versus thermal balloon endometrial ablation for the treatment of heavy menstrual bleeding. Int J Gynaecol Obstet 2017; 140:3-10. [PMID: 28984905 DOI: 10.1002/ijgo.12340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 07/28/2017] [Accepted: 10/04/2017] [Indexed: 11/08/2022]
Abstract
BACKGROUND Heavy menstrual bleeding is a common problem that can severely affect quality of life. OBJECTIVES To compare bipolar radiofrequency endometrial ablation and thermal balloon ablation for heavy menstrual bleeding in terms of efficacy and health-related quality of life (HRQoL). SEARCH STRATEGY Online registries were systematically searched using relevant terms without language restriction from inception to November 24, 2016. SELECTION CRITERIA Randomized control trials or cohort studies of women with heavy menstrual bleeding comparing the efficacy of two treatments were eligible. DATA COLLECTION AND ANALYSIS Data were extracted. Results were expressed as risk ratios (RRs) or weighted mean differences (WMDs) with 95% confidence intervals (CIs). MAIN RESULTS Six studies involving 901 patients were included. Amenorrhea rate at 12 months was significantly higher after bipolar radiofrequency endometrial ablation than after thermal balloon ablation (RR 2.73, 95% CI 2.00-3.73). However, no difference at 12 months was noted for dysmenorrhea (RR 1.04, 95% CI 0.68-1.58) or treatment failure (RR 0.78, 95% CI 0.38-1.60). The only significant difference for HRQoL outcomes was for change in SAQ pleasure score (12 months: WMD -3.51, 95% CI -5.42 to -1.60). CONCLUSIONS Bipolar radiofrequency endometrial ablation and thermal balloon ablation reduce menstrual loss and improve quality of life. However, bipolar radiofrequency endometrial ablation is more effective in terms of amenorrhea rate and SAQ pleasure.
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Affiliation(s)
- Yan Zhai
- Department of Obstetrics and Gynecology, Capital Medical University Affiliated Beijing Chaoyang Hospital, Beijing, China
| | - Zihan Zhang
- Department of Obstetrics and Gynecology, Capital Medical University Affiliated Beijing Chaoyang Hospital, Beijing, China
| | - Wei Wang
- Department of Obstetrics and Gynecology, Capital Medical University Affiliated Beijing Chaoyang Hospital, Beijing, China
| | - Tingping Zheng
- Department of Obstetrics and Gynecology, Capital Medical University Affiliated Beijing Chaoyang Hospital, Beijing, China
| | - Huili Zhang
- Department of Obstetrics and Gynecology, Capital Medical University Affiliated Beijing Chaoyang Hospital, Beijing, China
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Laberge P, Leyland N, Murji A, Fortin C, Martyn P, Vilos G. Ablation de l'endomètre dans la prise en charge des saignements utérins anormaux. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 38:S609-S628. [PMID: 28063570 DOI: 10.1016/j.jogc.2016.09.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bongers M. Hysteroscopy and heavy menstrual bleeding (to cover TCRE and second-generation endometrial ablation). Best Pract Res Clin Obstet Gynaecol 2015; 29:930-9. [DOI: 10.1016/j.bpobgyn.2015.03.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 03/18/2015] [Indexed: 11/24/2022]
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Endometrial Ablation: Normal Imaging Appearance and Delayed Complications. AJR Am J Roentgenol 2015; 205:W451-60. [DOI: 10.2214/ajr.14.13960] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Hysteroscopic Endometrial Resection Versus Laparoscopic Supracervical Hysterectomy for Abnormal Uterine Bleeding: Long-term Follow-up of a Randomized Trial. J Minim Invasive Gynecol 2015; 22:841-5. [PMID: 25881883 DOI: 10.1016/j.jmig.2015.04.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 04/02/2015] [Accepted: 04/03/2015] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To compare long-term efficacy of laparoscopic supracervical hysterectomy (LSH) and hysteroscopic endometrial ablation (HEA) in treating persistent abnormal uterine bleeding. DESIGN Canadian Task Force II-2. SETTING University hospital. PATIENTS One hundred fifty-three women treated for abnormal uterine bleeding by LSH or HEA. INTERVENTION Long-term follow-up assessment of reintervention rate and quality of life (QoL) using the Quality Metric's Health Survey Short Form 12. MEASUREMENT AND MAIN RESULTS This study is the long-term follow-up of a randomized control trial conducted in 2003 comparing LSH and HEA in terms of reoperation rate and QoL. Starting from November 2010 all patients included in the first trial were invited to participate in this study and clinically evaluated through vaginal examination and transvaginal ultrasound. After a mean follow-up of 14.4 years, 29% of patients (20/71) treated with HEA underwent further surgery, whereas no patients after LSH had symptom recurrence. The reintervention rate was significantly higher in the HEA group (p < .0001), with a relative risk of 1.39 (95% confidence interval, 1.20-1.61). The assessment of QoL demonstrated a higher score, in both physical and mental components, in the LSH group (p < .0001). CONCLUSION The lower reintervention rate and the better physical and mental health scores make LSH a more suitable procedure to treat recurrent abnormal uterine bleeding when compared with HEA.
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Laberge P, Leyland N, Murji A, Fortin C, Martyn P, Vilos G, Leyland N, Wolfman W, Allaire C, Awadalla A, Dunn S, Heywood M, Lemyre M, Marcoux V, Potestio F, Rittenberg D, Singh S, Yeung G. Endometrial Ablation in the Management of Abnormal Uterine Bleeding. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2015; 37:362-79. [DOI: 10.1016/s1701-2163(15)30288-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Preoperative uterine bleeding pattern and risk of endometrial ablation failure. Am J Obstet Gynecol 2014; 211:556.e1-6. [PMID: 25019488 DOI: 10.1016/j.ajog.2014.07.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 05/10/2014] [Accepted: 07/03/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The objectives of the study were to compare among women who had an endometrial ablation the risks of treatment failure and subsequent gynecological procedures between women with regular and irregular heavy uterine bleeding and to determine other characteristics associated with the risk of treatment failure. STUDY DESIGN This study was a retrospective cohort of 968 women who underwent endometrial ablation between January 2007 and July 2009. Preoperative bleeding pattern was categorized as regular or irregular. Treatment failure was defined as reablation or hysterectomy. Subsequent gynecological procedures included endometrial biopsy, dilation and curettage, hysteroscopy, reablation, or hysterectomy. We calculated the odds of treatment failure and gynecological procedures using multiple logistic regression. RESULTS Bleeding pattern prior to ablation was heavy and regular in 30% (n = 293), heavy and irregular in 36% (n = 352), and unspecified in 30% (n = 286). We found no differences in treatment failure (13% vs 12%, P = .9) or subsequent procedures (16% vs 18%, P = .7) between women with regular and irregular bleeding. Compared with the women with regular bleeding, the women with irregular bleeding were not at increased odds of treatment failure or subsequent procedures (odds ratio [OR], 1.07; 95% confidence interval [CI], 0.65-1.74 and OR, 1.17; 95% CI, 0.76-1.80, respectively). Factors associated with an increased odds of treatment failure and subsequent procedures included tubal ligation (OR, 1.94; 95% CI, 1.30-2.91 and OR, 1.71; 95% CI, 1.20-2.43, respectively); dysmenorrhea (OR, 2.42; 95% CI, 1.44-4.06 and OR, 1.93; 95% CI, 1.20-3.13, respectively); and obesity (OR, 1.82; 95% CI, 1.21-2.73 and OR, 1.75; 95% CI, 1.22-2.50, respectively). CONCLUSION Preoperative bleeding pattern did not appear to affect failure rates or the need for gynecological procedures after endometrial ablation. Other risk factors for ablation failure identified included preoperative dysmenorrhea, prior tubal ligation, and obesity.
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Lethaby A, Penninx J, Hickey M, Garry R, Marjoribanks J. Endometrial resection and ablation techniques for heavy menstrual bleeding. Cochrane Database Syst Rev 2013:CD001501. [PMID: 23990373 DOI: 10.1002/14651858.cd001501.pub4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Heavy menstrual bleeding (HMB) is a significant health problem in premenopausal women; it can reduce their quality of life and cause anaemia. First-line therapy has traditionally been medical therapy but this is frequently ineffective. On the other hand, hysterectomy is obviously 100% effective in stopping bleeding but is more costly and can cause severe complications. Endometrial ablation is less invasive and preserves the uterus, although long-term studies have found that the costs of ablative surgery approach the cost of hysterectomy due to the requirement for repeat procedures. A large number of techniques have been developed to 'ablate' (remove) the lining of the endometrium. The gold standard techniques (laser, transcervical resection of the endometrium and rollerball) require visualisation of the uterus with a hysteroscope and, although safe, require skilled surgeons. A number of newer techniques have recently been developed, most of which are less time consuming. However, hysteroscopy may still be required as part of the ablative techniques and some of these techniques must be considered to be still under development, requiring refinement and investigation. OBJECTIVES To compare the efficacy, safety and acceptability of of endometrial destruction techniques to reduce heavy menstrual bleeding (HMB) in premenopausal women. SEARCH METHODS We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials, Cochrane Central Register of Controlled Trials CENTRAL), MEDLINE, EMBASE, CINAHL, and PsycInfo, (from inception to June 2013). We also searched trials registers, other sources of unpublished or grey literature and reference lists of retrieved studies, and made contact with experts in the field and pharmaceutical companies that manufacture ablation devices. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing different endometrial ablation techniques in women with a complaint of HMB without uterine pathology were eligible. The outcomes included reduction of HMB, improvement in quality of life, operative outcomes, satisfaction with the outcome, complications and need for further surgery or hysterectomy. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion, assessed trials for risk of bias and extracted data. Attempts were made to contact authors for clarification of data in some trials. Adverse events were only assessed if they were separately measured in the included trials. Comparisons were made with individual techniques and an overall comparison between first and second-generation ablation methods was also undertaken. MAIN RESULTS Twenty five trials (4040 women) with sample sizes ranging from 20 to 372 were included in the review. A majority of the trials had a specified method of randomisation, adequate description of dropouts and no evidence of selective reporting. Less than half had adequate allocation concealment and most were unblinded.There was insufficient evidence to suggest superiority of a particular technique in the pairwise comparisons between individual ablation and resection methods.In the overall comparison of the newer 'blind' techniques (second-generation) with the gold standard hysteroscopic ablative techniques (first-generation) there was no evidence of overall differences in the improvement in HMB (12 RCTs) or patient satisfaction (11 RCTs).Surgery was an average of 15 minutes shorter (mean difference (MD) 14.9, 95% CI 10.1 to 19.7, 9 RCTs; low quality evidence), local anaesthesia was more likely to be employed (relative risk (RR) 2.8, 95% CI 1.8 to 4.4, 6 RCTs; low quality evidence) and equipment failure was more likely (RR 4.3, 95% CI 1.5 to 12.4, 3 RCTs; moderate quality evidence) with second-generation ablation. Women undergoing newer (second-generation) ablative procedures were less likely to have fluid overload, uterine perforation, cervical lacerations and hematometra than women undergoing the more traditional type of ablation and resection techniques (RR 0.18, 95% CI 0.04 to 0.79, 4 RCTs; RR 0.32, 95% CI 0.1 to 1.0, 8 RCTs; RR 0.22, 95% CI 0.08 to 0.61, 8 RCTs; and RR 0.32, 95% CI 0.12 to 0.85, 5 RCTs; all moderate quality evidence, respectively). However, women were more likely to have nausea and vomiting and uterine cramping (RR 2.0, 95% CI 1.3 to 3.0, 4 RCTs; and RR 1.2, 95% CI 1.0 to 1.4, 2 RCTs; both moderate quality evidence, respectively). The risk of requiring either further surgery of any kind or hysterectomy specifically was reduced with second-generation ablative methods compared to first-generation ablation up to 10 years after surgery (RR 0.69, 95% CI 0.48 to 0.99, 1 RCT; and RR 0.60, 95% CI 0.38 to 0.96, 1 RCT; both moderate quality evidence, respectively) but not at earlier follow up. Additional research is required to confirm this finding. AUTHORS' CONCLUSIONS Endometrial ablation techniques offer a less invasive surgical alternative to hysterectomy. The rapid development of a number of new methods of endometrial destruction has made systematic comparisons between individual methods and with the 'gold standard' first-generation techniques difficult. Most of the newer techniques are technically easier to perform than traditional hysteroscopy-based methods but technical difficulties with the new equipment need to be addressed. Overall, the existing evidence suggests that success, satisfaction rates and complication profiles of newer techniques of ablation compare favourably with hysteroscopic techniques.
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Affiliation(s)
- Anne Lethaby
- Obstetrics and Gynaecology, University of Auckland, Private Bag 92019, Auckland, New Zealand, 1142
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Herman MC, van den Brink MJ, Geomini PM, van Meurs HS, Huirne JA, Eising HP, Timmermans A, Pijnenborg JMA, Klinkert ER, Coppus SF, Nieboer TE, Catshoek R, van der Voet LF, van Eijndhoven HWF, Graziosi GCM, Veersema S, van Kesteren PJ, Langenveld J, Smeets NAC, van Vliet HAAM, van der Steeg JW, Lisman-van Leeuwen Y, Dekker JH, Mol BW, Berger MY, Bongers MY. Levonorgestrel releasing intrauterine system (Mirena) versus endometrial ablation (Novasure) in women with heavy menstrual bleeding: a multicentre randomised controlled trial. BMC WOMENS HEALTH 2013; 13:32. [PMID: 23927387 PMCID: PMC3751634 DOI: 10.1186/1472-6874-13-32] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 08/02/2013] [Indexed: 11/10/2022]
Abstract
BACKGROUND Heavy menstrual bleeding is an important health problem. Two frequently used therapies are the levonorgestrel intra-uterine system (LNG-IUS) and endometrial ablation. The LNG-IUS can be applied easily by the general practitioner, which saves costs, but has considerable failure rates. As an alternative, endometrial ablation is also very effective, but this treatment has to be performed by a gynaecologist. Due to lack of direct comparison of LNG-IUS with endometrial ablation, there is no evidence based preferred advice for the use of one of these treatment possibilities. METHOD/DESIGN A multicenter randomised controlled trial, organised in a network infrastructure in the Netherlands in which general practitioners and gynaecologists collaborate. DISCUSSON This study, considering both effectiveness and cost effectiveness of LNG-IUS versus endometrial ablation may well improve care for women with heavy menstrual bleeding. TRIAL REGISTRATION Dutch trial register, number NTR2984.
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Peeters JA, Penninx JP, Mol BW, Bongers MY. Prognostic factors for the success of endometrial ablation in the treatment of menorrhagia with special reference to previous cesarean section. Eur J Obstet Gynecol Reprod Biol 2013; 167:100-3. [DOI: 10.1016/j.ejogrb.2012.11.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Revised: 10/13/2012] [Accepted: 11/25/2012] [Indexed: 11/24/2022]
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Five-year follow-up after comparing bipolar endometrial ablation with hydrothermablation for menorrhagia. Obstet Gynecol 2012; 120:179; author reply 179. [PMID: 22914409 DOI: 10.1097/aog.0b013e31825d68fe] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Five-Year Follow-Up After Comparing Bipolar Endometrial Ablation With Hydrothermablation for Menorrhagia. Obstet Gynecol 2012. [DOI: 10.1097/aog.0b013e31825d6ae5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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