The case against endometrial ablation for treatment of heavy menstrual bleeding

Evaluation of Radiofrequency Endometrial Ablation: A 17-year Canadian Experience

STUDY OBJECTIVE

The purpose of this study was to better elucidate radiofrequency endometrial ablation (REA) durability by assessing the probability of failure as defined by need for postablation hysterectomy. Age at index REA, duration from REA until hysterectomy, and REA failure (REAF) risk factors were analyzed.

DESIGN

A retrospective cohort study was conducted using patient data between April 1, 2002, and March 31, 2019. REAF cases were identified using operative procedure codes. Cox proportional hazard regression assessed the effect of age at index REA on time to postablation hysterectomy. Kaplan-Meier survival curve evaluated timing of postablation hysterectomy, stratified by age at index REA.

SETTING

This study was conducted at Regina General Hospital in Regina, Saskatchewan, Canada.

PATIENTS

Patient population included those who were 21 years of age or older, were premenopausal, and had a history of heavy menstrual bleeding at the time of REA.

INTERVENTIONS

The intervention under investigation was REA.

MEASUREMENTS AND MAIN RESULTS

The overall probability of postablation hysterectomy was 22.6%. The probabilities of postablation hysterectomy were 36.1% for women younger than 30 years (n = 128), 28% for women 30 to 34.9 years old (n = 528), 29.6% for women 35 to 39.9 years old (n = 1152), and 17.6% for women 40 years and older (n = 2221). Characteristics associated with REAF included tubal occlusion, cesarean section, dysmenorrhea, and chronic pelvic pain (p <.01) among women younger than 40 years. Leiomyomas accounted for higher failure rates in women 40 years and older (p <.01).

CONCLUSION

Postablation hysterectomy is more likely to occur in women younger than 40 years. REA can be considered in women aged 30 to 39.9 years old, who have no known REAF risk factors. Women younger than 40 years with REAF risk factors will experience higher rates of hysterectomy. Thus, the decision to proceed with REA should be individualized with careful consideration for the underlying causes of abnormal uterine bleeding, while respecting patient autonomy.

Current practices in menstrual management in adolescents with cancer: A national survey of pediatric oncology providers

BACKGROUND

Adolescents and young adult (AYA) women with cancer are at risk of heavy menstrual bleeding (HMB) due to thrombocytopenia, coagulopathy, and/or disruption of the hypothalamic-pituitary-gonadal axis. Currently, little is known about current practices to help prevent and treat HMB in AYA women with cancer.

METHODS

We surveyed providers from 100 pediatric oncology centers. Face and content validity were assessed prior to distribution. Descriptive statistics, Chi-squared and Fisher exact tests were used for analysis.

RESULTS

Ninety-four percent of respondents have recommended preventative menstrual suppression. More than half of respondents agreed that patients with the following types of cancers should receive preventative menstrual suppression: sarcomas, acute leukemias, lymphomas, and germ cell tumors. The most preferred form of menstrual suppression was GnRH agonists. Almost 95% of respondents felt that it is important to consider menstrual suppression and that a formal guideline about initiation of menstrual suppression would be helpful. Only 46% felt comfortable personally managing menstrual suppression.

CONCLUSIONS

The vast majority of pediatric oncologists who responded to this national survey have used preventative menstrual suppression and feel that it is important to consider in many types of AYA cancers. Although pediatric oncologists are most often managing menstrual suppression, they do not feel comfortable doing so and desire guidelines to help with management. Future studies to assess which patients require menstrual suppression and which menstrual suppression is best tolerated and efficacious is needed.

Optimizing surgical management of patients who decline blood transfusion

PURPOSE OF REVIEW

This review highlights the complexity of caring for gynecologic patients who refuse blood transfusion and discusses the importance of early, targeted perioperative and intraoperative medical optimization. We review alternative interventions and the importance of medical management to minimize blood loss and maximize hematopoiesis, particularly in gynecologic patients who may have significant uterine bleeding. The review also focuses on intraoperative interventions and surgical techniques to prevent and control surgical blood loss.

RECENT FINDINGS

With improvements in surgical technique, greater availability of minimally invasive surgery, and increased use of preop UAE and cell salvage, definitive surgical management can be safely performed. New technologies have been developed that allow for safer surgeries or alternatives to traditional surgical procedures. Many medical therapies have been shown to decrease blood loss and improve surgical outcomes. Nonsurgical interventions have also been developed for use as adjuncts or alternatives to surgery.

SUMMARY

The care of a patient who declines blood transfusion may be complex, but gynecologic surgeons can safely and successfully offer a wide variety of therapies depending on the patient's goals and needs. Medical management should be implemented early. A multidisciplinary team should be mobilized to provide comprehensive and patient-centered care.