Combined Bipolar Radiofrequency Endometrial Ablation with Levonorgestrel Intrauterine System: A Novel Approach for Challenging Cases

Abstract

Study Objective: The failure rate after global endometrial ablation is 3 times in women with dysmenorrhea. We designed this study to compare hysterectomy rate in women with excessive menstrual bleeding and dysmenorrhea who underwent radiofrequency endometrial ablation (RFA) alone or combined with levonorgestrel intrauterine system (LNG-IUS). Design: Cohort Study (EVIDENCE LEVEL II). Setting: An academic institution in the Upper Midwest. Patients: Using a record linkage system, we first identified women who had a documented excessive menstruation with dysmenorrhea and underwent RFA from January 1, 2002 through February 28, 2010 at our institution. We compared the rate of hysterectomy and menstrual outcomes after ablation between women who had a LNG-IUS inserted after RFA and a reference cohort of women who only had RFA. Regression models were used to adjust for known risk factors. Intervention: RFA (NovaSure, Hologic Inc., Bedford, MA), and LNG-IUS (Mirena, Bayer HealthCare Pharmaceuticals Inc., Wayne, NJ). Measurements and Main Results: Out of 1275 women who had RFA in the study duration, 74 were included in the study (58 had RFA and 16 had RFA/LNG-IUS). The mean follow up was 25.3 months (95%CI 20.4, 30.2). The baseline characteristics were comparable.TableBaseline clinical characteristicsRFA/LNG-IUSRFAP valueAge, year44.8±5.040.5±5.90.007Parity2(range0,4)2(range0,5)0.652BMI, kg/m229.8±7.329.7±7.80.966Tubal ligation6(37.5%)26(44.8%)0.601Uterine length, mm9.1±1.39.2±1.00.847Preablation US11(68.8%)53(91.4%)0.329Endometrial thickness, mm7.6±4.37.9±4.50.836Fibroids4/11(36.4%)8/53(15.1%)0.196US features of adenomyosis8/11(72.7%)2/53(3.8%)<0.001RFA = radiofrequency ablation; LNG-IUS = levonorgestrel intrauterine system, BMI = body mass index; US = ultrasound Open table in a new tab RFA = radiofrequency ablation; LNG-IUS = levonorgestrel intrauterine system, BMI = body mass index; US = ultrasound To date, all women in the RFA/LNG-IUS did not require hysterectomy compared to 11 (18.9%) in the RFA group with amenorrhea documented in 10 (62.5%) of women in the RFA/LNG-IUS group vs 17 (29.3%) in the RFA alone group (P=0.015). Out of 16 women in the RFA/LNG-IUS, 1 (6.3%) women reported persistent pain at her last followup visit vs 13 (22.4% in the RFA group (P=0.277). Removal of the IUD was performed in 2 women in office with no difficulty. Conclusion: Inserting LNG-IUS immediately after RFA is feasible and can provide added benefit with improved outcome after endometrial ablation in certain clinically challenging cases.