Tips and advice for Essure removal

July 3, 2017|ObGyn

Sarah Cohen, MD, MPH;Mark Levie, MD;And Amanda Yunker, DO

Essure tubal microinserts were not designed to be removed. However, a small minority of women are requesting removal because of regret, complications, or the development of pelvic pain and other symptoms that may or may not be caused by the device.

Minimally invasive gynecologic surgeons have developed a variety of removal procedures and techniques for these women. There is general agreement that hysteroscopic removal is feasible only in the first 3 months following insertion of the device. After that, laparoscopic removal has become the norm. Small published reports and case series have documented the use of laparoscopic bilateral salpingectomy (BS) with and without hysterectomy, laparoscopic BS with cornuectomy, and laparoscopic salpingostomy, often followed by salpingectomy. There is not yet enough data to demonstrate that one method is superior to another, and we each have our own preferred approaches for preoperative imaging and removal.

Several principles clearly guide each of us, however. One is that the outer portion of the Essure microinsert is brittle and at risk of breaking if subjected to too much tension or to electrocautery. The other is the importance both of patient counseling regarding expectations from removal and of a thorough gynecologic history and assessment for alternate etiologies of symptoms that may be overlooked.

Here is some of our advice on working with patients to assess the need for, and possible outcomes of, removal, as well as how to approach the surgery.

Counseling, assessment, and consent

Dr. Cohen: We have to be frank with our patients that symptoms may or may not improve following Essure removal. In a recently published case series of 52 women who underwent Essure removal at our institution, three-quarters of the patients reported near or total improvement in the quality of life. However, a relatively high number – roughly 30% – reported some ongoing symptoms (J Minim Invasive Gynecol. 2017 Jun 6. doi: 10:1016/j.jmig.2017.05.015).

The most common indication for Essure removal in this series was pelvic pain (96%), followed by abnormal uterine bleeding (35%) and patient-reported allergic reaction (21%). The indications were not mutually exclusive.

An Essure device is disected out of the fallopian tube.

When evaluating possible reasons for symptoms following Essure placement, I ask numerous questions: Could the patient have an infection related to the placement? That’s fairly rare, but it’s certainly possible. Are there signs of malposition or migration of the device? Could it have perforated through the uterus, for instance, or become entangled with bowel adhesions? If the symptoms are more systemic – such as headache, fatigue, nausea, and weight gain – could the patient be reacting to the polyethylene terephthalate (PET) fibers in the device?

Importantly, could endometriosis or another underlying condition have developed since placement or worsened over time? Or, could her pelvic pain be worsened because of the cessation of hormonal contraception that coincided with Essure placement, rather than the device itself? For some women, Essure removal alone will not cure their symptoms.

In our cohort of 52 women, interestingly, 44% of those with pelvic pain had one or more concomitant or alternate causes of pain, including endometriosis, adenomyosis, and adhesions.

Dr. Levie: We can’t assume that Essure coils are at fault when patients present with pain and other symptoms, nor can we minimize complaints and concerns. We have to explore them.

It’s important that we inform women that pain may not be related to Essure microinserts. However, if, after thorough evaluation, the patient believes that the coils are the etiology of her pain and I cannot find another reason – or if she has regrets or is concerned about potential problems in the future – I am happy to remove them.

The majority of women will have resolution of pain after removal, but a certain percentage – up to 25%-30% – might not. I counsel patients accordingly, and I mention that the incidence of pelvic pain and abnormal bleeding rises with age. I also inform patients that, during removal, there is a small chance that a small fragment of the device might be left behind.

Dr. Yunker: In our case series of 29 women who underwent removal for the primary indication of pelvic pain, 88.5% reported significant relief at their postoperative visit (Contraception. 2016 Aug;94[2]:190-2). This, and other unpublished data, show that patients with gynecologic complaints specifically are the most likely to have resolution of symptoms, compared with those with more systemic or nongynecologic complaints.

The timing of the onset of pain after Essure placement can vary widely, and it is possible that even correctly placed Essure coils can be a source of pain. In our group of 29 women, intraoperative findings included the presence of incorrectly placed devices and endometriosis in some. The majority, however, had no abnormal findings.

Some patients have systemic symptoms that they feel are related and new since the device was placed. My counseling in these cases is that, while I do not have any physiologic evidence that the Essure coil is causing their symptoms, I’m hopeful that symptoms will improve with removal. If they do not, these patients must follow up with their primary care doctor for further work-up.