Prediction of treatment outcomes after global endometrial ablation

Comprehensive analysis of NovaSure® endometrial ablation in patients with heavy menstrual bleeding: Identifying success rate and predictive factors for post-NovaSure® hysterectomy

OBJECTIVE

To analyze success rate and predictive factors for post-NovaSure hysterectomy in patients with heavy menstrual bleeding.

STUDY DESIGN

469 patients undergoing NovaSure endometrial ablation (NEA) were included in this retrospective single center cohort study at Martini Hospital Groningen, the Netherlands. The outcomes of these procedures and predictive factors for undergoing additional post-Novasure hysterectomy were analyzed.

RESULTS

Of 446 patients undergoing successful NEA ablation 82.9 % were satisfied with the results after 3 months. At this time point 37.3 % of patients reported an amenorrhea. 51 patients (11.4 %) underwent a hysterectomy during the follow-up period with a mean number of 18.5 months after NEA. A shorter duration of the ablation procedure was significantly associated with undergoing a hysterectomy (p = 0.034). Patients with a higher BMI also underwent a hysterectomy more often (p = 0.017) as well as patients with a large uterine cavity (p = 0.041). Pathology results revealed that in 27 (52.9 %) of removed uteruses adenomyosis was present. Complications occurred in 2.9 % of procedures.

CONCLUSION

This study highlights the effectiveness of NEA in the setting of a large general teaching hospital and multiple characteristics associated with failure of treatment. The results of our study reaffirm the place of NEA as a safe and effective treatment for patients with menorrhagia.

Guideline No. 453: Endometrial Ablation in the Management of Abnormal Uterine Bleeding

OBJECTIVE

To provide an update of the current evidence-based guideline on the techniques and technologies used in endometrial ablation, a minimally invasive technique for the management of abnormal uterine bleeding of benign origin.

TARGET POPULATION

Women of reproductive age with abnormal uterine bleeding and benign pathology with or without structural abnormalities.

BENEFITS, HARMS, AND COSTS

Implementation of the guideline recommendations will improve the provision of endometrial ablation as an effective treatment for abnormal uterine bleeding. Following these recommendations would allow the surgical procedure to be performed safely and maximize success for patients.

EVIDENCE

The guideline was updated with published literature retrieved through searches of Medline and the Cochrane Library from January 2014 to April 2023, using appropriate controlled vocabulary and keywords (endometrial ablation, hysteroscopy, menorrhagia, heavy menstrual bleeding, abnormal uterine bleeding, hysterectomy). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies written in English. Grey (unpublished) literature was retrieved from the Association of Obstetricians and Gynecologists of Quebec (AOGQ) in 2023.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

Obstetricians, gynaecologists, and primary care providers.

SOCIAL MEDIA ABSTRACT

This is an updated version of the 2015 SOGC Endometrial Ablation guideline. The authors discuss special considerations, update evidence, and make new fluid deficit recommendations.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Ultrasound Appearance of the Endometrium Post-Radiofrequency Ablation

OBJECTIVE

To describe the ultrasonographic appearance of the post-ablative endometrium to improve knowledge of its sonographic findings.

METHODS

This was an Institutional Review Board approved prospective study of patients who underwent second-generation endometrial ablation from 2016 to 2019 at a single health system. Patients had postoperative transvaginal ultrasounds at 2, 6, and 12 months. Ultrasound reports were analyzed for endometrial thickness, description of the endometrium and myometrium, presence of uterine fibroids, and uterine size. Statistical tests for repeated measures were utilized.

RESULTS

There were 68 patients with the average age of 42 (SD 6) years and a BMI of 33 (SD 8). Preoperatively the average endometrial thickness was 10 mm, uterine length was 9.7 cm, and 38.2% had leiomyoma. The average endometrial thickness decreased at each ultrasound: 8.4 mm (SD 3.4), 7.2 mm (SD 3.0), and 5.8 mm (SD 2.5) at 2, 6, and 12 months, respectively. When comparing endometrial thickness postoperatively there was a significant difference at 2 and 12 months (P = .041), and 6 and 12 months (P = .031). There was no change during the postoperative period in the presence of leiomyoma, hyperechoic endometrium, hypoechoic endometrium, heterogeneous endometrium, and cystic endometrium on the ultrasounds.

CONCLUSION

After ablation with a second-generation device, the endometrial thickness on ultrasound decreases with time following surgery. Additional studies correlating these findings to clinical outcomes would be useful.

Evaluation of Radiofrequency Endometrial Ablation: A 17-year Canadian Experience

STUDY OBJECTIVE

The purpose of this study was to better elucidate radiofrequency endometrial ablation (REA) durability by assessing the probability of failure as defined by need for postablation hysterectomy. Age at index REA, duration from REA until hysterectomy, and REA failure (REAF) risk factors were analyzed.

DESIGN

A retrospective cohort study was conducted using patient data between April 1, 2002, and March 31, 2019. REAF cases were identified using operative procedure codes. Cox proportional hazard regression assessed the effect of age at index REA on time to postablation hysterectomy. Kaplan-Meier survival curve evaluated timing of postablation hysterectomy, stratified by age at index REA.

SETTING

This study was conducted at Regina General Hospital in Regina, Saskatchewan, Canada.

PATIENTS

Patient population included those who were 21 years of age or older, were premenopausal, and had a history of heavy menstrual bleeding at the time of REA.

INTERVENTIONS

The intervention under investigation was REA.

MEASUREMENTS AND MAIN RESULTS

The overall probability of postablation hysterectomy was 22.6%. The probabilities of postablation hysterectomy were 36.1% for women younger than 30 years (n = 128), 28% for women 30 to 34.9 years old (n = 528), 29.6% for women 35 to 39.9 years old (n = 1152), and 17.6% for women 40 years and older (n = 2221). Characteristics associated with REAF included tubal occlusion, cesarean section, dysmenorrhea, and chronic pelvic pain (p <.01) among women younger than 40 years. Leiomyomas accounted for higher failure rates in women 40 years and older (p <.01).

CONCLUSION

Postablation hysterectomy is more likely to occur in women younger than 40 years. REA can be considered in women aged 30 to 39.9 years old, who have no known REAF risk factors. Women younger than 40 years with REAF risk factors will experience higher rates of hysterectomy. Thus, the decision to proceed with REA should be individualized with careful consideration for the underlying causes of abnormal uterine bleeding, while respecting patient autonomy.

Evaluation and Management of Heavy Vaginal Bleeding (Noncancerous)

Heavy vaginal bleeding is a common, life-altering condition affecting around 30% of women at some point in their reproductive lives. Initial evaluation should focus on hemodynamic stability. A thorough history including the patient's menstrual cycle and personal and family bleeding history should be obtained. Causes are stratified using the structural and nonstructural International Federation of Gynecology and Obstetrics classification system. Further consideration of the patient's age is essential because this can help to narrow the differential diagnosis. Work-up includes laboratory and imaging studies. Treatment approach includes acute stabilization and long-term treatment with medical and surgical modalities.

Clinical analysis of 2152 cases of abnormal uterine bleeding treated by NovaSure endometrial ablation

OBJECTIVE

To evaluate the efficiency, postoperative hysterectomy rate, and influencing factors for therapeutic effect of the NovaSure endometrial ablation procedure in abnormal uterine bleeding (AUB).

METHODS

We conducted a retrospective cohort study of 2152 patients from the Department of Gynecology at the Third Xiangya Hospital, CSU from October 2010 to December 2018.

RESULTS

From the first year to the eighth year after operation, annual effective rate was above 95.24%, and the differences were not statistically significant. There are statistically significant differences between the effective and ineffective groups with regard to age, intrauterine polyps, total length of the uterus, systemic coagulation disorder, and preoperative hemoglobin. A multivariate logistic regression analysis showed that the risk factors associated with systemic coagulation disorders (P = 0.027) and high total uterine length (P = 0.003) affected NovaSure efficacy in the treatment of AUB. By December 2019, the postoperative hysterectomy rate was 1.86% (40/2152) and the complication rate was 1.67% (36/2152).

CONCLUSION

NovaSure is a reliable treatment for AUB and serious medical complications because of its simple operation, low amount of bleeding, quick postoperative recovery, and safe and effective short-term and long-term efficacy. However, it should be carefully selected for patients with a total uterus length exceeding 10 cm.

Water Vapor Endometrial Ablation for Heavy Menstrual Bleeding: 36-Month Follow-Up of a Prospective, Multicenter Pivotal Clinical Trial

Study Objective

To report 36-month follow-up of a pivotal trial that evaluated the safety and effectiveness of the AEGEA Water Vapor System for the treatment of heavy menstrual bleeding (HMB) secondary to Abnormal Uterine Bleeding due to Endometrial disorders or Leiomyomata (AUB-E and AUB-L).

Methods

A prospective, multicenter, single-arm clinical trial at 14 sites in the US, Canada, Mexico, and the Netherlands. Inclusion criteria included a Pictorial Blood Loss Assessment (PBLAC, Higham) score ≥150 and allowed treatment of subjects with leiomyomata classified by the International Federation of Gynecology and Obstetrics (FIGO) Types 2–6 up to 4 cm in diameter, a uterine cavity up to 12 cm in length (uterine sound), Essure^® contraceptive inserts and/or prior cesarean section. Follow-up assessments were conducted annually up to 36 months after endometrial ablation. The following outcomes were evaluated for 125/155 women: gynecological adverse events, qualitative assessment of menstrual flow, quality of life using the Menorrhagia Impact Questionnaire (MIQ), patient satisfaction, and medical or surgical reintervention for AUB.

Results

One hundred and fifty-five premenopausal women aged 30 to 50 years were enrolled from September 2014 through May 2015. Water vapor endometrial ablation was performed under varying anesthesia/sedation regimens in offices, surgical centers and operating rooms. There were 6 procedure-related adverse events that occurred between 12- and 36-month follow-up, 1 of which was deemed serious (hematometra managed successfully hysteroscopically). Seventy-two percent reported amenorrhea or light menstrual flow. The mean quality of life (MIQ) score improved from 14.7 at baseline to 6.4. Ninety-three percent reported “Satisfied” or “Very Satisfied.” Post-ablation hysterectomy for any indication was performed in 6.5% of patients, and the total rate of re-intervention for bleeding was 7.1%.

Conclusion

Outcomes 36-months after water vapor endometrial ablation for HMB are consistent with 12- and 24-month follow-up results in all subgroups evaluated. The AEGEA Water Vapor System increases the population of patients amenable to efficacious and acceptable treatment of Heavy Menstrual Bleeding (HMB) due to Abnormal Uterine Bleeding (AUB-E,-L). CinicalTrials.gov NCT01979861 registered November 8, 2013.

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.

Prognostic Factors for the Failure of Endometrial Ablation: A Systematic Review and Meta-analysis

OBJECTIVE

To provide an overview of prognostic factors predicting failure of second-generation endometrial ablation.

DATA SOURCES

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."

METHODS OF STUDY SELECTION

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.

TABULATION, INTEGRATION, AND RESULTS

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.

CONCLUSION

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.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42019126247.

Economic Evaluation of Global Endometrial Ablation Versus Inpatient and Outpatient Hysterectomy for Treatment of Abnormal Uterine Bleeding: US Commercial and Medicaid Payer Perspectives

Every year, abnormal uterine bleeding (AUB) exacts a heavy toll on women's health and leads to high costs for the US health care system. The literature shows that endometrial ablation results in fewer complications, shorter recovery and lower costs than more commonly performed hysterectomy procedures. The objective of this study was to model clinical-economic outcomes, budget impact, and cost-effectiveness of global endometrial ablation (GEA) versus outpatient hysterectomy (OPH) and inpatient hysterectomy (IPH) procedures. A decision tree, state-transition (semi-Markov) economic model was developed to simulate 3 hypothetical cohorts of women who received surgical treatment for AUB (GEA, OPH, and IPH) over 1, 2, and 3 years to evaluate clinical and economic outcomes for GEA vs. OPH and GEA vs. IPH. Two versions of the model were created to reflect both commercial health care payer and US Medicaid perspectives, and analyses were conducted for both payer types. Total health care costs in the first year after GEA were substantially lower compared with those for IPH and OPH. Budget impact analysis results showed that increasing GEA utilization yields total annual cost savings of about $906,000 for a million-member commercial health plan and about $152,000 in cost savings for a typical-sized state Medicaid plan with 1.4 million members. Cost-effectiveness analysis results for both perspectives showed GEA as economically dominant (conferring greater benefit at lower cost) over both OPH and IPH in the 1-year commercial scenario. This study demonstrates that, for some patients, GEA may prove to be a safe, uterus-sparing, cost-effective alternative to OPH and IPH for the surgical treatment of AUB.

Minimally invasive treatment of adenomyosis

The aim of the present review is to give a comprehensive overview of minimal invasive treatment options and suggest a minimally invasive approach in women with adenomyosis (AD). A review of relevant literature on medical and surgical treatment options is performed. Surgical options include endometrial ablation, hysteroscopic endometrial and adenomyoma resection, laparoscopic resection of AD, high-intensity focused ultrasonography (HIFU), and uterine artery embolization (UAE). This review summarizes treatment strategies for the management of AD and highlights the present lack of knowledge, which makes suggestions of evidence-based treatment difficult.

Incidence and predictors of failed second-generation endometrial ablation

Background

The need for any treatment following an endometrial ablation is frequently cited as “failed therapy,” with the two most common secondary interventions being repeat ablation and hysterectomy. Since second-generation devices have become standard of care, no large cohort study has assessed treatment outcomes with regard to only these newer devices. We sought to determine the incidence and predictors of failed second-generation endometrial ablation, defined as the need for surgical re-intervention.

We performed a retrospective cohort study at a single academic-affiliated community hospital. Subjects included women undergoing second-generation endometrial ablation for benign indications between October 2003 and March 2016. Second-generation devices utilized during the study period included the radiofrequency ablation device (RFA), hydrothermal ablation device (HTA), and the uterine balloon ablation system (UBA).

Results

Five thousand nine hundred thirty-six women underwent endometrial ablation at a single institution (3757 RFA (63.3%), 1848 HTA (31.1%), and 331 UBA (5.6%)). The primary outcome assessed was surgical re-intervention, defined as hysterectomy or repeat endometrial ablation. Of the total 927 (15.6%) women who required re-intervention, 822 (13.9%) underwent hysterectomy and 105 (1.8%) underwent repeat endometrial ablation. Women who underwent re-intervention were younger (41.6 versus 42.9 years, p < .001), were more often African-American (21.8% versus 16.2%, p < .001), and were more likely to have had a primary radiofrequency ablation procedure (hazard ratio 1.37; 95%CI 1.01 to 1.86). Older age was associated with decreased risk for treatment failure with women older than 45 years of age having the lowest risk for failure (p < .001). Age between 35 and 40 years conferred the highest risk of treatment failure (HR 1.59, 95% CI 1.32–1.92). Indications for re-intervention following ablation included menorrhagia (81.8%), abnormal uterine bleeding (27.8%), polyps/fibroids (18.7%), and pain (9.5%).

Conclusion

Surgical re-intervention was required in 15.6% of women who underwent second-generation endometrial ablation. Age, ethnicity, and radiofrequency ablation were significant risk factors for failed endometrial ablation, and menorrhagia was the leading indication for re-intervention.

Medical therapy versus radiofrequency endometrial ablation in the initial treatment of heavy menstrual bleeding (iTOM Trial): A clinical and economic analysis

BACKGROUND

Radiofrequency endometrial ablation (REA) is currently a second line treatment in women with heavy menstrual bleeding (MHB) if medical therapy (MTP) is contraindicated or unsatisfactory. Our objective is to compare the effectiveness and cost burden of MTP and REA in the initial treatment of HMB.

METHODS

We performed a randomized trial at Mayo Clinic Rochester, Minnesota. The planned sample size was 60 patients per arm. A total of 67 women with HMB were randomly allocated to receive oral contraceptive pills (Nordette ®) or Naproxen (Naprosyn®) (n = 33) or REA (n = 34). Primary 12-month outcome measures included menstrual blood loss using pictorial blood loss assessment chart (PBLAC), patients' satisfaction, and Menorrhagia Multi-Attribute Scale (MMAS). Secondary outcomes were total costs including direct medical and indirect costs associated with healthcare use, patient out-of-pocket costs, and lost work days and activity limitations over 12 months.

RESULTS

Compared to MTP arm, women who received REA had a significantly lower PBLAC score (median [Interquartile range, IQR]: 0 [0-4] vs. 15 [0-131], p = 0.003), higher satisfaction rates (96.8%vs.63.2%, p = 0.003) and higher MMAS (median [IQR]: 100 [100-100] vs. 100 [87-100], p = 0.12) at 12 months. Direct medical costs were higher for REA ($5,331vs.$2,901, 95% confidence interval (CI) of mean difference:$727,$4,852), however, when indirect costs are included, the difference did not reach statistical significance ($5,469 vs. $3,869, 95% CI of mean difference:-$339, $4,089).

CONCLUSION

For women with heavy menstrual bleeding, initial radiofrequency endometrial ablation compared to medical therapy offered superior reduction in menstrual blood loss and improvement in quality of life without significant differences in total costs of care.

CLINICAL TRIAL REGISTRATION

NCT01165307.

Endometrial ablation

Endometrial ablation (EA) includes a spectrum of procedures performed with or without hysteroscopic direction, designed to destroy the endometrium for the treatment of the symptom of heavy menstrual bleeding (HMB) secondary to a spectrum of causes, but most commonly those that are endometrial in origin (AUB-E) or ovulatory disorders (AUB-O). Resectoscopic endometrial ablation (REA) is often mistakenly referred to as the "first generation" technique, while proprietary devices that do not use the resectoscope (nonresectoscopic EA or NREA) are often misperceived as "second generation" devices. Indeed, the origins of NREA date back to the late 19th century with the use of steam, and the early and mid 20th century, when radiofrequency and cryotherapy based NREA techniques were published - long before the resectoscope was used and reported. The NREA devices have also been mislabeled as "global", a misleading term borrowed from the marketing departments of device manufacturers - there is no device that predictably treats the entire endometrium. Consequently, none can be construed as being "global". Instead, EA is a procedure designed for women as an alternative to hysterectomy, or, perhaps, medical therapy, when future fertility is no longer desired. Women who select EA should anticipate a relatively low risk procedure that will likely reduce their HMB to normal levels or less. This paper will review the spectrum of EA techniques and devices, their clinical outcomes and adverse events, and explore their value compared to hysterectomy and selected medical therapies.

Endometrial Ablation

The destruction of the endometrium in women with heavy menstrual bleeding has been used for well over a century, and the various techniques of delivering forms of thermal energy have been modified over the years to ensure a safe and effective treatment approach. Today, 6 nonresectoscopic devices are approved for use in the United States in addition to resectoscopic techniques that rely on the skillful use of the operative hysteroscope. Regardless of the technique used, endometrial ablation uniformly reduces menstrual blood loss, improves general and menstrual-related quality of life, and prevents hysterectomy in 4 of 5 women who undergo the procedure. When patients are appropriately selected, outcomes are optimized, and risks of serious complications are minimized. This article reviews the literature with singular reference to nonresectoscopic endometrial ablation procedures including historical background, appropriate patient selection, clinical outcomes data, complications, and special or unique considerations.

Non-surgical Management of Myomas

Uterine myomas are a common condition and the leading cause of hysterectomy. Clinically, myomas can be challenging because they range from asymptomatic to causing severe, debilitating symptoms and occur in many women before childbearing is complete. Thus, women often seek uterine-conserving and nonsurgical management of their myomas. In this review the available uterine-conserving treatment options from medical management through minimally invasive procedures are discussed. To the extent of research available, the sustainability of symptom improvement and the effects on future fertility are reviewed. Future research may lead to therapies that reduce the risks of major surgery, decrease side effects, and offer primary or secondary prevention options.

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: A Tale of Two Women

Endometrial ablation procedures are growing in popularity for the treatment of menorrhagia and dysmenorrhea. Sonography is the modality of choice in the evaluation of patients prior to ablation and as a follow-up for any postprocedure complications. After ablation, conditions including hematometra, postablation tubal sterilization syndrome, postablation endometriosis, and pregnancy complications have been documented. Sonographers should be aware of the conditions associated with endometrial ablations and the variety of sonographic findings that may be present.

Effect of Radiofrequency Endometrial Ablation on Dysmenorrhea

STUDY OBJECTIVE

To examine rates of dysmenorrhea after radiofrequency endometrial ablation in patients with and without known dysmenorrhea symptoms prior to the procedure in a diverse population.

DESIGN

Retrospective cohort study (Canadian Task Force classification II-2).

SETTING

Academic gynecology practice.

PATIENTS

A total of 307 women underwent endometrial ablation between 2007 and 2013 at our institution. Patients who had preoperative and postoperative pain symptom assessments as well as a description of pain timing recorded were included in our analysis. Exclusion criteria were age <19 years and operative biopsy findings consistent with complex atypical hyperplasia.

INTERVENTIONS

The difference in preoperative and postoperative rates of dysmenorrhea was evaluated. Demographic information and other outcome variables were used to evaluate factors associated with resolution of dysmenorrhea.

MEASUREMENTS AND MAIN RESULTS

A total of 307 patients who underwent radiofrequency endometrial ablation were identified. After exclusions, 296 charts were examined, and 144 patients met our enrollment criteria. The mean age of the study cohort was 45.4 ± 6.2 years; 57 patients (40%) were African American, 16 (11%) had a body mass index (BMI) > 40, and 41 (29%) were of normal weight. Preoperative dysmenorrhea was reported by 100 patients (69%); 48 of these patients (48%) experienced resolution of symptoms postoperatively. Only 3 of the 44 patients (7%) without preoperative dysmenorrhea reported new-onset dysmenorrhea postoperatively. Significantly fewer patients had dysmenorrhea after compared to before radiofrequency ablation (55 of 144 [38%] vs 100 of 144 [69%]; p < .001). Resolution of dysmenorrhea after ablation was associated with reduction in bleeding volume (p = .048) but not with a reduction in frequency of bleeding (p = .12).

CONCLUSIONS

Approximately one-half of women who undergo radiofrequency endometrial ablation to treat heavy menstrual bleeding who also have preoperative dysmenorrhea exhibit documented pain resolution after the procedure. Resolution of dysmenorrhea is more likely if menstrual flow volume is decreased postprocedure.

The role of pathologic evaluation of endometrial ablation resections in predicting ablation failure and adenomyosis in hysterectomy

Endometrial ablation is commonly performed to manage heavy menstrual bleeding. However, failure in symptom control eventually requiring hysterectomy is frequent. Adenomyosis is common in such failure cases. Ablations using a resectoscope will produce an Endo-Myometrial Resection (EMR) specimen. The value of histopathologic examination of EMRs in predicting treatment failure and adenomyosis has not been addressed. We retrieved histologic material from subjects with failed ablation (persistent symptoms requiring hysterectomy) and subjects with ablation followed by clinical improvement and no hysterectomy (control group). Material was evaluated for features of an abnormal endometrial distribution suggestive of adenomyosis: myometrial fragments with endometrium on opposite edges, myometrium with endometrium in ≥3 edges and areas of endometrium completely surrounded by myometrium (endometrial islands). Hysterectomy specimens from the study group were evaluated for the presence of adenomyosis and its distribution (superficial/deep). Both study and control groups consisted of 18 patients each. The number of fragments with endometrium on opposite sides was significantly higher in the study group: 2.11 vs 0.94 in the control group (p=0.005). Conversely, maximum aggregate dimension (2.3cm vs 2.79cm), number of fragments with endometrium on three sides (4.5 vs 2.78) and number of fragments with endometrial islands (4.5 vs 4.11) did not significantly differ between groups. Adenomyosis was seen in 72.2% hysterectomies from the study group; 27.8% involved deep myometrium. None of the EMR features were statistically associated with adenomyosis. Certain endomyometrial distribution patterns in EMR specimens correlate with future ablation failure and need for definitive surgery. This may be explained by residual endometrial tissue not resected due to a markedly irregular endomyometrial interface. Adenomyosis is frequent in cases of ablation failure. However, a significant association between EMR patterns studied and adenomyosis was not observed.

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.

Ambulatory management of heavy menstrual bleeding

Heavy menstrual bleeding (HMB) has significant adverse effects on the quality of life of many women, placing an economic burden on both health services and society at large. Thus, it is essential that all women with HMB have easy access to the proper diagnostic and therapeutic work-up in an outpatient fashion, avoiding the more time-consuming inpatient management. This new outpatient approach for HMB is one of the latest development of gynecological practice and can offer both diagnostic and therapeutic procedures. This manuscript aims to show the current possibilities of the modern management of HMB, which can be safely and effectively accomplished in the outpatient setting: global and directed endometrial biopsy, levonorgestrel intrauterine system insertion as well as minimally invasive surgical procedures (encompassing a variety of operative hysteroscopic procedures and second-generation endometrial ablation) are described below.

Female Sexual Function Improves After Endometrial Ablation

BACKGROUND

Many women have heavy menstrual bleeding during perimenopause that may interfere with overall quality of life and contribute to sexual dysfunction. We aimed to determine whether sexual function in women improves after endometrial ablation for heavy menstrual periods.

METHODS

Validated surveys (Female Sexual Function Index [FSFI], Female Sexual Distress Scale [FSDS], and Short-Form Health Survey [SF-12]) were administered to 136 women before and after endometrial ablation from August 2008 through June 2013. Scores at baseline and 6 months after surgery were compared using the paired t test.

RESULTS

A total of 97 women completed the FSFI and FSDS surveys at baseline and 6 months after ablation. Mean full-scale FSFI score increased from 26.5 to 28.8 (p < .001), with improvement in 5 of 6 FSFI domains. Mean FSDS score decreased from 13.6 to 9.7 (p < .001), showing decreased personal distress regarding sexual function. In assessing quality of life, SF-12 scores improved for global physical function (p < .001) and mental function (p = .002).

CONCLUSIONS

Female sexual function improved and personal distress associated with sexual function decreased after endometrial ablation for heavy menstrual cycles.

Cost-Effectiveness of Global Endometrial Ablation vs. Hysterectomy for Treatment of Abnormal Uterine Bleeding: US Commercial and Medicaid Payer Perspectives

Cost-effectiveness modeling studies of global endometrial ablation (GEA) for treatment of abnormal uterine bleeding (AUB) from a US perspective are lacking. The objective of this study was to model the cost-effectiveness of GEA vs. hysterectomy for treatment of AUB in the United States from both commercial and Medicaid payer perspectives. The study team developed a 1-, 3-, and 5-year semi-Markov decision-analytic model to simulate 2 hypothetical patient cohorts of women with AUB-1 treated with GEA and the other with hysterectomy. Clinical and economic data (including treatment patterns, health care resource utilization, direct costs, and productivity costs) came from analyses of commercial and Medicaid claims databases. Analysis results show that cost savings with simultaneous reduction in treatment complications and fewer days lost from work are achieved with GEA versus hysterectomy over almost all time horizons and under both the commercial payer and Medicaid perspectives. Cost-effectiveness metrics also favor GEA over hysterectomy from both the commercial payer and Medicaid payer perspectives-evidence strongly supporting the clinical-economic value about GEA versus hysterectomy. Results will interest clinicians, health care payers, and self-insured employers striving for cost-effective AUB treatments.

Surgical Management of Abnormal Uterine Bleeding in Fertile Age Women

Abnormal uterine bleeding is a common gynecological disease and represents one of the most frequent reasons for hospital admission to a specialist unit, often requiring further surgical treatment. Following the so-called PALM-COEIN system we will attempt to further clarify the surgical treatments available today. The first group (PALM) is characterized by structural lesions, which may be more appropriately treated by means of surgical management. Although hysterectomy remains the definitive and decisive choice, there are many alternative techniques available. These minimally invasive procedures offer the opportunity for a more conservative approach. Precise and accurate counseling facilitates better patient selection, based on the patient's desires, age and disease type, allowing treatment to be individually tailored to each woman.

Hysteroscopic Endometrial Resection Versus Laparoscopic Supracervical Hysterectomy for Abnormal Uterine Bleeding: Long-term Follow-up of a Randomized Trial

STUDY OBJECTIVE

To compare long-term efficacy of laparoscopic supracervical hysterectomy (LSH) and hysteroscopic endometrial ablation (HEA) in treating persistent abnormal uterine bleeding.

DESIGN

Canadian Task Force II-2.

SETTING

University hospital.

PATIENTS

One hundred fifty-three women treated for abnormal uterine bleeding by LSH or HEA.

INTERVENTION

Long-term follow-up assessment of reintervention rate and quality of life (QoL) using the Quality Metric's Health Survey Short Form 12.

MEASUREMENT AND MAIN RESULTS

This study is the long-term follow-up of a randomized control trial conducted in 2003 comparing LSH and HEA in terms of reoperation rate and QoL. Starting from November 2010 all patients included in the first trial were invited to participate in this study and clinically evaluated through vaginal examination and transvaginal ultrasound. After a mean follow-up of 14.4 years, 29% of patients (20/71) treated with HEA underwent further surgery, whereas no patients after LSH had symptom recurrence. The reintervention rate was significantly higher in the HEA group (p < .0001), with a relative risk of 1.39 (95% confidence interval, 1.20-1.61). The assessment of QoL demonstrated a higher score, in both physical and mental components, in the LSH group (p < .0001).

CONCLUSION

The lower reintervention rate and the better physical and mental health scores make LSH a more suitable procedure to treat recurrent abnormal uterine bleeding when compared with HEA.

Cost effectiveness of endometrial ablation with the NovaSure(®) system versus other global ablation modalities and hysterectomy for treatment of abnormal uterine bleeding: US commercial and Medicaid payer perspectives

OBJECTIVES

Abnormal uterine bleeding (AUB) interferes with physical, emotional, and social well-being, impacting the quality of life of more than 10 million women in the USA. Hysterectomy, the most common surgical treatment of AUB, has significant morbidity, low mortality, long recovery, and high associated health care costs. Global endometrial ablation (GEA) provides a surgical alternative with reduced morbidity, cost, and recovery time. The NovaSure(®) system utilizes unique radiofrequency impedance-based GEA technology. This study evaluated cost effectiveness of AUB treatment with NovaSure ablation versus other GEA modalities and versus hysterectomy from the US commercial and Medicaid payer perspectives.

METHODS

A health state transition (semi-Markov) model was developed using epidemiologic, clinical, and economic data from commercial and Medicaid claims database analyses, supplemented by published literature. Three hypothetical cohorts of women receiving AUB interventions were simulated over 1-, 3-, and 5-year horizons to evaluate clinical and economic outcomes for NovaSure, other GEA modalities, and hysterectomy.

RESULTS

Model analyses show lower costs for NovaSure-treated patients than for those treated with other GEA modalities or hysterectomy over all time frames under commercial payer and Medicaid perspectives. By Year 3, cost savings versus other GEA were $930 (commercial) and $3,000 (Medicaid); cost savings versus hysterectomy were $6,500 (commercial) and $8,900 (Medicaid). Coinciding with a 43%-71% reduction in need for re-ablation, there were 69%-88% fewer intervention/reintervention complications for NovaSure-treated patients versus other GEA modalities, and 82%-91% fewer versus hysterectomy. Furthermore, NovaSure-treated patients had fewer days of work absence and short-term disability. Cost-effectiveness metrics showed NovaSure treatment as economically dominant over other GEA modalities in all circumstances. With few exceptions, similar results were shown for NovaSure treatment versus hysterectomy.

CONCLUSION

Model results demonstrate strong financial favorability for NovaSure ablation versus other GEA modalities and hysterectomy from commercial and Medicaid payer perspectives. Results will interest clinicians, health care payers, and self-insured employers striving for cost-effective AUB treatments.