Ablation Procedures
Linda D. Bradley
Jonathan D. Emery
General Principles
Definition
Endometrial ablation is a minimally invasive gynecologic surgical treatment that destroys the endometrium, endometrial basalis layer, spiral arterioles, and superficial myometrium. Energy applied to the endometrium leads to tissue necrosis, contracture, scarring and fibrosis of the uterine cavity and endometrium. Anatomic alterations in the endometrium result in menstrual changes that may include: amenorrhea, hypomenorrhea, or eumenorrhea. This procedure is limited to women who have completed childbearing and who have patient perceived heavy menstrual bleeding.
Endometrial ablation technology has evolved over the past two decades. Manually performed and hysteroscopic-dependent resectoscopic endometrial ablation (REA), include: rollerball/roller-barrel ablation electrodes that desiccate the endometrium and wire loop electrodes that resect the endometrium and is called transcervical resection of the endometrium (TCRE). These first-generation technology ablation devices require fluid management awareness and expert hysteroscopic skills. Monopolar and bipolar hysteroscopic ablation technology are currently available. Automated endometrial ablation technology has evolved and requires less skill-intensive hysteroscopic ability and can be performed in the office under local anesthesia. These technical approaches are called nonresectoscopic endometrial ablation (NREA).
Current NREA ablative methods include; hydrothermal ablation (freely circulated hot fluid saline performed hysteroscopically), cryoablation (utilizing intra-uterine freezing probe with transabdominal ultrasound guidance), bipolar radiofrequency, microwave energy and Minerva (bipolar RF electrical current which ionizes argon gas within a sealed silicone membrane array).
Differential Diagnosis
Abnormal uterine bleeding may be attributed to a number of causes:
Anatomic
Adenomyosis
Endometrial polyps
Endocervical and cervical polyps
Leiomyoma
Endometritis
Caesarean section niche
Endometrial hyperplasia
Endometrial cancer
Endometrial sarcomas
Leiomyosarcoma
Endometrial stromal sarcomas
Uterine vascular lesions (arteriovenous malformations)
Hematologic
von Willebrand’s disease
Platelet dysfunction
ITP
Rare blood dyscrasia’s
Endocrinologic disorders
Hypothalamic–pituitary disorders
Polycystic ovarian syndrome
Prolactin disorders
Obesity and overweight
Thyroid dysfunction
Hypothyroidism
Hyperthyroidism
Adrenal dysfunction
Medication side effects
Eating disorders including anorexia or bulimia
Chronic diseases and systemic diseases
Liver disorder
Renal dysfunction
Cardiac
Pulmonary
Autoimmune diseases
Foreign bodies
Intrauterine devices
Suture
Hysteroscopic sterilization inserts
Anatomic Considerations
Endometrial ablation is an option for women with patient perceived heavy ovulatory menstrual bleeding with a normal uterine size, no Müllerian anomalies, normal uterine cavity (without intracavitary fibroids or endometrial polyps), negative endometrial biopsy without evidence of endometrial hyperplasia, and who have completed childbearing.
It is essential to evaluate the uterine cavity with hysteroscopy or saline infusion sonography to exclude intracavitary lesions such as endometrial polyps, type 0 or type 1 leiomyomas, endometrial hyperplasia or malignancy, and adenomyosis (Fig. 19.1A–D).
Ideally, women should be offered medical therapy initially for the treatment of heavy menstrual bleeding when there are no focal intracavitary lesions (Fig. 19.2). If medical therapy or the levonorgestrel intrauterine device is contraindicated, fails or patient refuses medical therapy, endometrial ablation or minimally invasive hysterectomy are therapeutic options.
Figure 19.1. A: Transvaginal ultrasound adenomyosis a contraindication for endometrial ablation. B: Preoperative imaging excluded this patient from endometrial ablation. Coronal SIS view revealing a 4-cm intracavitary fibroid. C: Contraindication: intracavitary fibroid must be excised prior to endometrial ablation. D: Failed endometrial ablation due to large intracavitary fibroid.
Failure and need for additional treatment following endometrial ablation is greater in women less than age 40 years, those who have had a tubal ligation, larger uterine cavities, and adenomyosis.
Hysterectomy risk increases with each decreasing stratum of age and exceeded 40% in women aged 40 years or younger.
Figure 19.2. Ideal endometrial cavity for endometrial ablation. Note: There are no intracavitary lesions identified.
Women less than age 45 years were 2.1 times more likely to have a subsequent hysterectomy. The risk increases through the first 8 years of follow-up.
The type of endometrial ablation procedure (first-generation or NREA ablative methods), setting of procedure (inpatient or outpatient), and leiomyomas were not predictors of hysterectomy.
Nonoperative Management
While the causes of abnormal uterine bleeding are diverse, treatment should be tailored specifically to the most likely etiology obtained with a patient-centric focused history and physical examination. The patient’s clinical narrative, imaging results, desire for future childbearing, quality of life, and personal preferences will determine treatment options for heavy menstrual bleeding.
Bleeding disorders must be considered and included in the differential diagnosis in order to offer appropriate therapeutic intervention and improved outcomes.
Patients who are overweight or obese are at greater risk for polycystic ovarian syndrome, menstrual dysfunction, endometrial hyperplasia, endometrial cancer, diabetes, and hypertension. Additional laboratory testing in this high-risk patient population may include fasting glucose or hemoglobin A1C, lipid panel, and endometrial biopsy.
A patient-focused history should be obtained in women with abnormal uterine bleeding.
Quality-of-life determinants must be addressed including the impact of heavy menstrual bleeding on work, social embarrassment, sexuality, body image, and cost of hygiene products, pain, and impact on daily functioning.
Tailored laboratory evaluation is selected based on the physical and pelvic examination, clinical history, quality-of-life indicators, family history, and duration of abnormal uterine bleeding.
Laboratory testing should be individualized and may include:
CBC with platelets
TSH
Prolactin
Androgen testing
von Willebrand’s assay
Complete metabolic profile
Pregnancy testing
Patients with regular predictable heavy menstrual bleeding are likely ovulatory. Treatment options for women needing contraception, without risk factors include hormonal contraception or levonorgestrel intrauterine devices.
Options for ovulatory bleeding in patient’s without a history of pulmonary embolism, deep venous vein thrombosis, myocardial infarct or stroke may be offered and include:
Tranexamic acid
Mirena intrauterine device
Progesterone therapy beginning day 5 of menses for 21 days
Combined oral or vaginal contraception (estrogen and progesterone)
Mini-pill (progesterone only)
Injectable medroxyprogesterone acetate
Nonsteroidals during menses in women without known platelet disorders
If the patient has anovulatory bleeding based upon a detailed history, then hormonal therapy is an option (excluding patients with known contraindications):
Oral contraceptive pills (consider continuous hormonal suppression for women who wish to avoid menses)
Levonorgestrel intrauterine device
Cyclic oral progesterone therapy (medroxyprogesterone, norethindrone acetate, megestrol)
Injectable medroxyprogesterone acetate
Nonsteroidal therapy in women without a known platelet disorder
Tranexamic acid has not been approved for anovulatory menstruation.
Short-term treatment (up to 6 months) with gonadotropin-releasing hormone (GNRH) agonist.
Imaging and Other Diagnostics
Prior to performing hysteroscopic ablation or NREA. Appropriate radiologic studies are needed to evaluate the uterus, endometrial cavity, and endometrium.
Available diagnostic procedures include:
Transvaginal ultrasound (TVUS)
While routine transvaginal imaging universally available—it is less sensitive in detecting intracavitary lesions in reproductive aged women compared to SIS.
In fact, in reproductive-aged patients one out of six patients with a “normal” endometrial echo may have an intracavitary lesion missed when only TVUS is performed.
Saline-infusion sonography (SIS)
3D saline infusion sonography
SIS is recommended to evaluate menstrual aberrations, because the instillation of saline provides an acoustic window permitting increased detection of intracavitary lesions and evaluates the relationship of fibroids to the endometrial/myometrial/serosal interface.
The International Federation of Gynecology and Obstetrics (FIGO) universal terminology and diagnostic schema provides great surgical guidance for gynecologists who perform endometrial ablation or hysteroscopic myomectomy. Incorporating SIS in the evaluation of women with abnormal uterine bleeding is essential. Endometrial ablation should not be performed in women with endometrial polyps or intracavitary fibroids.
The FIGO classification system facilitates triage and selection of appropriate patients for hysteroscopic myomectomy, enhances patient communication during informed consent, and improves surgical outcomes.
The FIGO classification system helps to identify patients with anatomic contraindications to endometrial ablation.
Diagnostic hysteroscopy
It is more cost-effective to perform hysteroscopy in the office setting.
Small-caliber flexible or rigid hysteroscopes permit excellent visualization of the endocervix and endometrial cavity.
If other imaging modalities are equivocal, nondiagnostic, or indeterminate, then office hysteroscopy can be used for further evaluation.
Endometrial biopsy is required to rule out endometrial hyperplasia and malignancy.
Preoperative Planning
Endometrial ablation is an alternative to hysterectomy for women with ovulatory heavy menstrual periods who ideally have failed medical therapy. It is also offered to women who perceive their menstrual periods to be heavy and have a normal-sized uterine cavity. Childbearing must be complete in women who desire endometrial ablation.
Patient should understand that the expected outcome of surgery is not permanent amenorrhea as less than 50% of women will develop amenorrhea. Managing patient expectation prior to surgery is essential. If a patient requests or expects amenorrhea she should be counseled for minimally invasive hysterectomy with removal of her cervix.
Due to the difficulty in evaluating the endometrium after endometrial ablation, caution should be taken when offering the procedure to women at increased risk of endometrial hyperplasia including women who are: nulliparous, obese, history of chronic anovulation, diabetes mellitus, tamoxifen therapy, or have a family history of hereditary nonpolyposis colorectal cancer. The risk/benefit profile should be discussed in detail and included in the informed consent.
Obtain a pregnancy test on the day of surgery.
Ideally, schedule the procedure in the early proliferative phase when the endometrium is thin or medically prepared with hormonal contraception (except for Novasure or Minerva devices).
Endometrial biopsy must be negative for endometrial hyperplasia (including simple or complex), endometrial hyperplasia with atypia, or endometrial cancer.
CBC with platelet count, TSH, and if clinically indicated by history, von Willebrand’s diagnostic panel.
Negative Pap test.
The endometrial cavity also evaluated by diagnostic hysteroscopy or saline infusion sonography to exclude intracavitary type 0 or type 1 leiomyomas, and endometrial polyps.
Müllerian anomalies must be excluded.
Hysteroscopic sterilization should not be performed concomitantly with endometrial ablation procedures due to the inability to obtain interpretable HSG at the required 3-month interval. If sterilization and ablation are requested, first perform hysteroscopic sterilization, then obtain the 3-month HSG. If tubal occlusion is demonstrated, endometrial ablation can then be scheduled.
Endometrial ablation should not be offered to women with postmenopausal bleeding.
Endometrial ablation should not be offered to women with postpartum bleeding.
Exclude patients with current evidence of pelvic inflammatory disease, endometritis, hematometra and sexually transmitted disease, suspected abdominal or pelvic cancer.
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