Endometrial ablation

Endometrial ablation
Endometrial ablation
	Schematic illustration of endometrial ablation
ICD-9-CM	68.23
	[ edit on Wikidata]

Last updated August 03, 2024

Endometrial ablation is a surgical procedure that is used to remove (ablate) or destroy the endometrial lining of the uterus. The goal of the procedure is to decrease the amount of blood loss during menstrual periods. Endometrial ablation is most often employed in people with excessive menstrual bleeding, who do not wish to undergo a hysterectomy, following unsuccessful medical therapy.^[1]

Endometrial ablation is typically done in a minimally invasive manner with no external incisions. Slender tools are inserted through the vagina and into the uterus. In some forms of the procedure, one of these tools may be a camera (hysteroscope) to assist with visualization. Other tools include those that harness electricity, high-energy radio waves, heated fluids, or cold temperature to destroy the endometrial lining.^[2]

The procedure is almost always performed as an outpatient treatment, either at a hospital, ambulatory surgery center, or physician office. Patients will most commonly undergo local and/or light sedative anesthesia, or if necessary, general or spinal anesthesia.^[3]

After the procedure, the endometrium heals by scarring over, thus reducing or eliminating future uterine bleeding.^[4] The patient's hormonal functions will remain unaffected because the ovaries are left intact. Due to the uterine changes that take place after undergoing ablation, patients are unlikely to be able to become pregnant after the procedure, and of pregnancies that do occur, complication risk is high. To reduce the associated mortality risks, it is often recommended for patients to adhere to birth control methods after undergoing endometrial ablation.^[3]

Indications

The primary indication for endometrial ablation is abnormal uterine bleeding, including chronic heavy menstrual bleeding, in premenopausal patients.^[5] Typically, these are patients for whom first-line medical therapy was unsuccessful or contraindicated.^[1]

Absolute contraindications for undergoing endometrial ablation include endometrial carcinoma, current pregnancy, and desire for future pregnancy.^[4]

Preparation and planning

Prior to undergoing endometrial ablation, patients will go through a pre-procedure evaluation and risk assessment. Components of this often include informed consent, anesthesia evaluation, and a pregnancy test (as current pregnancy is a contraindication to the procedure). All patients will undergo endometrial sampling to test for endometrial carcinoma, as this is an absolute contraindication to endometrial ablation. Some patients may also require further assessment of the uterus through hysteroscopy or saline infusion sonohysterography, and/or removal of any current IUD.

Depending on the treatment that is chosen, endometrial ablation is sometimes conducted after treatment with hormones, such as norethisterone or Lupron to reduce the thickness of the endometrium.^[6]

Procedure

Endometrial ablation may be done in-office or in an operating room. The procedure begins with cervical dilation, which temporarily stretches the cervix to make room for the ablation instruments and/or hysteroscope to enter the uterus. Dilation can be induced medically with pharmacologic agents, or mechanically with a series of metal tools of increasing diameter. After sufficient dilation, the ablation instrument is introduced into the uterine cavity, which is used to partially or fully destroy the endometrial lining. A hysteroscope may be used to assist in visualization of this process and/or ensure that final results are adequate.^[7]

The technique utilized to remove or destroy the endometrium varies with endometrial ablation operations. Options consist of:

Ablation with cryotherapy – The uterus is probed with a chilled probe. The uterine lining is destroyed when the extreme cold at the probe's tip freezes it in pieces. The procedure can be monitored via ultrasound. It takes roughly six minutes to complete one freezing cycle. The size and shape of the uterus will determine how many cycles are required.^[8]
Water-thermal ablation – For roughly 10 minutes, warm fluid is delivered into the uterus. The uterine lining is destroyed by the heat. This technique has the benefit of being usable in patients who have uteri that are shaped differently due to abnormal tissue growth. Lesions inside the uterus or uterine fibroids are two conditions that can lead to the uterus becoming misshapen.^[8]
Ablation with Radiofrequency – A flexible, triangular device inside the uterus is opened using a specialized tool. The uterine lining is destroyed by radiofrequency energy released by the ablation device in 1 to 2 minutes. After that, the device is taken out of the uterus.^[8]
Ablation using Electrocautery – The uterus is visualized using a thin scope. A tool is passed through the scope, such as a wire loop, a probe with a rollerball tip, or a probe with an electrode tip. The uterine lining is removed or destroyed by the device using electric current. General anesthesia is required for electrocautery ^[8] ablation. Less frequently than other techniques, this ablation technique is employed.^[8]
Radiofrequency Ablation – The uterus is filled with a device. The uterine lining is destroyed by the device's use of microwave energy.^[8]

After the ablation procedure is complete, any concomitant procedures that patients have opted for will also be completed. A common procedure after endometrial ablation is IUD insertion, as effective contraception following endometrial ablation is highly recommended. Other concomitant procedures may include myomectomy and/or tubal ligation.^[5]

Endometrial ablation is often an outpatient procedure that does not require an overnight hospital stay. Patients may experience cramping, vaginal discharge, and/or urinary changes during the recovery process.^[9]

Technique

A number of treatment options are available, all of which work by inserting tools into the cervix to destroy the ablate the endometrium.^[10] Commonly used ablation systems include:

The NovaSure – Endometrial Ablation System, FDA approved in 2001, utilizes a metallized mesh electrode array that is introduced into the uterine cavity, applying bipolar electrical energy that creates heat to ablate the endometrium. The Novasure average procedure time is 5 minutes from device insertion to removal and is usually performed under local and/or conscious sedation anesthesia. Most patients leave the treatment center within one hour of treatment. In the Novasure randomized controlled trial for FDA approval, the success rate (i.e. bleeding reduced to a normal or less level) was 78% and amenorrhea rate (i.e. bleeding eliminated) was 36%.
The Minerva – Endometrial Ablation System, FDA approved in July 2015, is the first new FDA-approved surgical treatment for heavy menstrual bleeding in over 15 years. Minerva works by generating heat from plasma energy that is created and contained inside a leak-proof ablation array that takes the shape of the uterine cavity. The hot membrane surface of the array ablates the endometrium. The Minerva procedure is the fastest FDA approved treatment, average procedure time is 3.1 minutes from device insertion to removal, and is usually performed under local and/or conscious sedation anesthesia. Most patients leave the treatment center within one hour of treatment. In the Minerva randomized controlled trial for FDA approval, the success rate was 93% and amenorrhea rate was 72%.
The Genesys HTA – Hydro-Thermal Ablation System, FDA approved in 2001, uses a hysteroscope device which is inserted into the uterus through the cervical canal, to help doctors safely confirm proper probe placement and to see the area they are treating. In this procedure, the doctor looks at the inside of the uterus with the hysteroscope and then fills the uterus with saline fluid. The fluid is then slowly heated and the lining of the uterus is burned so that menstrual bleeding periods become less heavy and, in some cases, even stops. The fluid is then cooled and removed by special tubing to protect the external areas of the body from any burns. The average procedure time is 26 minutes. In the HTA randomized controlled trial for FDA approval, the success rate was 68% and amenorrhea rate was 35%.^[11]
The Her Option – Endometrial Ablation System, FDA approved in 2001, is a treatment that creates sub-zero temperatures to freeze and ablate the endometrium. Following the application of local anesthetic around the cervix, a physician uses ultrasound to guide the placement of a cryoprobe to the right uterine horn. The cryoprobe is activated, reducing its temperature to minus 60 °C. The cryoprobe is kept in place while ice is formed in the uterine cavity, under ultrasound observation. Once the appropriate time has passed or the appropriate depth of ice has been achieved, the cryoprobe is warmed to 37 °C. The cryoprobe is then repositioned to the untreated left uterine horn and the procedure is repeated. Finally, the cryoprobe is warmed and removed. In the Her Option randomized controlled trial for FDA approval, the success rate was 67% and amenorrhea rate was 22%.
Transcervical Resection of the Endometrium (TCRE), commonly called Loop Resection with Rollerball Ablation, utilizes a hysteroscope through which a bi-polar radio frequency electrocautery cutting loop is deployed to resect, or remove, the superficial endometrium. This is followed by a bi-polar radio frequency rollerball tool to ablate the remaining underlying endometrium via cauterization.^[12] It is a proven procedure,^[13] being an outpatient procedure with rapid recovery.^[14]
The Thermachoice III balloon, FDA approved in 1997, was taken off the market in December 2015. This system utilized a heated saline filled balloon which was inserted into the uterine cavity to ablate the endometrium. The fluid was safely contained in a flexible and non-allergenic Silastic membrane that conformed to most uterine cavity shapes and sizes.

Older methods utilize hysteroscopy to insert instruments into the uterus to destroy the lining under visualization using a laser, or microwave probe.

Effectiveness

The U.S. Food and Drug Administration approves and audits clinical studies to test and evaluate the effectiveness of all endometrial ablation treatments. Two patient effectiveness outcomes are measured at one year following treatment: 1) success rate = the % of people who have their bleeding reduced to a normal period level or less, and 2) amenorrhea rate = the % of people that have their bleeding eliminated. According to the results of the Randomized Controlled Trials performed for the FDA approval of the different treatment options, effectiveness Success Rates range from a high of 93% to a low of 67%, and the Amenorrhea Rates range from a high of 72% to a low of 22%.^[15]

Complications

Although rare, the procedure can have complications^[4] including:

Infection
Hemorrhage
Damage to the uterus (beyond the endometrial lining)
Perforation of the uterus
Hematometra
Sterilization and/or difficulty conceiving
Post-ablation tubal sterilization syndrome

Related Research Articles

Dilationand curettage (D&C) refers to the dilation of the cervix and surgical removal of sections and or layers of the lining of the uterus and or contents of the uterus such as an unwanted fetus, remains of a non viable fetus, retained placenta after birth or abortion as well as any abnormal tissue which may be in the uterus causing abnormal cycles by scraping and scooping (curettage). It is a gynecologic procedure used for treatment and removal as well as diagnostic and therapeutic purposes, and is the most commonly used method for first trimester abortion or miscarriage.

The endometrium is the inner epithelial layer, along with its mucous membrane, of the mammalian uterus. It has a basal layer and a functional layer: the basal layer contains stem cells which regenerate the functional layer. The functional layer thickens and then is shed during menstruation in humans and some other mammals, including other apes, Old World monkeys, some species of bat, the elephant shrew and the Cairo spiny mouse. In most other mammals, the endometrium is reabsorbed in the estrous cycle. During pregnancy, the glands and blood vessels in the endometrium further increase in size and number. Vascular spaces fuse and become interconnected, forming the placenta, which supplies oxygen and nutrition to the embryo and fetus. The speculated presence of an endometrial microbiota has been argued against.

The uterus or womb is the organ in the reproductive system of most female mammals, including humans, that accommodates the embryonic and fetal development of one or more embryos until birth. The uterus is a hormone-responsive sex organ that contains glands in its lining that secrete uterine milk for embryonic nourishment.

Gynecologic hemorrhage represents excessive bleeding of the female reproductive system. Such bleeding could be visible or external, namely bleeding from the vagina, or it could be internal into the pelvic cavity or form a hematoma. Normal menstruation is not considered a gynecologic hemorrhage, as it is not excessive. Hemorrhage associated with a pregnant state or during delivery is an obstetrical hemorrhage.

Hysterectomy is the surgical removal of the uterus and cervix. Supracervical hysterectomy refers to removal of the uterus while the cervix is spared. These procedures may also involve removal of the ovaries (oophorectomy), fallopian tubes (salpingectomy), and other surrounding structures. The term “partial” or “total” hysterectomy are lay-terms that incorrectly describe the addition or omission of oophorectomy at the time of hysterectomy. These procedures are usually performed by a gynecologist. Removal of the uterus renders the patient unable to bear children and has surgical risks as well as long-term effects, so the surgery is normally recommended only when other treatment options are not available or have failed. It is the second most commonly performed gynecological surgical procedure, after cesarean section, in the United States. Nearly 68 percent were performed for conditions such as endometriosis, irregular bleeding, and uterine fibroids. It is expected that the frequency of hysterectomies for non-malignant indications will continue to fall given the development of alternative treatment options.

Heavy menstrual bleeding (HMB), previously known as menorrhagia or hematomunia, is a menstrual period with excessively heavy flow. It is a type of abnormal uterine bleeding (AUB).

<span class="mw-page-title-main">Asherman's syndrome</span> Medical condition

Asherman's syndrome (AS) is an acquired uterine condition that occurs when scar tissue (adhesions) forms inside the uterus and/or the cervix. It is characterized by variable scarring inside the uterine cavity, where in many cases the front and back walls of the uterus stick to one another. AS can be the cause of menstrual disturbances, infertility, and placental abnormalities. Although the first case of intrauterine adhesion was published in 1894 by Heinrich Fritsch, it was only after 54 years that a full description of Asherman syndrome was carried out by Joseph Asherman. A number of other terms have been used to describe the condition and related conditions including: uterine/cervical atresia, traumatic uterine atrophy, sclerotic endometrium, and endometrial sclerosis.

<span class="mw-page-title-main">Adenomyosis</span> Extension of endometrial tissue into the myometrium

Adenomyosis is a medical condition characterized by the growth of cells that proliferate on the inside of the uterus (endometrium) atypically located among the cells of the uterine wall (myometrium), as a result, thickening of the uterus occurs. As well as being misplaced in patients with this condition, endometrial tissue is completely functional. The tissue thickens, sheds and bleeds during every menstrual cycle.

<span class="mw-page-title-main">Vaginal bleeding</span> Medical condition

Vaginal bleeding is any expulsion of blood from the vagina. This bleeding may originate from the uterus, vaginal wall, or cervix. Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductive system, such as abnormal uterine bleeding.

<span class="mw-page-title-main">Hysteroscopy</span> Medical procedure

Hysteroscopy is the inspection of the uterine cavity by endoscopy with access through the cervix. It allows for the diagnosis of intrauterine pathology and serves as a method for surgical intervention.

<span class="mw-page-title-main">Endometrial polyp</span> Mass on the interior lining of the uterus

An endometrial polyp or uterine polyp is a mass in the inner lining of the uterus. They may have a large flat base (sessile) or be attached to the uterus by an elongated pedicle (pedunculated). Pedunculated polyps are more common than sessile ones. They range in size from a few millimeters to several centimeters. If pedunculated, they can protrude through the cervix into the vagina. Small blood vessels may be present, particularly in large polyps.

<span class="mw-page-title-main">Uterine myomectomy</span> Surgical removal of uterine fibroid

Myomectomy, sometimes also called fibroidectomy, refers to the surgical removal of uterine leiomyomas, also known as fibroids. In contrast to a hysterectomy, the uterus remains preserved and the woman retains her reproductive potential. It still may impact hormonal regulation and the menstrual cycle.

Endometritis is inflammation of the inner lining of the uterus (endometrium). Symptoms may include fever, lower abdominal pain, and abnormal vaginal bleeding or discharge. It is the most common cause of infection after childbirth. It is also part of spectrum of diseases that make up pelvic inflammatory disease.

A menstrual disorder is characterized as any abnormal condition with regards to a woman's menstrual cycle. There are many different types of menstrual disorders that vary with signs and symptoms, including pain during menstruation, heavy bleeding, or absence of menstruation. Normal variations can occur in menstrual patterns but generally menstrual disorders can also include periods that come sooner than 21 days apart, more than 3 months apart, or last more than 10 days in duration. Variations of the menstrual cycle are mainly caused by the immaturity of the hypothalamic-pituitary-ovarian (HPO) axis, and early detection and management is required in order to minimize the possibility of complications regarding future reproductive ability.

<span class="mw-page-title-main">Implantation (embryology)</span> First stage of pregnancy

Implantation, also known as nidation, is the stage in the mammalian embryonic development in which the blastocyst hatches, attaches, adheres, and invades into the endometrium of the female's uterus. Implantation is the first stage of gestation, and, when successful, the female is considered to be pregnant. An implanted embryo is detected by the presence of increased levels of human chorionic gonadotropin (hCG) in a pregnancy test. The implanted embryo will receive oxygen and nutrients in order to grow.

The endometrial biopsy is a medical procedure that involves taking a tissue sample of the lining of the uterus. The tissue subsequently undergoes a histologic evaluation which aids the physician in forming a diagnosis.

Hematometra is a medical condition involving collection or retention of blood in the uterus. It is most commonly caused by an imperforate hymen or a transverse vaginal septum.

Hypomenorrhea or hypomenorrhoea, also known as short or scanty periods, is extremely light menstrual blood flow. It is the opposite of heavy periods or hypermenorrhea which is more properly called menorrhagia.

<span class="mw-page-title-main">Intrauterine device</span> Form of birth control involving a device placed in the uterus

An intrauterine device (IUD), also known as intrauterine contraceptive device or coil, is a small, often T-shaped birth control device that is inserted into the uterus to prevent pregnancy. IUDs are a form of long-acting reversible birth control (LARC).

Robert S. Neuwirth was an American physician, inventor, and real estate developer. Neuwirth devoted his career to crafting and refining noninvasive practices promoting women's health. He was one of the first doctors to employ endoscopy in gynecological practice, in which a small optical instrument called an endoscope is used to examine areas tucked deep into the body. He is known as the first doctor to introduce laparoscopy to the United States, in 1968.

References

1 2 Bofill Rodriguez, Magdalena; Dias, Sofia; Jordan, Vanessa; Lethaby, Anne; Lensen, Sarah F; Wise, Michelle R; Wilkinson, Jack; Brown, Julie; Farquhar, Cindy (2022-05-31). Cochrane Gynaecology and Fertility Group (ed.). "Interventions for heavy menstrual bleeding; overview of Cochrane reviews and network meta-analysis". Cochrane Database of Systematic Reviews. 2023 (2): CD013180. doi:10.1002/14651858.CD013180.pub2. PMC 9153244 . PMID 35638592.
↑ Sharp, Howard T. (October 2006). "Assessment of New Technology in the Treatment of Idiopathic Menorrhagia and Uterine Leiomyomata". Obstetrics & Gynecology. 108 (4): 990–1003. doi:10.1097/01.AOG.0000232618.26261.75. ISSN 0029-7844. PMID 17012464.
1 2 ACOG Committee on Practice Bulletins (May 2007). "ACOG Practice Bulletin No. 81: Endometrial Ablation". Obstetrics & Gynecology. 109 (5): 1233–1248. doi:10.1097/01.AOG.0000263898.22544.cd. ISSN 0029-7844. PMID 17470612.
1 2 3 Sharp, Howard T. (October 2012). "Endometrial ablation: postoperative complications". American Journal of Obstetrics and Gynecology. 207 (4): 242–247. doi:10.1016/j.ajog.2012.04.011. ISSN 1097-6868. PMID 22541856.
1 2 Practice Committee of American Society for Reproductive Medicine (November 2008). "Indications and options for endometrial ablation". Fertility and Sterility. 90 (5 Suppl): S236–240. doi: 10.1016/j.fertnstert.2008.08.059 . ISSN 1556-5653. PMID 19007637.
↑ "Endometrial Ablation". www.hopkinsmedicine.org. 19 November 2019.
↑ Glasser, Mark H. (2009). "Practical tips for office hysteroscopy and second-generation "global" endometrial ablation". Journal of Minimally Invasive Gynecology. 16 (4): 384–399. doi:10.1016/j.jmig.2009.04.002. ISSN 1553-4650. PMID 19573815.
1 2 3 4 5 6 "Endometrial ablation - Mayo Clinic". www.mayoclinic.org. Retrieved 2023-02-15.
↑ "NovaSure endometrial ablation". University of Iowa Hospitals & Clinics. Retrieved 2023-02-17.
↑ James F. Carter. "Endometrial Ablation: More Choices, More Options" (PDF). Archived from the original (PDF) on 2012-09-13. Retrieved 2012-12-19– via Boston Scientific. Edited version of the original CME article that appeared in The Female Patient. 2005; 30(12):35-40.
↑ "HTA Ablation". Centre for Women's Health – Wichita. Archived from the original on 2 January 2015. Retrieved 15 September 2014.
↑ Hysteroscopic Surgery Archived 2014-06-12 at the Wayback Machine , by King's College Hospital. August 2013
↑ Cooper, K. G.; Bain, C.; Parkin, D. E. (1999). "Comparison of microwave endometrial ablation and transcervical resection of the endometrium for treatment of heavy menstrual loss: A randomised trial". The Lancet. 354 (9193): 1859–1863. doi:10.1016/S0140-6736(99)04101-X. PMID 10584722. S2CID 25228822.
↑ Page 122 in Desai (January 2002). Gynecology Endoscopic Surgery: Current Concepts. Jaypee Brothers Publishers. ISBN 978-81-7179-937-4.^{[ permanent dead link ]}
↑ "FDA letter to Endometrial Ablation Industry" (PDF). Food and Drug Administration .

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[:0-1] 1 2 Bofill Rodriguez, Magdalena; Dias, Sofia; Jordan, Vanessa; Lethaby, Anne; Lensen, Sarah F; Wise, Michelle R; Wilkinson, Jack; Brown, Julie; Farquhar, Cindy (2022-05-31). Cochrane Gynaecology and Fertility Group (ed.). "Interventions for heavy menstrual bleeding; overview of Cochrane reviews and network meta-analysis". Cochrane Database of Systematic Reviews. 2023 (2): CD013180. doi:10.1002/14651858.CD013180.pub2. PMC 9153244 . PMID 35638592.

[2] Sharp, Howard T. (October 2006). "Assessment of New Technology in the Treatment of Idiopathic Menorrhagia and Uterine Leiomyomata". Obstetrics & Gynecology. 108 (4): 990–1003. doi:10.1097/01.AOG.0000232618.26261.75. ISSN 0029-7844. PMID 17012464.

[:1-3] 1 2 ACOG Committee on Practice Bulletins (May 2007). "ACOG Practice Bulletin No. 81: Endometrial Ablation". Obstetrics & Gynecology. 109 (5): 1233–1248. doi:10.1097/01.AOG.0000263898.22544.cd. ISSN 0029-7844. PMID 17470612.

[:2-4] 1 2 3 Sharp, Howard T. (October 2012). "Endometrial ablation: postoperative complications". American Journal of Obstetrics and Gynecology. 207 (4): 242–247. doi:10.1016/j.ajog.2012.04.011. ISSN 1097-6868. PMID 22541856.

[:3-5] 1 2 Practice Committee of American Society for Reproductive Medicine (November 2008). "Indications and options for endometrial ablation". Fertility and Sterility. 90 (5 Suppl): S236–240. doi: 10.1016/j.fertnstert.2008.08.059 . ISSN 1556-5653. PMID 19007637.

[6] "Endometrial Ablation". www.hopkinsmedicine.org. 19 November 2019.

[7] Glasser, Mark H. (2009). "Practical tips for office hysteroscopy and second-generation "global" endometrial ablation". Journal of Minimally Invasive Gynecology. 16 (4): 384–399. doi:10.1016/j.jmig.2009.04.002. ISSN 1553-4650. PMID 19573815.

[:4-8] 1 2 3 4 5 6 "Endometrial ablation - Mayo Clinic". www.mayoclinic.org. Retrieved 2023-02-15.

[9] "NovaSure endometrial ablation". University of Iowa Hospitals & Clinics. Retrieved 2023-02-17.

[10] James F. Carter. "Endometrial Ablation: More Choices, More Options" (PDF). Archived from the original (PDF) on 2012-09-13. Retrieved 2012-12-19– via Boston Scientific. Edited version of the original CME article that appeared in The Female Patient. 2005; 30(12):35-40.

[11] "HTA Ablation". Centre for Women's Health – Wichita. Archived from the original on 2 January 2015. Retrieved 15 September 2014.

[12] Hysteroscopic Surgery Archived 2014-06-12 at the Wayback Machine , by King's College Hospital. August 2013

[13] Cooper, K. G.; Bain, C.; Parkin, D. E. (1999). "Comparison of microwave endometrial ablation and transcervical resection of the endometrium for treatment of heavy menstrual loss: A randomised trial". The Lancet. 354 (9193): 1859–1863. doi:10.1016/S0140-6736(99)04101-X. PMID 10584722. S2CID 25228822.

[14] Page 122 in Desai (January 2002). Gynecology Endoscopic Surgery: Current Concepts. Jaypee Brothers Publishers. ISBN 978-81-7179-937-4.^{[ permanent dead link ]}

[15] "FDA letter to Endometrial Ablation Industry" (PDF). Food and Drug Administration .

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