Endometrial ablation: postoperative complications

Antibiotic Prophylaxis in Obstetrics and Gynecology: A Comparative Review of Guidelines

Importance

The administration of prophylactic antibiotics in obstetrics and gynecology represents a pivotal intervention with a major contribution to the prevention of maternal and neonatal infectious morbidity.

Objectives

The aim of this study was to review and compare the most recently published guidelines on prophylactic antibiotic use in obstetric and gynecologic procedures.

Evidence Acquisition

A descriptive review of guidelines from the American College of Obstetricians and Gynecologists, the Society of Obstetricians and Gynaecologists of Canada, and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists on antibiotic prophylaxis was carried out.

Results

There is a consensus among the reviewed guidelines regarding the importance of antibiotic prophylaxis prior to cesarean delivery, hysterectomy, colporrhaphy and surgical-induced abortions, the optimal choice of antibiotics, and the timing of administration, as well as the indications for increased and additional doses. First-generation cephalosporins are unanimously recommended as first-line antibiotics. All the reviewed guidelines recommend antibiotic prophylaxis in case of preterm prelabor rupture of membranes, whereas they discourage routine antibiotic use in case of active preterm labor with intact membranes or cervical cerclage placement. There is also an overall agreement that antibiotic prophylaxis should not be given for hysteroscopic and laparoscopic procedures with no entry into the bowel or the vagina, endometrial biopsy, intrauterine device insertion, or cervical tissue excision surgeries. Moreover, all the guidelines agree that women undergoing hysterosalpingography should receive a course of antibiotics only when the fallopian tubes are abnormal or there is a history of pelvic inflammatory disease. In contrast, inconsistency was identified on the need of antibiotic prophylaxis in case of obstetric anal sphincter injuries, operative vaginal delivery, and early pregnancy loss. Finally, American College of Obstetricians and Gynecologists states that antibiotics should not be routinely offered for oocyte retrieval and embryo transfer.

Conclusions

Infectious complications following both obstetric and gynecological procedures are significant contributors of morbidity and mortality, rendering their prevention using antibiotic prophylaxis a crucial aspect of preoperative care. Nevertheless, antibiotic overuse should be avoided. Thus, it seems of paramount importance to develop consistent international practice protocols for the appropriate use of antibiotics in everyday practice to minimize their adverse effects and maximize their associated benefits.

Exploring thermal balloon endometrial ablation with Foley's catheter: Management for heavy menstrual bleeding

Background

Heavy menstrual bleeding is a common gynecological issue that often requires prompt treatment. Our study aimed to assess thermal balloon endometrial ablation with Foley's catheter as a viable, cost-effective, and minimally invasive procedure alternative to hysterectomy.

Methods

An experimental study was carried out on 114 married women experiencing heavy menstrual bleeding who did not wish to have further children and had either failed standard treatments or were not suitable for medical treatment. These women had a uterine size of 12 cm or less and an endometrial thickness of less than 18 mm. A 3-min balloon inflation-deflation procedure was performed. After 3 months, the effectiveness of the treatment was assessed by examining overall heavy menstrual bleeding outcomes, posttreatment transvaginal ultrasound results, number of bleeding days and pain per cycle, and scores from the Menorrhagia Outcome Questionnaire.

Results

The mean patient's age was 44.46 ± 4.184 years and a disease duration of 2.84 ± 1.53 years. Most patients were multiparous (86.0%) or grand multiparous (14.0%). Significant improvements were observed in endometrial thickness, Menorrhagia Outcome Questionnaire scores, pain levels, and the number of bleeding days postprocedure (p-value < 0.05). The majority of patients experienced a reduction in the pattern of irregular menstrual cycles. The procedure showed a success rate of 88.6%, with 11.4% of patients not responding. Some further interventions such as hysterectomy or repeated thermal balloon ablation were required due to complications like infection or balloon deflation.

Conclusion

The thermal balloon endometrial ablation using Foley's catheter is an effective treatment for heavy menstrual bleeding.

Platelet-rich fibrin improves repair and regeneration of damaged endometrium in rats

Purpose

Intrauterine adhesion (IUA) is the most common cause of uterine infertility. This study aims to evaluate whether platelet-rich fibrin (PRF) treatment can stimulate damaged endometrium regeneration in rats.

Methods

First, hematoxylin and eosin (HE) staining, scanning and transmission electron microscopy, and ELISAs were used to evaluate the microstructure of PRF. Then, mechanical damage was used to establish an IUA rat model. A total of 40 SD female rats were randomized to three groups: PRF transplantation group, IUA group, and sham group. Rats were sacrificed at 3, 7, and 14 days and uteruses were obtained for further analysis. Finally, functional and histological recovery of the damaged endometrium was analyzed by pregnancy test, HE staining, Masson's staining, and immunohistochemistry.

Results

PRF has two distinct zones, platelets and fibrin zone. Long and narrow fibrin fibers interconnected with each other and formed a three-dimensional, flexible, and elastic structure; platelet aggregates were trapped in fibrin fibers, and each platelet is associated with several fibrin fibers. PRF exudates promoted endometrial stromal cell proliferation and migration in vitro. PRF transplantation was beneficial for maintaining uterine structure, promoting endometrial luminal epithelium and endometrial gland regeneration, and decreasing fibrotic areas in vivo.

Conclusion

Intrauterine administration of PRF was demonstrated to be effective in preventing IUA and stimulating damaged endometrium regeneration in rats. This study not only provided a promising method for its potential in endometrial regeneration in women who suffer from uterine infertility but also may prevent IUA after intrauterine surgery in clinical cases.

Endometrial Cryoablation for the Treatment of Heavy Menstrual Bleeding: 36-Month Outcomes from the CLARITY Study

Study Objective

To examine long-term outcomes from the pivotal study that evaluated the safety and effectiveness of the Cerene^® Cryotherapy Device (Channel Medsystems, Berkeley, CA) in premenopausal women with heavy menstrual bleeding due to benign causes who have completed childbearing.

Methods

The prospective, multicenter, single-arm, open-label study had eight sites in the USA, one in Mexico, and two in Canada. Inclusion criteria included uterine sound ≤10 cm, endometrial cavity length 2.5 to 6.5 cm, age 25 to 50 years, a pictorial blood loss assessment chart score of ≥150, no submucosal myomata and/or uterine obstruction, distortion, or abnormality. A total of 242 subjects underwent a 2.5-minute cryoablation. Long-term follow-up visits were conducted at Month 24 and Month 36. Data collected included gynecological adverse events, description of last menstrual period, contraception status, self-report of pregnancy, medical or surgical interventions to treat abnormal uterine bleeding, satisfaction, recommendation, and quality of life (QoL). QoL outcomes were measured with the Menorrhagia Impact Questionnaire (MIQ) and the Premenstrual Symptoms Impact Survey (PMSIS™).

Results

201 subjects completed their Month 36 final study visit. Subject outcomes were comparable to those at Month 12. Eighty-nine percent of subjects reported amenorrhea, a lighter-than-normal, or normal period, 91% of subjects had no or slight limitations in MIQ measured activities, and 85% reported premenstrual symptoms at a low frequency. Eighty-five percent of the subjects were satisfied or very satisfied. The cumulative incidence of hysterectomy was 5% and reintervention was 8.7%. Forty-nine gynecologic adverse events (AE) were reported; one non-serious AE, postcoital bleeding, was reported as related to the procedure. No serious device-related or procedure-related AEs were reported.

Conclusion

Study data demonstrate that the positive effects of Cerene Cryotherapy Device treatment are sustained through Month 36 and that the risks associated with the device and procedure are low (ClinicalTrials.gov; NCT02842736).

Hysteroscopic Access and Uterine Cavity Evaluation 12 Months Post-Endometrial Ablation with the Cerene® Cryotherapy Device

STUDY OBJECTIVE

To evaluate if physical access and the ability to systematically assess the post-ablation uterine cavity were preserved at 12 months after endometrial ablation with the Cerene® Cryotherapy Device (Channel Medsystems®, Emeryville, CA).

DESIGN

A prospective, multi-center, single-arm study.

SETTING

In the clinic at 8 US sites and outpatient hospital setting at 2 sites in Canada and 1 site in Mexico.

PATIENTS OR PARTICIPANTS

230 of 242 subjects post-ablation continued in the study at the Month 12 visit. 223 subjects were available for a diagnostic hysteroscopic evaluation.

INTERVENTIONS

Subjects who had previously been treated with a 2.5-minute cryoablation of the endometrium utilizing the Cerene® Device underwent a diagnostic hysteroscopy at the Month 12 follow-up visit.

MEASUREMENTS AND MAIN RESULTS

The uterine cavity was accessible in 220 of 223 subjects (98.7%) and not accessible in 3 (1.3%), due to pain (n=2) and cervical stenosis (n=1). Visualization of the uterine cavity was possible in 204 of 220 subjects (92.7%) with one or both tubal ostia identified in 89.2% (182/204) of subjects. Both tubal ostia were visible in 160 of 204 subjects (78.4%) and one ostium in 22 of 204 subjects (10.8%). The cavity was not visualized in the remaining 16 of 220 subjects (7.2%) due to intrauterine adhesions (n=14), technical difficulties (n=1), or menstruation (n=1). In 95.6% (195/204) of subjects where the cavity was visualized, the hysteroscopic view was judged adequate to evaluate the uterine cavity for pathologic change. No significant complications occurred during the hysteroscopic evaluations.

CONCLUSION

This is the largest study to date conducted to hysteroscopically evaluate the post-ablation uterine cavity. Uterine cavity assessment with in-office hysteroscopy one year after the use of the Cerene® Cryotherapy Device is attainable, enabling both diagnostic and therapeutic procedures within the endometrial cavity.

Post-Ablation Tubal Sterilization Syndrome: Does Route of Sterilization Matter?

OBJECTIVE

To compare the prevalence of clinical post-ablation tubal sterilization syndrome among women who underwent abdominal (i.e. peripartum or laparoscopic) vs. hysteroscopic permanent contraception in addition to endometrial ablation.

STUDY DESIGN

This study was a retrospective cohort study conducted at an academic medical center. We included women (N=188) who successfully underwent both endometrial ablation and permanent contraception between 2005 and 2017. Forty-one women underwent hysteroscopic permanent contraception and 147 underwent abdominal (i.e. peripartum or laparoscopic) permanent contraception. The primary outcome was the prevalence of clinical post-ablation tubal sterilization syndrome, as defined by new or worsening cyclic pelvic pain after completion of both procedures.

RESULTS

The overall prevalence of the syndrome was 19.1% (34 of 178 women who followed up), with no detected difference between those who underwent hysteroscopic (six out of 38, 15.8%) vs. abdominal permanent contraception (28 out of 140, 20.0%, p=0.55). In multivariate regression modeling, when adjusted for race, parity, gynecologic pathologies, hormonal medication use, and the presence of baseline pain (both pelvic and non-pelvic) only younger patient age was marginally associated with increased odds of the syndrome (aOR 1.85, 95% CI 1.01-3.45, p=0.05), while abdominal as compared to hysteroscopic permanent contraception was not (aOR 1.29, 95% CI 0.59-2.84, p=0.53). Of the 28 patients with clinical post-ablation tubal sterilization syndrome who underwent hysterectomy and/or salpingectomy as treatment for their pain, none showed signs of hematosalpinx or hematometra at the time of surgery or on final pathology.

CONCLUSION

We did not find evidence that route of permanent contraception affects the risk of post-ablation tubal sterilization syndrome development. Younger patients may be at higher risk of this syndrome.

Tubal interruption and subsequent surgery for pain after endometrial ablation: A retrospective cohort study

BACKGROUND

Endometrial ablation (EA) is an alternative to hysterectomy for abnormal uterine bleeding (AUB), with reduced recovery time and fewer operative risks. However, post-ablation pain may be associated with subsequent surgery, including hysterectomy. It is uncertain what factors affect surgery rates for post-ablation pain, particularly with respect to timing and technique of tubal interruption.

AIM

To evaluate the relationship between tubal interruption and post-ablation pain and subsequent surgery.

MATERIALS AND METHODS

We conducted a retrospective cohort study involving 324 patients at a Melbourne tertiary hospital from 2009 to 2020. The primary outcome was subsequent pelvic surgery for pain following EA.

RESULTS

Pain following EA was reported by 29.7% of patients, with 10.5% of patients undergoing subsequent surgery for pain. Patients with tubal interruption were more likely to undergo subsequent surgery for pain than those with no tubal interruption (odds ratio (OR): 3.49, 95% CI: 1.59-7.66; P = 0.002). Tubal ligation was strongly associated with subsequent surgery for pain (OR: 3.12, 95% CI: 1.48-6.57; P = 0.003). In contrast, those with salpingectomy did not have an increased risk of subsequent surgery for pain, compared to those with no tubal interruption (OR: 1.5; 95% CI 0.32-7.13). Pre-ablation pain (adjusted OR: 2.98, 95% CI: 1.37-6.48; P = 0.006) and previous caesarean section (OR: 2.66; 95% CI: 1.13-6.25; P = 0.025) were also associated with subsequent surgery for pain.

CONCLUSION

Our results suggest that tubal interruption, pre-ablation pain and previous caesarean section are associated with subsequent surgery for pain. These results can better inform preoperative counselling regarding the risk of subsequent surgery after EA.

Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding

BACKGROUND

Heavy menstrual bleeding (HMB) is common in otherwise healthy women of reproductive age, and can affect physical health and quality of life. Surgery is usually a second-line treatment of HMB. Endometrial resection/ablation (EA/ER) to remove or ablate the endometrium is less invasive than hysterectomy. Hysterectomy is the definitive treatment and can be via open (laparotomy) approach, or via minimally invasive approaches (vaginally or laparoscopically). Each approach has its own advantages and risk profile.

OBJECTIVES

To compare the effectiveness, acceptability and safety of endometrial resection or ablation versus different routes of hysterectomy (open, minimally invasive hysterectomy, or unspecified route) for the treatment of HMB.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility specialised register, CENTRAL, MEDLINE, Embase and PsycINFO (July 2020), and reference lists, grey literature and trial registers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared techniques of endometrial resection/ablation with hysterectomy (by any technique) for the treatment of HMB in premenopausal women.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 10 RCTs (1966 participants) comparing EA/ER to hysterectomy (open (abdominal), minimally invasive (laparoscopic or vaginal), or unspecified (or at surgeon's discretion) route of hysterectomy). The results were rated as moderate-, low- and very low-certainty evidence. Endometrial resection/ablation versus open hysterectomy We found two trials. Women having EA/ER are probably less likely to perceive an improvement in HMB compared to women having open hysterectomy (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.84 to 0.95; 2 studies, 247 women; moderate-certainty evidence) and probably have a 13% risk of requiring further surgery for treatment failure (compared to 0 on the open hysterectomy group; 2 studies, 247 women; moderate-certainty evidence). Both treatments probably lead to similar quality of life at two years (mean difference (MD) -5.30, 95% CI -11.90 to 1.30; 1 study, 155 women; moderate-certainty evidence) and satisfaction rate at one year (RR 0.91, 95% CI 0.82 to 1.00; 1 study, 194 women; moderate-certainty evidence). There may be no difference in serious adverse events (RR 1.29, 95% CI 0.32 to 5.20; 2 studies, 247 women; low-certainty evidence). EA/ER probably reduces time to return to normal activity compared to open hysterectomy (MD -21.00 days, 95% CI -24.78 to -17.22; 1 study, 197 women; moderate-certainty evidence). Endometrial resection/ablation versus minimally invasive hysterectomy We found five trials. The proportion of women with perception of improvement in HMB at two years may be similar between groups (RR 0.97, 95% CI 0.90 to 1.04; 1 study, 79 women; low-certainty evidence). Blood loss may be higher in the EA/ER group when assessed using the Pictorial Blood Assessment Chart (MD 44.00, 95% CI 36.09 to 51.91; 1 study, 68 women; low-certainty evidence). Quality of life is probably lower in the EA/ER group compared to the minimally invasive hysterectomy group at two years according to the 36-item Short Form (SF-36) (MD -10.71, 95% CI -15.11 to -6.30; 2 studies, 145 women; moderate-certainty evidence) and Menorrhagia Multi-Attribute Scale (RR 0.82, 95% CI 0.70 to 0.95; 1 study, 616 women; moderate-certainty evidence). EA/ER probably increases the risk of further surgery for HMB compared to minimally invasive hysterectomy (RR 7.70, 95% CI 2.54 to 23.32; 4 studies, 922 women; moderate-certainty evidence) and treatments probably have similar rates of any serious adverse events (RR 0.75, 95% CI 0.35 to 1.59; 4 studies, 809 women; moderate-certainty evidence). Women with EA/ER are probably less likely to be satisfied with treatment at one year (RR 0.90, 95% CI 0.85 to 0.94; 1 study, 558 women; moderate-certainty evidence). We were unable to pool data for time to return to work or normal life because of extreme heterogeneity (99%); however, the three studies reporting this all had the same direction of effect favouring EA/ER. Endometrial resection/ablation versus unspecified route of hysterectomy We found three trials. EA/ER may lead to a lower perception of improvement in HMB compared to unspecified route of hysterectomy (RR 0.89, 95% CI 0.83 to 0.95; 2 studies, 403 women; low-certainty evidence). Although EA/ER may lead to similar quality of life using the SF-36 General Health Perception at two years' follow-up (MD -1.90, 95% CI -8.67 to 4.87; 1 study, 209 women; low-certainty evidence), the proportion of women with improvement in general health at one year may be lower (RR 0.85, 95% CI 0.77 to 0.95; 1 study, 185 women; low-certainty evidence). EA/ER probably has a risk of 5.4% of requiring further surgery for treatment failure (compared to 0 with total hysterectomy; 2 studies, 374 women; moderate-certainty evidence) and reduces the proportion of women with any serious adverse event (RR 0.21, 95% CI 0.06 to 0.80; 2 studies, 374 women; moderate-certainty evidence). Both treatments probably lead to a similar satisfaction rate at one year' follow-up (RR 0.96, 95% CI 0.88 to 1.04; 3 studies, 545 women; moderate-certainty evidence). EA/ER may lead to shorter time to return to normal activity (MD -18.90 days, 95% CI -24.63 to -13.17; 1 study, 172 women; low-certainty evidence).

AUTHORS' CONCLUSIONS

Endometrial resection/ablation (EA/ER) offers an alternative to hysterectomy as a surgical treatment for HMB. Effectiveness varies with EA/ER compared to different hysterectomy approaches. The perception of improvement in HMB with EA/ER is probably lower compared to open and unspecified route of hysterectomy, but may be similar compared to minimally invasive. Quality of life with EA/ER is probably similar to open and unspecified route of hysterectomy, but lower compared to minimally invasive hysterectomy. Further surgery for treatment failure is probably more likely with EA/ER compared to all routes of hysterectomy. Satisfaction rates also vary. EA/ER probably has a similar rate of satisfaction compared to open and unspecified route of hysterectomy, but a lower rate of satisfaction compared to minimally invasive hysterectomy. The proportion having any serious adverse event appears similar in all groups, but specific adverse events did reported difference between EA/ER and different routes. We were unable to draw conclusions about the time to return to normal activity, but the direction of effect suggests it is likely to be shorter with EA/ER.

Combination of Laparoscopic Salpingectomy and Endometrial Ablation: A Potentially Underused Procedure

Despite the advantages of a decreased risk of epithelial-cell ovarian cancer and the extremely minimally invasive nature of the procedure, combined salpingectomy and endometrial ablation is a potentially underused procedure in the United States to treat abnormal uterine bleeding and desired sterilization. The lack of utilization of this combined procedure might be based on factors other than clinical considerations, including slow acceptance and adoption of Committee Opinions expressing the value of salpingectomy over sterilization. Committee Opinions and randomized clinical trials have demonstrated the benefit of salpingectomy for sterilization and epithelial-cancer risk reduction, and there could be an additional protection against postablation tubal sterilization syndrome. This Commentary discusses the advantages and rationale for consideration of expanding usage of the combined approach.

Pathological findings in the endometrium after microwave endometrial ablation

The acceptance of MEA in Japan is well demand due to its outstanding effectiveness and safety. Infrequently, a repeat MEA or hysterectomy is needed for recurrent menorrhagia in case of failure ablation. The reasons of recurrent menorrhagia subsequent MEA treatment are unclear. The objective of current study is to identify the possible causes of menorrhagia repetition following MEA, together with the observation of histological changes in the endometrium due to this treatment compared with normal cycling endometrial tissue. A total of 170 patients, 8 (4.7%) of them carried out hysterectomy after 16.8 months (range, 2-29 months) of MEA treatment. Normal (n = 47) and MEA (n = 8) treated paraffin embedded endometrial tissue were prepared for hematoxylin and eosin (H&E) and immunostaining study to recognize the histological changes in the endometrium as a result of MEA treatment. The histological features observed increased tubal metaplasia (TM) including negative expression of the estrogen receptor (ER) and progesterone receptor (PR) in the endometrium subsequent MEA treatment. Increased TM together with the absence of ER and PR expression might be a reasonable explanation for repetition menorrhagia in cases of failure ablation. Further study is required to clarify the molecular mechanisms of tubal metaplasia and the expression loss of hormone receptor in the endometrium as a result of MEA treatment. Current studies propose that low dose estrogen-progestin may not be effective with recurrent menorrhagia patient's due to the inadequacy of hormone receptor expression in the endometrium following MEA.

A Prospective, Multicenter, Clinical Trial Evaluating the Safety and Effectiveness of the Cerene Device to Treat Heavy Menstrual Bleeding

STUDY OBJECTIVE

To evaluate the safety and effectiveness of a novel cryoablation device (Cerene Cryotherapy Device, Channel Medsystems, Emeryville, CA) in premenopausal women with heavy menstrual bleeding owing to benign causes.

DESIGN

A prospective, multi-center, single-arm, open label, non-randomized study.

SETTING

At 11 academic and private practices in North America: 8 clinic sites in the United States, and 3 outpatient hospital sites (1 in Mexico and 2 in Canada).

PATIENTS

A total of 242 subjects comprise the intent-to-treat population. Subject demographics were similar to other published endometrial ablation studies performed.

INTERVENTIONS

Subjects were treated with a single-use disposable cryoablation device (Cerene) which delivers a 2.5-minute treatment to the endometrium. Analgesia and local anesthesia were administered per investigator discretion; intravenous sedation was used in only 3% of subjects and no general anesthesia was used.

MEASUREMENTS AND MAIN RESULTS

There were no device or procedure-related serious adverse events, nor unanticipated adverse device effects. Cerene cryoablation was effective in reducing menstrual blood loss, which was measured by pictorial blood loss assessment chart (PBLAC) score. Mean score dropped from 360.6 at pretreatment (±332.1) to 51 at 12 months posttreatment (±64.1), with 81% of 230 evaluable subjects reporting a PBLAC score of ≤75 and 85% of evaluable subjects reporting a PBLAC score of ≤ 100. The median pain rating was ≤2 (mild) throughout the treatment. Of 223 subjects that underwent hysteroscopic evaluation at 12 months, the uterine cavity was visualized in 220 subjects. Quality of life improved with 90% of reporting subjects indicating satisfied or very satisfied at month 12.

CONCLUSION

This study demonstrated that Cerene cryoablation is safe and effective, offering the benefits of reduced menstrual blood loss with limited use of pain medication, high patient tolerability, quality of life improvement, and preserved access to the uterine cavity.

Radiofrequency endometrial ablation with a novel endometrial tip for the management of heavy menstrual bleeding and abnormal uterine bleeding: a prospective study

Aim: To evaluate the safety and efficacy of a radiofrequency ablation system with a novel endometrial tip (RFA-EMT) for the management of heavy menstrual bleeding (HMB) or abnormal uterine bleeding (AUB).Methods: This is a prospective study including a total of 38 premenopausal women with heavy menstrual bleeding (HMB) or abnormal uterine bleeding (AUB) that failed to respond to medical therapy. Hysteroscopic evaluation and curettage biopsy were performed just before the procedure. The procedure was timed to occur during the early proliferative phase (cycle days 4-10). RFA-EMT procedures were performed by a single surgeon with the patient under general anesthesia with a laryngeal mask airway. Primary outcome was reduction in bleeding, reported as amenorrhea, hypomenorrhea, and eumenorrhea, which were measured via hemoglobin level and pictorial blood assessment chart (PBAC) score. Secondary outcomes were adverse events, dysmenorrhea with numeric rating scale (NRS) score, and endometrial thickening in the early proliferative phase, as assessed by transvaginal ultrasonography.Results: There were no peri- or post-procedural complications. Combined amenorrhea, hypomenorrhea, and eumenorrhea rates at 3 and 6 months were 97.4% and 100%, respectively. The hemoglobin level was significantly increased, and the PBAC score, NRS score, and endometrial thickening were significantly decreased after 3 months. These trends were maintained for 6 months after the procedure.Conclusion: RFA-EMT, a new technique, is safe and effective for women with HMB or AUB for which medical therapy has failed.

Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding

BACKGROUND

Heavy menstrual bleeding (HMB) is an important cause of ill health in women of reproductive age, causing them physical problems, social disruption and reducing their quality of life. Medical therapy has traditionally been first-line therapy. Surgical treatment of HMB often follows failed or ineffective medical therapy. The definitive treatment is hysterectomy, but this is a major surgical procedure with significant physical and emotional complications, as well as social and economic costs. Less invasive surgical techniques, such as endometrial resection and ablation, have been developed with the purpose of improving menstrual symptoms by removing or ablating the entire thickness of the endometrium.

OBJECTIVES

To compare the effectiveness, acceptability and safety of techniques of endometrial destruction by any means versus hysterectomy by any means for the treatment of heavy menstrual bleeding.

SEARCH METHODS

Electronic searches for relevant randomised controlled trials (RCTs) targeted-but were not limited to-the following: the Cochrane Gynaecology and Fertility Group's specialised register, CENTRAL via the Cochrane Register of Studies Online (CRSO), MEDLINE, Embase, PsycINFO, and the ongoing trial registries. We made attempts to identify trials by examining citation lists of review articles and guidelines and by performing handsearching. Searches were performed in 1999, 2007, 2008, 2013 and on 10 December 2018.

SELECTION CRITERIA

Any RCTs that compared techniques of endometrial resection or ablation (by any means) with hysterectomy (by any technique) for the treatment of heavy menstrual bleeding in premenopausal women.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted data and assessed trials for risk of bias.

MAIN RESULTS

We identified nine RCTs that fulfilled our inclusion criteria for this review. For two trials, the review authors identified multiple publications that assessed different outcomes at different postoperative time points for the same women. No included trials used third generation techniques.Clinical measures of improved bleeding symptoms and satisfaction rates were observed in women who had undergone hysterectomy compared to endometrial ablation. A slightly lower proportion of women who underwent endometrial ablation perceived improvement in bleeding symptoms at one year (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.85 to 0.93; 4 studies, 650 women, I² = 31%; low-quality evidence), at two years (RR 0.92, 95% CI 0.86 to 0.99; 2 studies, 292 women, I² = 53%) and at four years (RR 0.93, 95% CI 0.88 to 0.99; 2 studies, 237 women, I² = 79%). Women in the endometrial ablation group also showed improvement in pictorial blood loss assessment chart compared to their baseline (PBAC) score at one year (MD 24.40, 95% CI 16.01 to 32.79; 1 study, 68 women; moderate-quality evidence) and at two years (MD 44.00, 95% CI 36.09 to 51.91; 1 study, 68 women). Repeat surgery resulting from failure of the initial treatment was more likely to be needed after endometrial ablation than after hysterectomy at one year (RR 16.17, 95% CI 5.53 to 47.24; 927 women; 7 studies; I² = 0%), at two years (RR 34.06, 95% CI 9.86 to 117.65; 930 women; 6 studies; I² = 0%), at three years (RR 22.90, 95% CI 1.42 to 370.26; 172 women; 1 study) and at four years (RR 36.32, 95% CI 5.09 to 259.21;197 women; 1 study). The satisfaction rate was lower amongst those who had endometrial ablation at two years after surgery (RR 0.87, 95% CI 0.80 to 0.95; 4 studies, 567 women, I² = 0%; moderate-quality evidence), and no evidence of clear difference was reported between post-treatment satisfaction rates in groups at other follow-up times (1 and 4 years).Most adverse events, both major and minor, were more likely after hysterectomy during hospital stay. Women who had an endometrial ablation were less likely to experience sepsis (RR 0.19, 95% CI 0.12 to 0.31; participants = 621; studies = 4; I² = 62%), blood transfusion (RR 0.20, 95% CI 0.07 to 0.59; 791 women; 5 studies; I² = 0%), pyrexia (RR 0.17, 95% CI 0.09 to 0.35; 605 women; 3 studies; I² = 66%), vault haematoma (RR 0.11, 95% CI 0.04 to 0.34; 858 women; 5 studies; I² = 0%) and wound haematoma (RR 0.03, 95% CI 0.00 to 0.53; 202 women; 1 study) before hospital discharge. After discharge from hospital, the only difference that was reported for this group was a higher rate of infection (RR 0.27, 95% CI 0.13 to 0.58; 172 women; 1 study).Recovery time was shorter in the endometrial ablation group, considering hospital stay, time to return to normal activities and time to return to work; we did not, however, pool these data owing to high heterogeneity. Some outcomes (such as a woman's perception of bleeding and proportion of women requiring further surgery for HMB), generated a low GRADE score, suggesting that further research in these areas is likely to change the estimates.

AUTHORS' CONCLUSIONS

Endometrial resection and ablation offers an alternative to hysterectomy as a surgical treatment for heavy menstrual bleeding. Both procedures are effective, and satisfaction rates are high. Although hysterectomy offers permanent and immediate relief from heavy menstrual bleeding, it is associated with a longer operating time and recovery period. Hysterectomy also has higher rates of postoperative complications such as sepsis, blood transfusion and haematoma (vault and wound). The initial cost of endometrial destruction is lower than that of hysterectomy but, because retreatment is often necessary, the cost difference narrows over time.

Optimizing surgical management of patients who decline blood transfusion

PURPOSE OF REVIEW

This review highlights the complexity of caring for gynecologic patients who refuse blood transfusion and discusses the importance of early, targeted perioperative and intraoperative medical optimization. We review alternative interventions and the importance of medical management to minimize blood loss and maximize hematopoiesis, particularly in gynecologic patients who may have significant uterine bleeding. The review also focuses on intraoperative interventions and surgical techniques to prevent and control surgical blood loss.

RECENT FINDINGS

With improvements in surgical technique, greater availability of minimally invasive surgery, and increased use of preop UAE and cell salvage, definitive surgical management can be safely performed. New technologies have been developed that allow for safer surgeries or alternatives to traditional surgical procedures. Many medical therapies have been shown to decrease blood loss and improve surgical outcomes. Nonsurgical interventions have also been developed for use as adjuncts or alternatives to surgery.

SUMMARY

The care of a patient who declines blood transfusion may be complex, but gynecologic surgeons can safely and successfully offer a wide variety of therapies depending on the patient's goals and needs. Medical management should be implemented early. A multidisciplinary team should be mobilized to provide comprehensive and patient-centered care.

Histopathologic Features of Postablation Tubal Sterilization Syndrome

Postablation tubal sterilization syndrome (PATSS) is an uncommon complication of endometrial ablation in patients with antecedent tubal ligation characterized by cyclic pelvic pain. Recurrent tubal distention resulting from retrograde menstruation into occluded proximal fallopian tube segments by residual/regenerated cornual endometrial tissue is postulated to be the cause. Reports of PATSS have largely focused on the clinicoradiologic and operative findings. Detailed descriptions of the gross pathologic findings of PATSS are sparse and rarer still are examples in which the histologic manifestations are discussed. Three patients with a history of tubal ligation and subsequent endometrial ablation who underwent hysterectomy and bilateral salpingo-oophorectomy for pelvic pain were identified. A clinical suspicion of PATSS was conveyed to the pathologist at the time of initial pathologic examination in only 2 of the 3 cases. Pathologic findings in all 3 cases were similar and included hematosalpinx of the proximal fallopian tubes, intraluminal hemosiderotic material, mural hemosiderosis, and pseudoxanthomatous salpingitis featuring plical and mural lipofuscin-laden macrophages, along with inactive to attenuated endometrium with variable submucosal myometrial hyalinization/scarring compatible with postablative changes. The pathologic features, in conjunction with the appropriate clinicoradiologic findings, were interpreted as consistent with PATSS. PATSS complicates an estimated 5% to 10% of endometrial ablations, but is likely underreported due to a lack of awareness. Pathologists should consider PATSS in hysterectomy specimens that show postablative endometrial changes accompanied by hematosalpinx and pseudoxanthomatous salpingitis of the proximal segments of ligated fallopian tubes. To our knowledge, this is the first study to depict the histopathologic features of PATSS.

Late-onset endometrial ablation failure

Endometrial ablation, first reported in the 19th century, has gained wide acceptance in the gynecologic community as an important tool for the management of abnormal uterine bleeding when medical management has been unsuccessful or contraindicated. The introduction of global endometrial ablation (GEA) devices beginning in 1997 has provided unsurpassed safety addressing many of the concerns associated with their resectoscopic predecessors. As of this writing the GEA market has surpassed a half-million devices in the United States per annum and has an expected compound annual growth rate (CAGR) projected to be 5.5% from 2016 to 2024.

While the short term safety and efficacy of these devices has been reported in numerous clinical trials we only recently are becoming aware of the high incidence of late-onset endometrial ablation failures (LOEAFs) associated with these procedures. Currently, about a quarter of women who undergo a GEA procedure will eventually require a hysterectomy while an unknown number have less than satisfactory results. In order to reduce these suboptimal outcomes physicians must better understand the etiology and risk factors that predispose a patient toward the development of LOEAF as well as current knowledge of patient and procedure selection for EA as well as treatment options for these delayed complications.

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Over 500,000 endometrial ablations (EAs) are performed in the U. S. each year.

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Late-onset endometrial ablation failures (LOEAFs) are the most common complication of EA.

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25% of women who undergo EA will require hysterectomy within 5 years.

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Reducing the incidence of LOEAFs requires improved patient selection for EA.

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Ultrasound-guided reoperative hysteroscopic surgery (UGRHS) reduces the need hysterectomy following LOEAF.

Endometrial ablation for heavy menstrual bleeding

Endometrial ablation can be described as one of the great gynecological success stories. It has changed the management of heavy menstrual bleeding dramatically. The development of newer (second generation) endometrial ablative techniques has enabled clinicians to set up comprehensive 'one stop clinics' based on an outpatient service to treat heavy menstrual bleeding effectively without the need for general anesthetic or conscious sedation. This article describes the rationale and evidence for use of different endometrial auto-ablative systems along with relevant technical and clinical aspects. It also addresses the essentials of a successful approach to outpatient endometrial ablation along with discussion on risks, complications and contraindications of the procedure.

Maternal serum markers, characteristics and morbidly adherent placenta in women with previa

OBJECTIVE

To examine associations with morbidly adherent placenta (MAP) among women with placenta previa.

STUDY DESIGN

Women with MAP (cases) and previa alone (controls) were identified from a cohort of 236,714 singleton pregnancies with both first and second trimester prenatal screening, and live birth and hospital discharge records; pregnancies with aneuploidies and neural tube or abdominal wall defects were excluded. Logistic binomial regression was used to compare cases with controls.

RESULT

In all, 37 cases with MAP and 699 controls with previa alone were included. Risk for MAP was increased among multiparous women with pregnancy-associated plasma protein-A (PAPP-A) ⩾95th percentile (⩾2.63 multiple of the median (MoM); adjusted OR (aOR) 8.7, 95% confidence interval (CI) 2.8 to 27.4), maternal-serum alpha fetoprotein (MS-AFP) ⩾95th percentile (⩾1.79 MoM; aOR 2.8, 95% CI 1.0 to 8.0), and 1 and ⩾2 prior cesarean deliveries (CDs; aORs 4.4, 95% CI 1.5 to 13.6 and 18.4, 95% CI 5.9 to 57.5, respectively).

CONCLUSION

Elevated PAPP-A, elevated MS-AFP and prior CDs are associated with MAP among women with previa.

Sonographic findings in postmenopausal women with a prior endometrial ablation: interpretation and management of women with endometrial thickening and bleeding

OBJECTIVE

To understand the meaning of endometrial thickening and bleeding in postmenopausal women who had previously undergone endometrial ablation (EA).

DESIGN

Retrospective observational study. Canadian Task Force III.

SETTING

Obstetrics and Gynecology Unit, Magna Graecia University, Catanzaro, Italy.

PATIENTS

Sixty-three postmenopausal women who had previously undergone EA.

INTERVENTIONS

A retrospective evaluation of clinical charts of postmenopausal women who had a follow-up visit after EA between January 2000 and August 2014.

MEASUREMENTS AND MAIN RESULTS

The rates of endometrial thickening (with or without bleeding), endometrial atrophy, and cancer were determined. Postmenopausal bleeding was reported in 9 patients (14.3%). Endometrial thickening was observed in 51 patients (80.9%; mean ± SD endometrial thickness, 7.7 ± 3.0 mm). A significantly (p < .05) greater number of patients with an endometrial thickness of 5 to 10 mm was observed compared with those with an endometrial thickness of <5 mm or >10 mm. A significant (p = .001) difference in increase in endometrial thickness was observed between patients with and without bleeding. Overall, hysteroscopy plus endometrial biopsy was scheduled in 24 patients. In all bleeding women, a histological diagnosis of endometrial atrophy was demonstrated. Concerning bleeding-free women, in 14 patients with endometrial thickening of >10 mm, mucosal atrophy was detected. The only bleeding-free patient in whom an endometrial echogenic fluid collection was detected had a histological diagnosis of endometrioid endometrial cancer. Thus, patients who underwent hysteroscopy had a 95.8% rate of mucosal atrophy and a 4.2% rate of endometrial cancer. The overall cancer rate in our global population (menopause with previous EA) was 1.6%.

CONCLUSION

Postmenopausal bleeding and sonographic detection of endometrial thickening in patients with previous EA are not necessarily related to a malignant disease. Nonetheless, ultrasound visualization of endometrial thickening plus an echogenic endometrial fluid collection in these patients always warrants an invasive diagnostic procedure regardless of whether or not bleeding is reported.

Preoperative uterine bleeding pattern and risk of endometrial ablation failure

OBJECTIVE

The objectives of the study were to compare among women who had an endometrial ablation the risks of treatment failure and subsequent gynecological procedures between women with regular and irregular heavy uterine bleeding and to determine other characteristics associated with the risk of treatment failure.

STUDY DESIGN

This study was a retrospective cohort of 968 women who underwent endometrial ablation between January 2007 and July 2009. Preoperative bleeding pattern was categorized as regular or irregular. Treatment failure was defined as reablation or hysterectomy. Subsequent gynecological procedures included endometrial biopsy, dilation and curettage, hysteroscopy, reablation, or hysterectomy. We calculated the odds of treatment failure and gynecological procedures using multiple logistic regression.

RESULTS

Bleeding pattern prior to ablation was heavy and regular in 30% (n = 293), heavy and irregular in 36% (n = 352), and unspecified in 30% (n = 286). We found no differences in treatment failure (13% vs 12%, P = .9) or subsequent procedures (16% vs 18%, P = .7) between women with regular and irregular bleeding. Compared with the women with regular bleeding, the women with irregular bleeding were not at increased odds of treatment failure or subsequent procedures (odds ratio [OR], 1.07; 95% confidence interval [CI], 0.65-1.74 and OR, 1.17; 95% CI, 0.76-1.80, respectively). Factors associated with an increased odds of treatment failure and subsequent procedures included tubal ligation (OR, 1.94; 95% CI, 1.30-2.91 and OR, 1.71; 95% CI, 1.20-2.43, respectively); dysmenorrhea (OR, 2.42; 95% CI, 1.44-4.06 and OR, 1.93; 95% CI, 1.20-3.13, respectively); and obesity (OR, 1.82; 95% CI, 1.21-2.73 and OR, 1.75; 95% CI, 1.22-2.50, respectively).

CONCLUSION

Preoperative bleeding pattern did not appear to affect failure rates or the need for gynecological procedures after endometrial ablation. Other risk factors for ablation failure identified included preoperative dysmenorrhea, prior tubal ligation, and obesity.

Global ablation techniques

Global endometrial ablation techniques are a relatively new surgical technology for the treatment of heavy menstrual bleeding that can now be used even in an outpatient clinic setting. A comparison of global ablation versus earlier ablation technologies notes no significant differences in success rates and some improvement in patient satisfaction. The advantages of the newer global endometrial ablation systems include less operative time, improved recovery time, and decreased anesthetic risk. Ablation procedures performed in an outpatient surgical or clinic setting provide advantages both of potential cost savings for patients and the health care system and improved patient convenience.

Placenta accreta, increta, and percreta

Placenta accreta is an abnormal adherence of the placenta to the uterine wall that can lead to significant maternal morbidity and mortality. The incidence of placenta accreta has increased 13-fold since the early 1900s and directly correlates with the increasing cesarean delivery rate. The prenatal diagnosis of placenta accreta by ultrasound along with risk factors including placenta previa and prior cesarean delivery can aid in delivery planning and improved outcomes. Referral to a tertiary care center and the use of a multidisciplinary care team is recommended.

Does adjuvant long-acting gestagen therapy improve the outcome of hysteroscopic endometrial resection in women of low-resource settings with heavy menstrual bleeding?

OBJECTIVE

To test for the hypothesis of the beneficial effect of long-acting gestagens as an adjuvant postoperative therapy on the outcome of hysteroscopic transcervical endometrial resection (TCRE) in women of low-resource settings and suffering from ovulatory heavy menstrual bleeding (menorrhagia).

DESIGN

Randomized controlled trial (Canadian Task Force classification I).

SETTING

Low-resource tertiary care university hospital.

PATIENTS

Seventy-one premenopausal women with established ovulatory menorrhagia.

INTERVENTION

After randomization, 37 patients were treated with TCRE plus gestagen and 34 patients with TCRE alone.

MEASUREMENTS AND MAIN RESULTS

Variations in menstrual patterns and bleeding scores, as well as amenorrhea and repeat surgery rates with treatment, were determined 1 year after resection. In those who continued to menstruate at 6 months, treatment with TCRE plus gestagen was associated with a significant reduction in the number of days bleeding from 7.2 to 3.4 (p ≤ .0001), increased cycle length from 24 to 30 (p = .02), a 60% reduction in dysmenorrhea score from 62 to 25 (p ≤ .0001), and a 60% reduction in premenstrual syndrome score from 55 to 22 (p = .04). Amenorrhea rates at 12 months in the TCRE plus gestagen and TCRE alone groups were 40% versus 26% (p = .02), with combined amenorrhea and hypomenorrhea rates of 75% versus 64% (p = .02), respectively. At 12 months, repeat surgery rates were higher in the TCRE alone group (21% vs 3%, p < .05).

CONCLUSION

In a low-resource setting, the adjuvant postoperative long-acting gestagen therapy has proven to be superior in inducing amenorrhea after hysteroscopic TCRE.