Diagnosis and treatment of global endometrial ablation failure

One in seven women suffer with abnormal uterine bleeding during their reproductive years, according to Fraser et al. (Exp Rev Obstet Gynecol. 2009;4:179-89). Heavy menstrual bleeding (menorrhagia) is the most common pattern. Global endometrial ablation has become a very popular surgical technique for women complaining of menorrhagia, disinterested in either medical management or definitive therapy – hysterectomy – or where medical management has failed. With proper patient selection, endometrial ablation yields an 80%-90% success rate in reducing heavy menstrual flow and is associated with a 90% patient satisfaction rate (Cochrane Database Syst Rev. 2009 Oct 7;[4]:CD001501).

Over time however, the rate of failure increases. Failure rates between 16% at 5 years to nearly 26% at 8 years have been reported.

Literature is replete with conditions believed to increase risk of endometrial ablation failure. This list includes untreated uterine cornua, endometrial regrowth, the presence of submucous leiomyomas or polyps, abnormal uterine cavity, enlarged uterine cavity (width and/or length), endometrial ablation in a young patient, parity of five or greater, unsuspected adhesiolysis, postablation tubal sterilization syndrome, history of dysmenorrhea, smoking, obesity, prior cesarean section, previous gynecologic surgery, and procedure length. Interestingly, type of global endometrial ablation procedure or original bleeding pattern does not influence failure rate.

In this edition of the Master Class in Gynecologic Surgery, Dr. Morris Wortman discusses not only the prevention of endometrial ablation failure, but also how to treat the problem via conservative surgical management.

Dr. Wortman is a clinical associate professor of obstetrics and gynecology at the University of Rochester (N.Y.) and is the director at the Center for Menstrual Disorders and Reproductive Choice, also in Rochester. Dr. Wortman has lectured extensively on endometrial ablation and has authored several scientific articles in peer reviewed journals.
 

Dr. Miller is clinical associate professor at the University of Illinois at Chicago, and past president of the AAGL and the International Society for Gynecologic Endoscopy. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in private practice in Naperville and Schaumburg, Ill.; director of minimally invasive gynecologic surgery and the director of the AAGL/SRS fellowship in minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.; and the medical editor of this column, Master Class. He reported being a subinvestigator on a study sponsored by Channel Medsystems. Email him at obnews@frontlinemedcom.com.

Why failures occur and how to correct them

BY MORRIS WORTMAN, MD

Since the introduction almost 20 years ago of devices for nonresectoscopic – or “global” – endometrial ablation, the procedure has been widely adopted as the treatment of choice for abnormal uterine bleeding that is refractory to medical management.

Between 400,000 and 500,000 endometrial ablations are done in the United States every year in women who have completed childbearing, and it probably won’t be long before the procedure surpasses hysterectomy in prevalence for the management of abnormal bleeding.

Endometrial ablation (EA) dates back to the late 19th century, but global endometrial ablation (GEA) – its latest evolution – has offered improved safety, acceptable outcomes, and technical simplicity. Along with its success, however, has come awareness that a substantial number of women will eventually experience complications: persistent or recurrent vaginal bleeding, cyclic pelvic pain, or the inability to adequately sample the endometrium in cases of postmenopausal bleeding.

In recent years, the literature has begun to address the incidence of these delayed complications and the requirement for subsequent hysterectomy. A 2007 practice bulletin issued by the American College of Obstetricians and Gynecologists stated that hysterectomy rates within 4 years of endometrial ablation are at least 24% (Obstet Gynecol. 2007 May;109[5]:1233-48). And a study published the following year reported that 26% of 3,681 women undergoing EA at Kaiser Permanente facilities in Northern California required hysterectomy within 8 years (Obstet Gynecol. 2008 Dec;112[6]:1214-20).

It appears that the vast majority of what we now refer to as late-onset EA failures – complications attributable to EA that occur beyond a perioperative period of 1 month – will occur within 5 years. Some EA failures have occurred over 5-10 years, however, and in my practice we have seen late-onset complications occurring 17 or more years after the initial ablation.

In our practice, we are successfully managing delayed complications after GEA using ultrasound-guided reoperative hysteroscopy to fully explore the uterine cavity and excise areas of endometrial growth and other disease. In 2014, we published a retrospective review of 50 women whom we treated for delayed complications after a variety of GEA techniques; almost 90% avoided hysterectomy during a mean follow-up period of 18 months (J Minim Invasive Gynecol. 2014 Mar-Apr;21[2]:238-44).

Our experience since then has included reoperative surgery on more than 115 GEA failures. Additionally, we’ve managed 220 patients who have undergone various hysteroscopic and resectoscopic endometrial ablations, some of which date back to the use of the Nd:YAG laser in the late 1980s.

The fact that late-onset EA failures occur does not mean that hysterectomy should routinely be performed as a first-line treatment for intractable uterine bleeding. Overall, there is much more morbidity associated with hysterectomy than with EA.

What failures do suggest is that there are certain risk factors for late-onset EA complications. Our experience in treating women who have experienced late-onset EA failure has provided us with insight into who may be at greatest risk for late-onset EA failure and how patients can best be selected for the procedure. We’ve also learned more about the diagnosis of delayed complications.