Before the Burn: Predicting Endometrial Ablation Failure.

Background: Endometrial ablation is a safe and effective minimally invasive surgical procedure. Despite the high success rate of endometrial ablation for heavy uterine bleeding management, some patients experience persistent symptoms after the procedure, necessitating a hysterectomy. The aim of this study is to determine the pre-operative clinical predictive factors of failure of endometrial ablation in the management of uterine bleeding. Methods: Retrospective cohort study of endometrial ablation procedures performed for treating heavy uterine bleeding. Results: Ninety five patients were included in the study. The failure rate was 24.2%. There was a statistically significant association between ablation failure and fluid deficit (p = 0.002) and intra-operative blood loss (p = 0.047). There was a statistically significant moderate association between adenomyosis (p = 0.003, φ = 0.37) and failed endometrial ablation. However, the age, body mass index (BMI), parity, number of miscarriages, number of cesarean sections, uterine length, endometrial thickness and procedure duration had no significant association with endometrial ablation. There was no significant relationship between the uterine abnormalities in general and the outcome of the endometrial ablation (p = 0.637). However, patients with combined adenomyosis and dysmenorrhea had a statistically significant association with outcome of the endometrial ablation (p = 0.016, φ = 0.28) and were more likely to have a failed endometrial ablation (crude odds ratio (COR) = 4.67, 95% confidence interval (CI), 1.35–16.09). Logistic regression to adjust for related factors revealed that the adenomyosis (adjusted odds ratio (AOR) = 50.83, 95% CI, 3.64–706.75, p = 0.003) and fluid deficit (AOR = 1.003, 95% CI, 1.000–1.006, p = 0.044) had a higher likelihood of an unsuccessful outcome. Hysterectomy was performed in 47.8% of patients who had failure of the ablation. Conclusions: Among pre-operative factors, adenomyosis, fluid deficit and combined adenomyosis and dysmenorrhea were found to predict failure of hysteroscopic endometrial ablation. Clinical Trial Registration: It was registered in https://www.clinicaltrials.gov database with Identifier: NCT05483348.

Objective: To find out the probable reasons for endometrial ablation failure. Study design: This retrospective observational study was conducted in Basildon and Thurrock University Hospitals. Patients undergoing microwave endometrial ablation or radiofrequency ablation but required additional treatment (medical/surgical) after the procedure were included in the study. The patients having the procedure between 2012 to 2019 were followed up and included in the study. Patient’s baseline characteristics including age, BMI, presenting complaint, clinical and sonographic findings including uterine cavity length, and details of the ablation procedure were collected. The endometrial biopsy results, further treatment, and histology in patients who underwent hysterectomy were also noted and appropriate statistical analysis was conducted. Result: Among the 653 patients that underwent endometrial ablation (either radio-frequency/ microwave), from 2012 to 2019, 100 patients had ablation failure. All patients had undergone hysteroscopy and had a normal histopathology examination prior to undergoing ablation. The most common symptom of failure was a recurrence of heavy bleeding. 67% of patients with ablation failure opted for hysterectomy, 15% for repeat ablation, and 18% had medical management. The results showed that increased age, higher BMI, a larger uterine cavity, and the presence of fibroids and/or adenomyosis are associated with a higher risk of endometrial ablation failure. Conclusion: This study provides insight into the salient factors contributing to ablation failure which may guide future decisions toward better patient selection and counseling for endometrial ablation.

To provide an overview of prognostic factors predicting failure of second-generation endometrial ablation. 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." 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. 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. 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. PROSPERO, CRD42019126247.

INTRODUCTION: Endometrial ablation (EA) failure occurs when a patient requires repeat EA or hysterectomy. Obese patients have a slightly increased risk of EA failure. Providers may withhold EA from patients with a very high body mass index (BMI) due to a presumed trend of increasing EA failure with increasing BMI. We sought to evaluate this trend to enable providers to better select ideal candidates for EA. METHODS: An IRB-approved retrospective cohort study was conducted, which included patients who underwent EA between 2006 and 2018 and with minimum 5-year follow-up within our health system. Patients were grouped by BMI class, and the EA failure rate for each class was calculated. A Cochran–Armitage test of trend was performed to evaluate for significance with alpha = 0.05. Pathology reports from hysterectomies that followed EA were reviewed. RESULTS: We identified 3,398 patients. Endometrial ablation failure rates by BMI category were 20.0% (normal), 23.3% (overweight), 21.2% (class I), 24.3% (class II), 24.2% (class III), and 18.3% (BMI greater than 50), with P=.24 for the trend. A total of 926 pathology reports were reviewed, and seven patients had a uterine malignancy. CONCLUSIONS/IMPLICATIONS: We demonstrated no trend towards increased EA failure with increasing BMI. Strengths include a large sample size, especially of patients with a very high BMI, and a high rate of follow-up within our system. Limitations include the retrospective nature of the study and data from a single system. These findings suggest providers should not be discouraged from offering EA to patients with very high BMI.

Prognostic factors for the success of endometrial ablation in the treatment of menorrhagia with special reference to previous cesarean section

Effect of Undiagnosed Deep Adenomyosis After Failed NovaSure Endometrial Ablation

Although most women who undergo rollerball endometrial ablation for the treatment of menorrhagia are very satisfied with the outcome of their surgery, a consistent proportion of patients report continued or worsened symptoms, including pelvic pain and continued menorrhagia. Approximately 10% of women who have endometrial ablation eventually undergo hysterectomy to treat their symptoms. This study investigated the risk factors for failure of rollerball endometrial ablation. All women who underwent endometrial ablation for treatment of menorrhagia at the authors' institutions during the years 1990 to 2000 (N = 240; mean age = 43.1 years) were sent a questionnaire asking about their level of satisfaction with the surgery and any posttreatment problems or further surgeries. One hundred seventy-six (72%) of the 240 women responded and made up the study population. The average time from initial endometrial ablation to questionnaire was 49 months (range = 13-132 months). Seventy-four percent of women reported satisfaction with the outcome of their treatment, and 15% expressed dissatisfaction. Thirteen percent of subjects had either new or worse pelvic pain after treatment. Eleven women underwent a second endometrial ablation, 5 had additional laparoscopic pelvic surgery, and 21 (12%) eventually underwent a hysterectomy. Ninety (51%) of the 176 women who were treated with endometrial ablation had a tubal ligation, 80 of which had been done previously and 10 of which were performed concurrently with ablation. The women who had a tubal ligation were generally younger with a higher gravidity. Both groups reported similar degrees of pelvic pain before endometrial ablation (50%-54%), but women in the tubal ligation group had a higher rate of posttreatment continued (37% vs. 23%, P = .04) and new or worse (21% vs. 5%, P = .001) pelvic pain. They also had a higher rate of hysterectomies performed after endometrial ablation (17% vs. 7%, P = .05). When the results of the questionnaire were subjected to multivariate Cox proportional hazard analysis, tubal ligation was a risk factor for postablation hysterectomy (hazard ratio = 3.3, 95% CI = 1.1-9.7, P = .03) and new or worsened pain (hazard ratio = 3.2, 95% CI = 1.0-10.6, P = .05). In general, age did not predict the rate of hysterectomy or pain, except that women age 40 to 45 years had a greater degree of new pain (hazard ratio = 0.1, 95% CI = 0.01-1.0, P = .05), and women more than 45 years old reported new pain significantly less often than younger women. Increasing age was associated with decreased bleeding after ablation. Women in the youngest age group, less than 35 years, were the only group not likely to have significantly less bleeding after endometrial ablation.

A common gynecological problem for approximately 30% of women at reproductive age in European countries is heavy menstrual bleeding (HMB). Although hysterectomy is a highly successful treatment for this benign problem, it also risks serious complications due to its nature as a major operation. Less invasive HMB treatment options include insertion of a levonorgestrel-releasing intrauterine system, medical treatment (such as tranexamic acid and oral contraceptive pill), or endometrial ablation (which aims to destroy endometrial tissue and the superficial myometrium to reduce/stop menstrual bleeding). Endometrial ablation failure may result in the objective outcome of hysterectomy. This meta-analysis and review aimed to assess hysterectomy risk following nonresectoscopic endometrial ablation treatment to improve understanding and HMB patient counseling. Various nonresectoscopic ablation techniques versus their associated hysterectomy rates were investigated, and subgroup analyses were performed. Following a comprehensive and thorough search process of the MEDLINE, CENTRAL, and EMBASE databases, 53 articles ultimately met the inclusion criteria for inclusion in the systematic review. Between 1992 and 2017, in the included studies, 48,071 patients underwent endometrial ablation. A high risk of bias was found in 13 studies (mainly due to selection or reporting bias), whereas 12 studies maintained low risk of bias. However, exclusion of the 13 high-risk studies for a subgroup analysis yielded similar results to the original meta-analysis. Results of the analysis indicated a consistently increasing post–endometrial ablation hysterectomy, with 2% increments annually between 1 and 5 years following the procedure, rising to 4.3% after 1 year and 12.4% after 5 years. In 2 studies, a post–10-year follow-up found a mean hysterectomy rate of 21.3%. Between both various study designs and the different varieties of devices used, no major differences in hysterectomy rates were found, respectively. Limitations of the review include a high risk for heterogeneity found among studies in almost all analyses utilized by this analysis. Publication bias and methodological issues (variation of population size and study type) lent to the heterogeneity. Because of this variation, the authors performed analyses of subgroups with different study designs. In addition, of the 53 studies included, 15 of them included fewer than 50 participants, which was corrected in this analysis via an inverse variance. Overall, the study indicated that hysterectomy risk following endometrial ablation increases from 4.3% at the 1-year mark to 12.4% at the post–5-year mark. Neither differences in nonresectoscopic endometrial ablation techniques nor study design seemed to affect hysterectomy rates. This systematic review's data can be applied to clinical practice and used for counseling patients about hysterectomy risks within 5 years of endometrial ablation.

Keywords: diagnostic hysteroscopy; endometrial ablation; hysteroscopic metroplasty; hysteroscopic myomectomy; outpatient hysteroscopy

A randomised controlled trial comparing the Cavaterm endometrial ablation system with the Nd:YAG laser for the treatment of dysfunctional uterine bleeding

To compare the effectiveness of the Cavaterm thermal balloon endometrial ablation system with the Nd:YAG laser for the treatment of dysfunctional uterine bleeding. Randomised controlled trial. Minimal access gynaecological surgery unit in a district general hospital. Seventy-two women with dysfunctional uterine bleeding requesting conservative surgical management of their condition. Women with a normal endometrial biopsy and normal uterine cavity were randomly allocated to endometrial ablation by Cavaterm or Nd:YAG laser. Patients completed pre-operative and 6- and 12-month post-operative questionnaires assessing menstrual symptoms, quality of life, sexual activity and procedural satisfaction and acceptability. All patients received a single dose of gonadotropin-releasing hormone analogue one month pre-operatively and kept blinded to the procedure performed until after the 6-month assessment. The primary outcome measure was amenorrhoea rate. Secondary outcomes were effect on blood loss, quality of life, sexual activity, patient satisfaction and procedure acceptability. Seventy-two women were randomised. Amenorrhoea rates at 12 months in the Cavaterm and endometrial laser ablation groups were 29% vs 39% (P = 0.286), with combined amenorrhoea and hypomenorrhoea rates of 73% vs 69%, respectively. At 12 months, repeat surgery rates were higher in the endometrial laser ablation group (15% vs 12%, P = 0.395). Cavaterm was an acceptable procedure and 93% of patients satisfied or very satisfied at 12 months (95% endometrial laser ablation). Both treatments were associated with an increase from baseline in the SF-12 physical score (Cavaterm mean difference -3.9, 95% CI -7.9, 0.2, ns; endometrial laser ablation mean difference -5.1, 95% CI -9.5, -0.7, P = 0.003) and mental health score (Cavaterm mean difference -5.6, 95% CI -9.9, -1.3, P = 0.001; endometrial laser ablation mean difference -5.9, 95% CI -11.7, -0.2, P = 0.04). Patient's own assessment of health (EQ-5D VAS) improved from baseline in both groups (Cavaterm mean difference -7.6, 95% CI -13.9, -1.3, P = 0.02; endometrial laser ablation mean difference -5.4, 95% CI -14.9, 4.2, ns). EQ-5D index scores also improved (Cavaterm mean difference -0.06, 95% CI -0.2, 0.005, ns; endometrial laser ablation mean difference -0.17, 95% CI -0.3, -0.02, P = 0.02). There were no major complications in either group. The results with the Cavaterm thermal balloon endometrial ablation system are as good as those obtained with the Nd:YAG laser when used for the treatment of dysfunctional uterine bleeding in the short term. It results in a significant reduction in menstrual blood loss, patient satisfaction and improvement in patient quality of life. Larger studies with longer follow up are required to determine its place in the modern treatment of dysfunctional uterine bleeding.

Endometrial ablation in the management of abnormal uterine bleeding.

Predictors of Long-Term NovaSure Endometrial Ablation Failure

BackgroundAbnormal uterine bleeding needs surgical treatment if medical therapy fails. After introduction of non-hysteroscopic endometrial ablation as alternative to hysteroscopic endometrial resection, we aimed to compare short and long-term outcomes for women treated with these two minimally-invasive procedures. A secondary goal was comparing the present cohort to a previous cohort of women treated with hysteroscopic resection only.Materials and methodsHistorical cohort study of women treated for abnormal uterine bleeding with hysteroscopic resection or endometrial ablation at Haukeland University Hospital during 2006–2014. Similar patient file and patient-reported outcome data were collected from 386 hysteroscopic resections in a previous cohort (1992–1998). Categorical variables were compared by Chi-square or Fisher´s Exact-test, linear variables by Mann-Whitney U-test and time to hysterectomy by the Kaplan-Meier method.ResultsDuring 2006–2014, 772 women were treated with endometrial resection or ablation, 468 women (61%) consented to study-inclusion; 333 women (71%) were treated with hysteroscopic resection and 135 (29%) with endometrial ablation.Preoperative characteristics were significantly different for women treated with hysteroscopic resection compared to endometrial ablation in the 2006-2014-cohort and between the two time-cohorts regarding menopausal, sterilization and myoma status (p≤0.036). The endometrial ablation group had significantly shorter operation time, median 13 minutes (95% Confidence Interval (CI) 12–14) and a lower complication rate (2%) versus operation time, median 25 minutes (95% CI 23–26) and complication rate (13%) in the hysteroscopy group, all p ≤0.001. The patient-reported rate of satisfaction with treatment was equivalent in both groups (85%, p = 0.955). The endometrial ablation group had lower hysterectomy rate (8% vs 16%, p = 0.024). Patient-reported satisfaction rate was higher (85%) in the 2006-2014-cohort compared with the 1992-1998-cohort (73%), p<0.001.ConclusionsEndometrial ablation has similar patient satisfaction rate, but shorter operation time and lower complication rate and may be a good alternative to hysteroscopic resection for treatment of abnormal uterine bleeding.

Retrospective Cohort Study of 350 Women Who Have Undergone Endometrial Ablation with and without Myomectomy