Chapter 19 Ablation Procedures
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 heavyovulatory 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 aretherapeutic 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 tuballigation, 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 arerequested, 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.
SURGICAL MANAGEMENT
■ Endometrial ablation may be accomplished using one of three operative techniques: rollerball/rollerbarrel endometrial ablation, transcervical resection of the endometrium (TCRE), and nonhysteroscopic endometrial ablation technology (Fig. 19.3).
■ Historically, endometrial ablation was performed utilizing the operative hysteroscope with monopolar or bipolar technology. Later, nonhysteroscopic technology emerged including thermal balloon ablation (ThermaChoice® Uterine Balloon Therapy; Johnson & Johnson, New Brunswick, NJ, USA [FDA approval obtained in 1997]), cryoablation (Her Option™; Cooper Surgical, Trumbull, CT, USA [FDA approval obtained in 2001]), heated free fluid (Hydro ThermAblator [Hydro ThermAblator [HTA™] System; Boston Scientific, Natick, MA, USA [FDA approval obtained in 2001]), bipolar radiofrequency ablation (NovaSure® endometrial ablation; Hologic, Inc., Bedford, MA, USA [FDA approval obtained in 2001]), microwave ablation (MEA® System, previously produced by Microsulis Medical Limited, Denmead, UK [FDA approval obtained in 2003]), and radiofrequency bipolar electrical current utilizes ionized argon gas within a sealed silicone membrane array (Minerva®; Minerva Surgical, Inc., Redwood City, CA [FDA approval in 2015]). These techniques do not require hysteroscopic assistance during performance of the procedure with the exception of hydrothermal ablation.
Figure 19.3. Instrumentation for transcervical resection of endometrium.
■ While the original hysteroscopically assisted techniques have been in use since the late 1980s, use of nonhysteroscopic devices for endometrial ablation have surpassed resectoscopic techniques due to ease of use, shorter learning curve, do not require a fluid management system, and typically involve a shorter procedural time than traditional hysteroscopic ablation technology.
■ Nonhysteroscopic devices have been adopted for use in the office setting as well as ambulatory surgical centers.
Positioning
■ Endometrial ablation procedures may be done in the office or outpatient surgical center. The caveats of surgical positioning are applicable to both locations.
■ Once the patient is under adequate anesthesia, proper patient positioning begins with placing the legs in Allen stirrups or appropriate leg rests in the dorsal lithotomy position. The buttocks should be at the edge of the operating table as this facilitates placement of vaginal retractors or an open-sided speculum.
■ The operating table should be flat at all times during the procedure in order to decrease the risk of intraoperative air or fluid embolism
■ Air or fluid embolism can occur if the uterus is positioned higher than the heart (Trendelenburg position).
■ If a prolonged procedure is anticipated anti-thromboembolic stockings or sequential compression devices is advised.
■ Appropriate sterile draping should be utilized.
■ When first-generation endometrial ablation is performed that requires fluid media, utilize a funnel bag beneath the buttocks to capture excess fluid and measure.Approach
■ Endometrial ablation may be accomplished by a variety of techniques including:
■ Resectoscopic techniques
■ Rollerball or rollerbarrel endometrial ablation (Fig. 19.4).
■ Hysteroscopic transcervical resection of the endometrium (TCRE)
■ Nonhysteroscopic or global approaches
■ Novasure
■ Hydrothermal ablation
■ Cryoablation
■ Microwave
■ Minerva
■ A description of the procedure of each nonhysteroscopic device is outside the scope of this chapter. Each device uses a specific form of energy to systematically ablate the endometrium in a uniform manner.
■ Gynecologists should thoroughly understand the indications for use (IFU) for each device.
Figure 19.4. Rollerball endometrial ablation.
■ Ideally, gynecologists should utilize simulation prior to the procedure.
■ Consider working with a mentor or proctor for the first several cases.
■ Hysteroscopically guided endometrial ablation allows the surgeon to treat a uterine cavity that has minor anatomic changes (arcuate uterus, concave tubal ostia, larger uterine cavity). Additionally, removal of intracavitary lesions that were not detected preoperatively is possible when the operative hysteroscope is utilized.
■ Ancillary equipment to perform hysteroscopic endometrial ablation includes rollerball, rollerbarrel, or wire loop.■ The rollerball and rollerbarrel are used to ablate the endometrium (Fig. 19.5).
■ The rollerball attachment does not produce these tissue fragments but rather desiccates endometrial tissue and the basalis layer.
■ Whereas, the wire loop can be used to perform endomyometrial resection, a procedure that resects the endometrium and superficial portion of the myometrium. Samples of this tissue can also aid in the diagnosis of adenomyosis and provide another opportunity to evaluate endometrial pathology (Figs. 19.6 and 19.7).
Figure 19.5. Rollerball endometrial ablation posterior wall completed.
Figure 19.6. Endomyometrial resection.
■ Bipolar and monopolar technologies are widely available for endometrial ablation. When monopolar endometrial ablation or endomyometrial resection is performed, the energy should be set to between 60 and 80 W of cutting current. When monopolar current is used, hypo-osmolar distendingmedia is utilized. Bipolar instrumentation utilizes of saline as the distending media.
■ A hysteroscopic fluid management system is mandatory during operative hysteroscopic procedures that utilize fluid. Fluid management systems increase patient safety because they decrease the risk of fluid overload by providing instantaneous fluid deficit feedback, are automated to stop fluid inflow if perforation occurs (rapid fluid loss), and permit adjustment in the intrauterine pressure.
Figure 19.7. Endomyometrial posterior wall resection completed.Procedures and Techniques (Video 19.1)
Placement of dispersive pads
■ Once the patient is anesthetized and placed in proper position, placement of a dispersive grounding pad is required if using monopolar current.
Examination under anesthesia
■ Bimanual examination is mandatory prior to surgery to confirm uterine position and uterine size.
Surgical pep
■ Antiseptic preparation of the vagina and perineum. Sterile draping
■ A sterile drape with a funnel pouch in placed under the buttock to securely collect all hysteroscopic fluids.
■ Confirm that funnel draping is secure to minimize fluid leaking onto the floor.
Fluid monitor setting
■ At the outset determine the upper limits of fluid deficit that will be permitted based on the patients pulmonary, cardiac, and renal status.
■ For patients with normal renal, pulmonary, and cardiac status, preset fluid monitors to stop the procedure if the fluid deficit exceeds 1,500 mL of a hypotonic solution (1.5% glycine or 3% sorbitol) or 2,500 mL of an isotonic solution (saline).
■ Lower fluid deficit thresholds may be required in women with cardiac, pulmonary, or renal comorbidities.
Assemble the hysteroscope
■ Assemble the hysteroscope with resectoscopic attachments, light source, distending media pump, and tubing. Connect outflow tubing to fluid management system canisters to calculate fluid deficit.
■ Open the inflow channel and purge all air from the inflow tubing prior to insertion of the hysteroscope to decrease risk of air emboli.
Set power settings
■ Set power generator to 60 to 80 W of electrosurgical cutting capacity and 60 to 80 W electrosurgical coagulation capacity when a monopolar device is used.
■ Utilize the default setting for bipolar devices.Begin procedure
■ Place an appropriately sized open-sided speculum (or weighted vaginal retractor) into the vagina to allow for visualization of the uterine cervix.
■ If a “vaginoscopic approach” is utilized, eliminate this step.
■ Once the cervix is visualized, placement of a single-toothed at the anterior lip of the cervix. Consider, placement on the posterior lip if a markedly retroverted/retroflexed uterus is encountered.
■ Using cervical dilators, sequential dilatation of the cervix to accommodate the diameter of the preferred operative hysteroscope. Do not “over dilate” the cervix as this will led to egress of fluid and prevent uterine distention resulting in poor intraoperative visualization.
Set intrauterine pressure
■ Set the intrauterine pressure to reflect the patient’s mean arterial pressure (MAP). The anesthesiologist can provide this information.
■ This will usually range between 70 and 125 mg. The intrauterine pressure settings are not static. Adjustments in the intrauterine pressure are an inherent component of surgery and are encouraged.
■ Variation in intrauterine pressure facilitates excellent visualization throughout surgery and is influenced by blood, uterine distensibility, and the presence of intracavitary lesions. Operate in a visible field. Do not be hesitant to increase the intrauterine fluid pressure.
■ Remember that it’s not how much fluid you need to complete the surgical procedure; it is the amount of fluid deficit that matters most.
Insert the hysteroscope
■ Insert the hysteroscope into the cervix under direct visualization with the inflow valve open. Look for the “black hole” while advancing the hysteroscope. When the surgeon only sees white it means that the hysteroscope is too close to the cervix, fundus or endometrial tissue.
■ Once in the endometrial cavity, identify all intrauterine landmarks including the tubal ostia, fundus, anterior and lateral walls, and endocervix. Do not proceed with endometrial ablation if landmarks are not clearly identified as a false track could have been created.
■ During surgery, manipulate the inflow and outflow valves as well in order to maintain a clear view, dissipate bubbles, debris, and blood. On occasion if poor visualization occurs despite these maneuvers, remove the entire hysteroscope and re-insert.
■ Endometrial ablation begins by marking the endometrium at the lower uterine segment circumferentially in order to delineate the limits of the ablation.
■ The endocervix should not be ablated. Marking the endpoint of the endometrial ablation simply means touching the lower uterine segment with the rollerball/rollerbarrel which creates a visual char and will define the endpoint of the ablation procedure (Tech Fig. 19.1).
■ Endometrial ablation begins by ablating each tubal ostium. Then rollerball across the fundus, or incorporate the technique of “pointillism,” which means connecting tiny rollerball dots across the fundus and tubal ostia in order to completely ablate the fundus.
■ Place the rollerball on the posterior wall and slowly move the rollerball to the lower uterine segment where the previously defined limits of the endometrium were marked.
■ Then rollerball the lateral walls and finally the anterior wall. The endocervix is never ablated.
■ Always keep the rollerball in view at all times and activate the energy only when the loop is being returned to the hysteroscope. This decreases the risk of injury.
■ Sequential rollerball endometrial ablation creates a furrow of desiccated tissue with each pass of the rollerball.
■ Slightly overlap each rollerball pass with the prior pass, to minimize untreated endometrium. This technique will treat the endometrium in a uniform manner to a depth of 5 to 6 mm.
Tech Figure 19.1. Mark the lower uterine segment to prevent cauterization of the endocervical canal and hematometria.
■ This same technique applies to use of the wire loop for performingendomyometrial ablation (EMR). This will create floating chips and will need to be removed with the hysteroscope periodically to maintain vision.
■ At the completion of the procedure, record the total IV fluids used, type of hysteroscopic fluid used, total hysteroscopic fluid used, hysteroscopic fluid deficit, estimated blood loss, and complications. This should be recorded in the brief operative note and included in the final surgical report. If endomyometrialresection is performed, remove all tissue fragments for histopathology analysis.
Completing the procedure
■ Remove all surgical instruments from the vagina after assessing for excessive blood loss. Once the tenaculum is removed from the cervical stroma, assess the tenaculum site and apply pressure if needed. Confirm correct surgical counts and labeling of the pathologic specimen. Perform a vaginal inspection “vaginal sweep” to confirm that no foreign bodies are left in the vagina. Remove the patient from lithotomy position.
Intraoperative surgical caveats
■ Throughout the surgical procedure, be vigilant to monitor fluid deficits, vital signs, and blood loss.
■ In the event of excessive bleeding at the completion of the procedure, reassess for uterine perforation, cervical laceration, or myometrial bleeding. Do not awaken the patient from anesthesia. Inform the anesthesiologist, circulating nurse, and scrub nurse of the concerns and potential next steps.
■ Consider injection of a dilute solution of vasopressin (20 units vasopressin mixed in 200 mL saline) and injection of 5 mL into the cervical stroma at 11, 2, 4, and 7 o’clock positions. This will help decrease bleeding from the endomyometrial interface. If the bleeding does not significantly decrease within 5 minutes, then consider the following:
■ Reinsert the hysteroscope and distend the uterine cavity to quickly survey the endometrial cavity. If visualization is poor with a rapid fluid deficit noted on infusion pump and bowel or omentum are seen then uterine perforation is likely.
■ Determine if a laparoscopic/laparotomic approach is needed if significant hemodynamic changes or if there is a high concern for bowel injury.
■ Inform the anesthesiologist and nursing team of your concerns and next steps. Determine if colorectal or general surgery intraoperative consultation is required. If blood transfusion is likely inform the blood bank.
■ If there is concern about hemodynamic status or bowel injury, the patient should be prepped for laparoscopy. If uterine perforation is confirmed, then the entire bowel should be evaluated for burns, perforation, mesenteric bleeding, or other intra-abdominal injury. If the uterine perforation site isbleeding, then it should be sutured to ensure hemostasis.
■ If no evidence of uterine perforation and brisk bleeding continues despite vasopressin, would advise placement of an intrauterine Foley catheter to tamponade the endomyometrial interface. Chose a Foley that distends to at least 10 to 30 mL and inflate until resistance is met. Document the amount of fluid used to distend the balloon. If the patient is very uncomfortable after she awakens from anesthesia, deflate a few milliliters at a time and keep in situ for 2 to 4 hours. Then deflate by half of the initial volume, leave 1 to 2 hours. If no additional bleeding, then remove completely. Maintain a pad count throughout the postoperative period. Follow hemodynamic status and serial CBCs.
PEARLS AND PITFALLS
Treatment should only include the endometrium.
Avoid treating the cervix, to minimize the development of central hematometra. Treat only to the lower uterine segment.
Comprehensive preop imaging with saline infusion sonography, hysteroscopy, or MRI.
Do not rely on endometrial biopsy alone without imaging. It is important to exclude intracavitary pathology such as endometrial polyps, intracavitary fibroids, endometrial hyperplasia. or malignancy.
Counsel patients regarding the need for lifelong contraception.
Do not tell the patient that endometrial ablation is a method of contraception.
Pregnancies have been reported up to one decade after endometrial ablation.
Pregnancies following endometrial ablation can be complicated and associated with prematurity, postpartum hemorrhage, retained products of conception, ectopic pregnancy, and death.
Re-evaluate the patient who presents months or years later after ablation with pain— even in the absence of menstruation.
Patients may develop central uterine hematometra, cervical stenosis, retrograde endometriosis, or cornual hematometra, and present with chronic or cyclical pain.
Evaluate with pelvic imaging such as TVUS or MRI. Passage of a uterine sound may disrupt intrauterine adhesions and egress of blood from the hematometra.
Recurrence of heavy menses after endometrial ablation, should be offered conservative medical therapy or minimally invasive hysterectomy.
Avoid offering a repeat endometrial ablation, as this is an off-label FDA indication.
Serious complications have been reported in patients who have been treated with another endometrial ablation including: uterine perforation, hemorrhage, excessive fluid absorption, and genital tract burns.
POSTOPERATIVE CARE
■ Patients should have pelvic rest including avoiding intercourse, tub bathing, and use of tampons for one week.
■ Generally, patients may return to work 2 to 3 days following endometrial ablation.
■ Clear or serosanguinous leukorrhea is common for several weeks after the procedure. If it persists more than 4 weeks after surgery, gently sound the uterus in the office, as filmy intrauterine adhesions may occur that prevent egress of blood or transudate.
■ Most patients need nonsteroidal medication for 2 to 7 days after procedure.
■ Generally minimal need for narcotics beyond 1 to 3 days following surgery.
■ Patients should contact office for low grade fever, foul smelling discharge, or increasing pelvic pain.
■ Continue contraception if needed until menopausal.
■ If abnormal uterine bleeding or postmenopausal bleeding occurs, then reassessment is mandatory.
OUTCOMES
■ Outcomes will vary by the age of the patient when the procedure was initially performed and length of time from when the procedure was performed.
■ Randomized clinical trials demonstrate amenorrhea in less than 50% of most patients. MRI imaging has demonstrated persistent endometrial tissue after ablation.
■ Many women have improvement in dysmenorrhea.
■ Long-term failure of endometrial ablation may be up to 40% of women who undergo endometrial ablation under the age 40.
■ Failures are higher in:
■ women younger than age 45;
■ parity of greater than five;
■ prior tubal sterilization;
■ history of dysmenorrhea;
■ preoperative ultrasound consistent with adenomyosis;
■ intramural fibroids greater than 3 cm.
■ The most common indications for hysterectomy after ablation are due to bleeding, pain, and pain and bleeding. Surgical findings in postendometrial ablation hysterectomized patients include hematometra, intramural fibroids, adenomyosis, and endometriosis.
COMPLICATIONS
■ Immediate complications intraoperatively:
■ Uterine perforation
■ Fluid overload
■ Bowel, bladder, or vessel injury due to perforation
■ Pregnancy-related complications:
■ Pregnancy may occur following endometrial ablation. Endometrial ablation is not a form of contraception.
■ Asherman’s syndrome
■ Miscarriage
■ Ectopic pregnancy■ Placentation complications including:
■ Placenta accreta
■ Placenta increta
■ Placenta percreta
■ Intrauterine growth restriction
■ Amniotic band syndrome
■ Preterm rupture of membranes
■ Increased rate of cesarean delivery
■ Fetal death
■ Postpartum hemorrhage and retained products of conception
■ Uterine rupture
■ Increased risk of postpartum hysterectomy due to hemorrhage and retained products of conception
■ Long-term complications
■ Postablation tubal sterilization syndrome
■ Unilateral or bilateral pelvic pain or cramping with or without bleeding
■ Vaginal spotting
■ Swollen fallopian tubes with the etiology linked to retrograde menstruation of cornual hematometra.
■ Persistent endometrial tissue after endometrial ablation
■ Chronic pelvic pain
■ Cyclical pelvic pain
■ Adenomyosis
■ Hematometra at the cornual region
■ Hematosalpinx—unilateral or bilateral
■ Recurrent bleeding necessitating hysterectomy
■ Dysmenorrhea
■ Cervical stenosis
■ Inability to evaluate endometrium with hysteroscopy, endomerial biopsy, transvaginal ultrasound, saline infusion sonography, or MRI
■ The endometrium may be ill-defined, indeterminate, or not visualized completely.
■ Adenomyosis may be noted with imaging.
■ Inability to sample the endometrium due to iatrogenic synechiae following endometrial ablation.
■ Pregnanc
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