Endometrial ablation: the next generation

Randomised controlled trial of bipolar radio-frequency endometrial ablation and balloon endometrial ablation

OBJECTIVE

To compare the effectiveness of two second-generation ablation techniques, bipolar radio-frequency impedance-controlled endometrial ablation (NovaSure) and balloon ablation (ThermaChoice), in the treatment of menorrhagia.

DESIGN

Double-blind, randomised, controlled trial.

SETTING

A large teaching hospital with 500 beds in The Netherlands.

POPULATION

Women suffering from menorrhagia referred by their general practitioner.

METHODS

Women suffering from menorrhagia, without intracavitary abnormalities, were randomly allocated to bipolar radio-frequency ablation (bipolar group) and balloon ablation (balloon group) in a 2:1 ratio. At follow up, both women and observers were unaware of the type of treatment that had been performed.

MAIN OUTCOME MEASURES

The main outcome measure was amenorrhea at 3, 6 and 12 months after randomisation.

RESULTS

One hundred and twenty-six women were included in the study, of which 83 were allocated to the bipolar group, and 43 to the balloon group. No complications occurred in either of the treatment groups. At the one-year follow up stage, amenorrhea rates were 43% (34/83) in the bipolar group and 8% (3/43) in the balloon group (treatment effect in time P < 0.001). At this stage, 90% of the patients in the bipolar group were satisfied with the result of the treatment against 79% in the balloon group (treatment effect in time P= 0.003).

CONCLUSION

The bipolar radio-frequency impedance-controlled endometrial ablation system is more effective than balloon ablation in the treatment of menorrhagia.

The long-term effectiveness of endometrial laser ablation: a survival analysis

OBJECTIVES

To assess the long-term effectiveness of endometrial laser ablation and factors that predict long-term outcome.

SETTING

A university teaching hospital.

STUDY DESIGN

Postal questionnaires were sent to all women who underwent endometrial laser ablation between 1992 and 1998.

RESULTS

Of 215 patients who underwent endometrial laser ablation, 174 (80.9%) returned the questionnaire. Duration of follow-up was 1.5-9 years. The procedure was reported as a success by 138 (79.3%) and a failure by 36 (20.7%). Twenty-four patients (13.8%) subsequently underwent hysterectomy for excessive bleeding. Using survival curve estimates the percentage that remained free of failure was 95.3% at 1 year and 76.2% at 4 years. Increasing patient age was significantly associated with reduced risk of failure (hazard ratio 0.91 for every year increase in age). An inexperienced operator significantly increased the hazard of failure.

CONCLUSION

Endometrial laser ablation is effective in the long-term in the majority (76.2%) of patients. Older women can expect to have a lower risk of failure.

New surgical treatments for menorrhagia

CONTEXT

Hysterectomy is a common and effective treatment for menorrhagia but is associated with substantial post-operative convalescence time and morbidity. In the early 1990s endometrial resection or ablation became a well-established day-case alternative for the surgical treatment of menorrhagia. Both endometrial resection and ablation require general anaesthesia, a high level of skill in hysteroscopic surgery, and can be long procedures. More recently, various new techniques have been developed that can be done in an outpatient setting under local anaesthesia and with a low risk of complications. The effectiveness of most new second-generation ablation technologies has not been confirmed in randomised trials and it is possible that these techniques will not prove to be as effective or as safe as originally thought.

STARTING POINT

Massimiliano Pellicano and colleagues (Am J Obstet Gynecol 2002; 187: 545-50) compared a second-generation ablation technique, thermal destruction of the endometrium with a heated-water-filled silicone balloon with hysteroscopic endometrial resection. 82 women were randomised and followed up for 2 years. Thermal destruction was quicker than hysteroscopic resection, and was associated with a similar level of postoperative satisfaction and reintervention rate. This study suggests that thermal destruction is as effective a technique as endometrial resection. WHERE NEXT? Many second-generation ablation techniques are now available. Some may prove more effective than others, but much larger studies are needed to address safety. The development of progestagen-releasing intrauterine devices, which provide effective treatment for menorrhagia and are also an effective and reversible form of contraception, may mean that the uptake of second-generation surgical ablation techniques is less widespread than some proponents of these new technologies suggest.

Pregnancy after hydrothermal endometrial ablation and laparoscopic sterilisation

Hydrothermal ablation (HTA) is a newly introduced technique of endometrial ablation. This report describes the first case of pregnancy and miscarriage following successful HTA performed 4 years after laparoscopic tubal sterilisation. The diagnosis of such pregnancies can be difficult and the risk of pregnancy complications is potentially increased.

A retrospective cohort study comparing microwave endometrial ablation with levonorgestrel-releasing intrauterine device in the management of heavy menstrual bleeding

OBJECTIVE

To compare microwave endometrial ablation (MEA) with a levonorgestrel-releasing intrauterine device (Mirena) in the management of heavy menstrual bleeding.

DESIGN

A retrospective cohort study

SAMPLE

Thirty-nine women were treated with MEA and 23 women with Mirena, in the South East Regional Health Service of South Australia during 1998 to 2001; the mean duration of follow-up was 14.6 months.

MAIN OUTCOME MEASURES

Primary measures included acceptability of the treatment process, effectiveness of the treatment, and satisfaction with outcomes. Secondary measures included side effects, complications and quality of life (using the SF-36).

RESULTS

Acceptability of the treatment process and satisfaction with outcomes was very high for both procedures. Each treatment led to a statistically significant reduction in menstrual bleeding (p < 0.0001) and dysmenorrhoea scores (p < 0.002).

CONCLUSIONS

There were no statistical differences between the two treatments for any of the primary or secondary outcome measures assessed. The treatments seem equally effective in the management of heavy menstrual loss.