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تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
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Overview of endometrial ablation

Overview of endometrial ablation
Literature review current through: Jan 2024.
This topic last updated: Jan 29, 2024.

INTRODUCTION — Patients with abnormal uterine bleeding (AUB), including heavy menstrual bleeding (HMB), have a variety of medical (eg, estrogen-progestin contraceptives, 52 mg levonorgestrel-releasing intrauterine device [LNG 52 mg IUD], high-dose oral progestins) and surgical (eg, endometrial ablation, uterine artery embolization, hysterectomy) treatment options. Endometrial ablation (the surgical destruction of the uterine lining) has become an increasingly popular treatment; it is minimally invasive, successful ablation avoids chronic use of medications, and its use has led to a decrease in other surgical interventions (eg, dilation and curettage, hysterectomy) [1]. However, it is not appropriate for some patients (eg, patients with endometrial hyperplasia or carcinoma, patients desiring future childbearing). In addition, endometrial ablation is often not used as initial management; in the United States, one cost-effective approach to the management of AUB is to start with the LNG 52 mg and, if unsuccessful, follow with endometrial ablation and, lastly, hysterectomy.

Endometrial ablation can be performed using a non-resectoscopic ablation device (which is inserted into the uterine cavity and delivers energy to uniformly destroy the uterine lining) or under hysteroscopic visualization using resectoscopic instruments (to ablate or resect the endometrium). Non-resectoscopic endometrial ablation (NREA) techniques are more widely practiced than resectoscopic ablation (REA) techniques, since they require less specialized training and often have a shorter operative time [2].

This topic will provide an overview of endometrial ablation. Other related topics are discussed separately:

Techniques for NREA (see "Endometrial ablation: Non-resectoscopic techniques")

Techniques for REA (see "Endometrial ablation or resection: Resectoscopic techniques")

Management of AUB (see "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Management")

TERMINOLOGY — Terminology used to describe endometrial ablation varies. In this topic review, the following terms will be used:

Endometrial ablation – Surgical destruction of the endometrium. The endometrium must be destroyed or resected to the level of the basalis (figure 1), which is approximately 4 to 6 mm deep, depending on the stage of the menstrual cycle. In this topic review, endometrial ablation will refer to either NREA or REA, or resection of the endometrium.

Non-resectoscopic endometrial ablation (NREA) – Endometrial ablation is performed with a disposable device which is inserted into the uterine cavity and delivers energy to uniformly destroy the uterine lining. Non-resectoscopic technologies approved by the US Food and Drug Administration (FDA) and available for use in the United States include bipolar radiofrequency (NovaSure), cryotherapy (Cerene), circulating hot water (Hydro ThermAblator), a combined thermal and bipolar radiofrequency (Minerva), and vapor ablation (Mara). These techniques are also referred to as global or second-generation ablation.

Other non-resectoscopic technologies, including cryotherapy (Her Option), the hot liquid-filled balloon (ThermaChoice), and microwave (Microwave Endometrial Ablation), are not clinically available in the United States.

These devices are described in detail separately. (See "Endometrial ablation: Non-resectoscopic techniques".)

Resectoscopic endometrial ablation (REA) – Endometrial ablation or resection performed under hysteroscopic visualization with resectoscopic electrosurgical instruments (eg, rollerball, wire loop, vaporizing electrode) or with laser. Endometrial resection is often referred to as transcervical resection of the endometrium. Resectoscopic ablation methods are also referred to as standard or first-generation ablation. The term hysteroscopic ablation is also sometimes used for these methods; however, this designation would also include the circulating hot water non-resectoscopic technique, since it involves instilling water through a hysteroscope.

These devices are described in detail separately. (See "Endometrial ablation or resection: Resectoscopic techniques".)

PATIENT SELECTION

Indications — The primary indication for endometrial ablation is treatment of chronic heavy menstrual bleeding (HMB) in premenopausal patients. It may also be used for acute AUB in hemodynamically stable patients in whom medical therapy is contraindicated or unsuccessful. (See "Managing an episode of acute uterine bleeding", section on 'Surgical management'.)

Ablation in premenopausal patients with anovulatory bleeding or postmenopausal patients is discussed below. (See 'Relative contraindications' below.)

Absolute contraindications — Endometrial ablation is contraindicated in patients with the following conditions or characteristics [3,4]:

Endometrial hyperplasia or carcinoma – Endometrial ablation is not a treatment for endometrial hyperplasia or carcinoma. (See "Endometrial hyperplasia: Management and prognosis" and "Overview of resectable endometrial carcinoma".)

Endometrial ablation itself does not increase the risk of subsequent endometrial carcinoma [5,6], but data are limited. A population-based study of nationwide data from Finland from 1997 to 2014 that compared 5484 patients who underwent endometrial ablation with age-matched controls; mean follow-up was 7.3 years [7]. The age range was 30 to 49 years and mean age at ablation was 42.4±4.4 years. In the ablation group, only three patients developed endometrial carcinoma (0.05 percent) and the incidence was lower than among controls (standardized incidence ratio 0.56, 95% CI 0.12-1.64). Two of the cases were early stage and one was unknown stage. The overall rate of endometrial hyperplasia was not reported, but among the 1086 patients who underwent hysterectomy after ablation, hyperplasia was the indication in 20 (1.8 percent). It is somewhat reassuring that the endometrial carcinomas were detected at an early stage, but there were so few events that more study is needed regarding whether ablation results in a delay in diagnosis.

Endometrial ablation may interfere with subsequent evaluation of the endometrium. This is discussed in more detail below. (See 'Evaluation' below.)

Current pregnancy

Desire to preserve fertility – Pregnancy is contraindicated following endometrial ablation since the destruction of the endometrium may result in abnormal implantation or placentation [8,9]. (See 'Pregnancy after ablation' below.)

However, endometrial ablation does not prevent pregnancy. Thus, patients must be counseled that contraception is necessary following the procedure, and some patients choose to undergo concomitant ablation and sterilization. (See 'Permanent contraception' below.)

Active pelvic infection

Current use of intrauterine device (IUD) – Placement of an IUD concomitant with, or following, endometrial ablation is discussed in detail below. (See 'Intrauterine device insertion' below.)

Relative contraindications — Relative contraindications for endometrial ablation include:

Risk factors for endometrial carcinoma – The safety of endometrial ablation has not been well studied in patients who do not currently have, but are at increased risk of developing, endometrial carcinoma (table 1). In the absence of high-quality data, the decision to perform endometrial ablation in such patients depends mainly on three factors: the degree to which endometrial ablation may limit future diagnosis of malignancy, the magnitude of the risk of endometrial carcinoma, and the feasibility of other therapeutic options.

Such patient groups include (see "Endometrial carcinoma: Epidemiology, risk factors, and prevention", section on 'Risk factors'):

Chronic anovulation – Patients with chronic anovulation are at increased risk of endometrial hyperplasia and carcinoma [10-12], and often have other comorbidities (eg, obesity, diabetes, hypertension) that further increase this risk, limit the use of other medical therapies (eg, steroid hormones, antifibrinolytics), or increase the risk of complications of major surgery.

For such patients, correction of anovulation is the optimal approach to treatment. In patients in whom correction of anovulation is not possible, other treatment options (eg, progestins) are preferable to endometrial ablation until ovulation is reestablished or menopause occurs. (See "Treatment of polycystic ovary syndrome in adults", section on 'Menstrual dysfunction'.)

Obesity – There are few data about endometrial ablation in patients with obesity. In one study including 968 patients undergoing endometrial ablation for AUB with an etiology that was endometrial (AUB-E) or ovulatory dysfunction (AUB-O) (figure 2), patients with body mass index (BMI) ≥30 kg/m2 compared with <30 kg/m2 had higher rates of treatment failure (adjusted odds ratio [OR] 1.8, 95% CI 1.2-2.7) [13].

Tamoxifen – We suggest not performing endometrial ablation in patients who are taking tamoxifen; residual endometrium remains after endometrial ablation and uterine cavity assessment with office biopsy or sonohysterography after uterine ablation is difficult. (See 'Evaluation' below.)

There are few data regarding endometrial ablation in such patients [14-17]. In a series of 16 patients treated with endometrial resection while being treated with tamoxifen for breast cancer, amenorrhea occurred in all patients and there was no evidence of endometrial hyperplasia or carcinoma at a median follow-up of seven years (range 2 to 13 years) [17]. However, this is a small sample size, and biopsy may be difficult after endometrial resection.

Lynch syndrome – Patients with Lynch syndrome (hereditary nonpolyposis colorectal cancer) are at a markedly increased risk of endometrial carcinoma and are advised to undergo hysterectomy after they have completed childbearing. Thus, AUB in this population should not be treated with endometrial ablation. (See "Lynch syndrome (hereditary nonpolyposis colorectal cancer): Screening and prevention of endometrial and ovarian cancer".)

Postmenopausal patients – We do not perform endometrial ablation in postmenopausal patients, which is consistent with guidelines from the American Society for Reproductive Medicine and American College of Obstetricians and Gynecologists [4,18].

Postmenopausal bleeding requires diagnostic evaluation of the endometrium to exclude malignancy, which may be more difficult following endometrial ablation (see 'Absolute contraindications' above). There are also no data regarding the sonographic appearance of the endometrium in postmenopausal patients following endometrial ablation. (See 'Endometrial sampling' below and "Overview of the evaluation of the endometrium for malignant or premalignant disease".)

In postmenopausal patients with bleeding due to benign causes, management is often expectant or with etiology specific treatment (eg, removal of an endometrial polyp, use of a continuous rather than cyclic regimen for hormone therapy). Given these other options, it does not appear that the benefit of endometrial ablation outweighs the risk of a missed diagnosis of endometrial carcinoma in postmenopausal patients. (See "Approach to the patient with postmenopausal uterine bleeding".)

While endometrial ablation has been described in such patients (mostly in those with persistent bleeding while on postmenopausal hormone therapy), these prospective series have included fewer than 50 subjects and most patients were followed for less than five years [19].

Patients desiring amenorrhea – Endometrial ablation is not indicated for patients who wish to be amenorrheic for nonmedical reasons; in fact, many patients do not develop amenorrhea after ablation [3]. (See 'Outcomes' below and "Hormonal contraception for menstrual suppression".)

Myometrial thinning following uterine surgery – Endometrial ablation in patients with thinning of the anterior wall of the myometrium may result in injury to the adjacent viscera (ie, bladder, bowel) if the energy used for ablation passes through the uterine tissue [20,21]. Thinning of the myometrium is usually due to a prior uterine surgery (eg, cesarean delivery, myomectomy).

There are no data to establish the minimum myometrial thickness required to prevent complications. As NREA typically ablates 4 to 6 mm into tissue, our practice is to avoid performing NREA in cases where there is known thin tissue (eg, presence of an isthmocele in the lower uterine segment); surgeons should use clinical judgment to assess the risk of thermal injury when offering NREA to a patient with a history of cesarean birth or transmural myomectomy. Instructions for use of the manufacturer of the Microwave Endometrial Ablation system (not available in the United States) are even more stringent and advise a minimum myometrial thickness of 10 mm as documented by ultrasound; reports of thermal injury to adjacent structures in patients with no uterine perforation were reported when this device was first introduced [22]. By contrast, REA may be used in patients with myometrial thinning (especially at the level of a prior lower uterine segment scar), as this area can be avoided with resectoscopic instruments.

Rates of complications appear to be similar for patients with and without a prior cesarean birth [23]. In a retrospective cohort study including over 700 patients with HMB treated with endometrial ablation, patients with a history of one or more cesarean births (23 percent) compared with no cesarean births had similar rates of operative complications and treatment failure [24]. Myometrial thickness was not measured.

Evaluation of myometrial thickness is discussed below. (See 'Assessment of the uterus' below.)

Uterine anomalies – Endometrial ablation should generally be avoided in patients with congenital anomalies of the uterus (eg, septum, unicornuate uterus).

While there are case reports of NREA in patients with a bicornuate uterus, this is not standard practice [25,26]. Some surgeons with advanced hysteroscopic skills may be able to safely and successfully perform ablation in patients with uterine anomalies using REA techniques or with NREA devices such as the hydrothermablator.

Factors associated with treatment failure — In patients with certain characteristics, endometrial ablation may not be as safe or effective as other therapeutic options.

Large cavity size – In patients with a large uterus on pelvic examination (>10 weeks size), it is prudent to sound the uterus to assess cavity depth prior to planning an endometrial ablation, as ablation may be incomplete in patients with a cavity larger than the device's set maximum sounding length. Successful improvement of uterine bleeding symptoms has been reported following partial ablation with REA or resection, but not for NREA techniques [27,28].

Each NREA device can accommodate a different minimum (4 to 6 cm) and maximum (10 to 12 cm) uterine cavity size. The cavity sizes for each device are listed in the table (table 2).

Cavity size is less important for REA, but operative duration, irrigation fluid absorption, and potential blood loss make these methods impractical in patients with a uterus >12 weeks size.

Adenomyosis – Uterine adenomyosis is not a contraindication to endometrial ablation, although patients with this condition may have a lower treatment success rate. In a retrospective study of 816 patients who were followed for five years after endometrial ablation, patients with versus without a preoperative ultrasound suggestive of adenomyosis had a 1.7-fold increased risk of subsequent hysterectomy or repeat endometrial ablation [29].

Grand multiparity – Grand multiparity appears to be a risk factor for treatment failure. In the retrospective study of 816 patients described above, patients with a parity of ≥5 compared with <5 had a sixfold increased risk of subsequent repeat endometrial ablation or hysterectomy [29].

Intracavitary lesions

Fibroids – Endometrial ablation in patients with intracavitary (submucosal or intramural myomas that protrude into the uterine cavity) fibroids is controversial. The presence of a lesion protruding into the uterine cavity may interfere with the function of some ablation devices, and ablation procedures do not remove or shrink fibroids. In addition, at least one study found no histologic effect on leiomyomas following bipolar radiofrequency endometrial ablation [30]. However, fibroids are a common etiology of AUB, and NREA is a less challenging procedure than hysteroscopic myomectomy; thus surgeons may desire to perform ablation for patients with an isolated intracavitary fibroid.

NREA techniques are not explicitly approved by the US Food and Drug Administration (FDA) for use with submucosal fibroids, although this patient population was included in the approval studies for some of the devices [31,32]. Thus, when performing NREA in patients with intracavitary fibroids, the surgeon should obtain informed consent regarding off-label use of the device.

REA can usually be performed in patients with small intracavitary fibroids, or alternatively, a concomitant hysteroscopic myomectomy may be appropriate. (See 'Hysteroscopic myomectomy' below.)

Outcomes of patients with intracavitary fibroids undergoing endometrial ablation are conflicting.

-Comparative data show that NREA devices are less effective in patients with intracavitary fibroids than in those with a normal uterine cavity [33-36]. As an example, in a retrospective cohort study of patients who underwent Hydro ThermAblator procedures, patients with submucosal fibroids (1 to 4 cm) compared with controls had higher rates of HMB (12 versus 3 percent) and hysterectomy (12 versus 1 percent) at an average of 5.8 years postoperatively [34].

-In a prospective single-arm study including patients with fibroids up to 3 cm who underwent bipolar radiofrequency ablation, 95 percent had improvement in uterine bleeding at one-year [37].

-In a randomized trial including patients with HMB and uterine fibroids, those treated with thermal balloon (45 patients) compared with rollerball ablation (48 patients), had statistically significant and similar reductions in menstrual bleeding; more intraoperative complications occurred in the rollerball ablation group [38]. Further study is needed to establish which of the NREA devices can be used in patients with intracavitary fibroids and appropriate criteria for such use.

Polyps – Endometrial polyps also distort the uterine cavity and may interfere with some ablation devices [39]. As such, endometrial polyps are typically removed prior to endometrial ablation. However, patients with endometrial polyps were included in the FDA approval studies for the Microwave Endometrial Ablation device, NovaSure, Cerene cryoablation, and ThermaChoice hot liquid-filled balloon [32,40,41]. (See "Endometrial polyps".)

Younger age – While there is no minimum age requirement for endometrial ablation, it is seldom used in patients <30 to 35 years given higher rates of treatment failure in such patients [42,43]. In one retrospective study including 1169 premenopausal patients who underwent endometrial ablation, those who subsequently underwent hysterectomy compared with no hysterectomy were younger (mean age 39 and 41.4 years, respectively); the majority (80 percent) of hysterectomies occurred within the first three years after ablation [44].

Acute retro- or anteflexion or retro- or anteversion of the uterus – In patients with acute retro- or anteflexion or retro- or anteversion, incomplete ablation may result if the fundus cannot be reached with the ablation device. Thus, REA rather than NREA may be preferable in such patients. (See 'Choosing the type of ablation' below.)

CHOOSING THE TYPE OF ABLATION — NREA is performed in most cases of endometrial ablation; however, the choice must be individualized to the patient and the surgeon's familiarity with the procedure. Both approaches to endometrial ablation result in comparable rates of amenorrhea and patient satisfaction. (See 'Outcomes' below.)

Advantages of NREA include:

Less frequent use of general anesthesia [45].

Shorter operative duration [45].

Decreased risk of some surgical complications (eg, irrigation fluid overload) [45].

Technical skill requirements tend to be less of a barrier; many surgeons are more experienced with NREA techniques. However, it is useful for a gynecologist who performs endometrial ablation to be trained in both NREA and REA techniques.

Disadvantages of NREA:

Higher incidence of equipment failure [45].

NREA techniques are generally more costly per procedure than REA, mostly because of the additional cost of disposable materials. However, NREA procedures are more commonly performed under local anesthesia and/or in an office setting, which offset the equipment costs. In addition, in cost-utility model studies from the United Kingdom, microwave and hot liquid-filled balloon compared with REA were less expensive and accrued more quality adjusted life years [46,47]. It is important to note that cost-utility calculations may vary in different health care settings.

Thus, in our practice, we typically perform REA only for patients with any of the following (algorithm 1):

A uterine cavity shape (eg, acute retro- or anteflexion) or size (eg, >10 weeks) that will not accommodate an NREA device. For such patients, incomplete ablation may result if the fundus cannot be reached with an NREA device. (See 'Factors associated with treatment failure' above.)

A concomitant procedure (eg, submucous fibroid resection) is planned. (See 'Concomitant procedures' below.)

A history of multiple cesarean births or myometrial procedures (to avoid ablating over the hysterotomy scar). (See 'Relative contraindications' above.)

Prior endometrial ablation in whom a repeat endometrial ablation is planned. (See 'Repeat endometrial ablation' below.)

PREOPERATIVE EVALUATION AND PREPARATION — Preoperative evaluation, including perioperative risk assessment, and preparation are generally the same for endometrial ablation as for hysteroscopy. Pregnancy testing is performed; cervical cultures are appropriate if cervicitis is suspected. (See "Overview of hysteroscopy", section on 'Preoperative evaluation and preparation'.)

Aspects of the preoperative evaluation and preparation specific to endometrial ablation are reviewed here.

Informed consent — Patients who are considering endometrial ablation should be counseled about other medical, interventional radiologic, and surgical options for treatment. (See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Management".)

It is important to advise patients that a successful result is most likely to be a reduction in the volume of uterine bleeding, and amenorrhea is not guaranteed. In addition, endometrial ablation does not regulate bleeding in patients with irregular patterns. The risks of persistent or recurrent heavy menstrual bleeding (HMB) and of surgical complications should be reviewed (see 'Outcomes' below and 'Complications' below). This discussion should be documented on the surgical consent form and in the medical record.

Endometrial sampling — Endometrial sampling is performed in all patients prior to endometrial ablation to exclude endometrial hyperplasia or carcinoma. Ideally, this should be performed with enough time to receive the results and cancel the procedure, if neoplasia is found. However, if sampling has not yet been performed by the day of the procedure, it should be done just prior to the ablation.

Assessment of the uterus — The uterine cavity should be assessed for the presence of intracavitary lesions (eg, myomas, endometrial polyps), or other abnormalities (eg, uterine septum) that may interfere with endometrial ablation or that can be removed concomitantly (see 'Patient selection' above and 'Hysteroscopic myomectomy' below). We use saline infusion sonography (SIS) or office hysteroscopy to assess the uterine cavity. Transvaginal ultrasound (TVUS) alone can identify uterine lesions but does not define the contour of the cavity.

Patients with a history of transmural uterine surgery (eg, cesarean birth, myomectomy) should also be evaluated for myometrial thinning (see 'Relative contraindications' above). For such patients, we use SIS. Alternatively, office hysteroscopy may be combined with TVUS.

For patients with a large uterus (>10 weeks size), the cavity depth should also be assessed. (See 'Factors associated with treatment failure' above.)

Endometrial preparation — Endometrial preparation with hormonal agents (to thin the endometrium and facilitate tissue destruction) is used prior to some REA and NREA procedures [31,32,41,48]. Methods that do not require hormonal suppression (either no endometrial preparation or nonhormonal preparation) offer the advantages of avoiding the one- to two-month pretreatment time and drug-related adverse effects (eg, menopausal symptoms).

Techniques that do not require endometrial preparation – Due to the expense, side effects, and delay of surgery, we prefer techniques that do not require preoperative thinning (eg, radiofrequency ablation); these include:

Bipolar radiofrequency ablation (NovaSure) – This technique does not require pretreatment since the device adjusts to differing tissue depths [49].

Combined thermal and bipolar radiofrequency device (Minerva) – This technique may be performed during either the proliferative or secretory phase of the cycle.

Cryoablation device (Cerene) – While medications to thin the endometrial lining may be used, the procedure also can be performed in the early proliferative phase of the menstrual cycle without endometrial preparation.

Endometrial resection.

Techniques that require endometrial preparation – For techniques that require endometrial preparation, hormonal suppression with a gonadotropin-releasing hormone (GnRH) agonist (eg, intramuscular leuprolide 3.75 mg/month initiated 30 to 60 days prior to the procedure) is the most studied method [18]. The benefits of hormonal suppression are well established for REA but not for NREA techniques. In a meta-analysis of 12 randomized trials of mostly REA or endometrial resection (one trial used hot liquid-filled balloon ablation), patients receiving pretreatment with a GnRH agonist compared with placebo or no pretreatment had a shorter operative duration (an average of 4.8 minutes shorter) [3]. At one year after surgery, patients in the GnRH agonist group compared with the no treatment group had lower rates of moderate or heavy menstrual bleeding (relative risk [RR] 0.7, 95% CI 0.6-0.9) and higher rates of amenorrhea (RR 1.6, 95% CI 1.2-2).

The effectiveness of other hormonal agents is less certain:

Use of progestins (eg, oral medroxyprogesterone acetate [MPA] 15 mg daily) instead of GnRH agonists offers the advantage of fewer adverse effects (eg, menopausal symptoms). Randomized trials comparing progestins or danazol with GnRH agonists have found similar improvement in postablation uterine bleeding; however, these trials lacked statistical power [50,51]. We prefer not to use danazol, since it is poorly tolerated by most patients.

There are few data regarding endometrial preparation with estrogen-progestin contraceptives or GnRH antagonists.

Nonhormonal methods of preparation include performing the procedure during the follicular phase of the menstrual cycle and uterine curettage [52]. Randomized trials and observational data suggest that hot liquid balloon and microwave ablation may be performed successfully using alternative methods (eg, curettage or timing during the follicular phase of the menstrual cycle) [53-56]. As an example, five-year follow-up from a randomized trial of microwave endometrial ablation showed that patients in whom the procedure was scheduled after menses compared with those who had preprocedure hormonal suppression had no significant differences in rates of amenorrhea (84 and 87 percent) or hysterectomy (11 and 6 percent) [56]. Further study of this issue is needed.

PERIOPERATIVE ISSUES

Antibiotic prophylaxis — Antibiotics are not routinely administered prior to endometrial ablation for prevention of surgical site infection or endocarditis since postablation infection is rare. (See "Overview of hysteroscopy", section on 'Preoperative evaluation and preparation'.)

Anesthesia — General principles of anesthesia for endometrial ablation are the same as for operative hysteroscopy procedures. (See "Overview of hysteroscopy", section on 'Pain management'.)

Issues specific to endometrial ablation are described here.

NREA techniques – NREA can be performed using local, regional, or general anesthesia [18,57,58]. For procedures under local (eg, intracervical, paracervical, intrauterine) anesthesia , some surgeons also offer patients oral or intravenous procedural sedation (see "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications"). In a review of 25 studies involving 2013 patients undergoing endometrial ablation under local anesthesia, acceptability rates were high (77 to 94 percent) [59].

Administration of an oral nonsteroidal anti-inflammatory drug (NSAID) at least one hour preoperatively is recommended by most NREA device manufacturers [18,49,60-63]. NSAIDs may be useful to inhibit uterine contractions; however, in patients receiving local anesthesia, randomized trial data show that NSAIDs given prior to operative hysteroscopy reduce postoperative, but not intraoperative, pain. (See "Overview of hysteroscopy", section on 'Pain management'.)

REA techniques – REA ablation is usually performed with regional or general anesthesia. While there are reports of performing this type of ablation using local anesthesia, in our clinical experience, it is not well tolerated.

Operative setting

NREA techniques – NREA can be performed as an office-based procedure [64,65], and offers the advantages of a familiar setting for the patient, easier scheduling, and lower procedural costs. The disadvantages of the office setting are the inability to switch to general anesthesia if the patient is not tolerating the procedure and the need to transfer the patient to an operating room if complications occur.

Candidates for office surgery should be at low risk for surgical or anesthesia complications. Physicians who offer ablation in the office need to be trained in administering and responding to complications of procedural sedation; assisting personnel must also be trained appropriately [66]. Emergency equipment must be available (eg, updated emergency cart, pulse oximeter, oxygen, wall suction) and protocols to handle rare complications such as local anesthesia toxicity, excessive bleeding, uterine perforation, allergic reactions, or severe vagal reactions. (See "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications".)

REA techniques – REA is performed in the operating room, since it typically requires regional or general anesthesia and close monitoring of irrigation fluid absorption. For laser techniques, the expense and size of the equipment preclude office use.

Concomitant procedures

Hysteroscopic myomectomy — In patients who have a submucosal leiomyoma, some surgeons perform a hysteroscopic myomectomy immediately followed by endometrial ablation [67,68]. If a combined procedure is performed, it is prudent to perform the myomectomy followed by REA or resection rather than NREA [69]. This is because REA and resection are performed under direct visualization, and the operator can avoid desiccating or resecting the endometrium or exposed myometrium that were attached to the myoma, which may avoid the spread of energy through areas of thin myometrium.

NREA devices have not been approved by the United States Food and Drug Administration (FDA) for concomitant use with hysteroscopic myomectomy; the manufacturer of the microwave endometrial ablation system (though not clinically available in the United States) states that surgery that thins the myometrium should not be performed concurrently with ablation [61]. In addition, there are no safety data on the use of NREA techniques in patients having a concurrent hysteroscopic myomectomy.

It is uncertain whether a combined procedure is more effective at improving uterine bleeding symptoms than myomectomy alone and a combined procedure may neither increase nor decrease the rate of subsequent hysterectomy [70,71]. The only comparative study that evaluated myomectomy alone versus in combination with ablation was a retrospective cohort study of 177 patients with submucosal fibroids and abnormal uterine bleeding (AUB); the combination of hysteroscopic myomectomy with endometrial ablation (rollerball or rollerbarrel method) or resection was associated with a greater improvement in bleeding symptoms than myomectomy alone (96 versus 81 percent) [71]. Further study is needed to establish whether a combined procedure impacts control of bleeding symptoms or operative complications.

Hysteroscopic myomectomy is discussed separately. (See "Uterine fibroids (leiomyomas): Hysteroscopic myomectomy".)

Permanent contraception — Laparoscopic permanent contraception can be performed concurrent with, or subsequent to, an ablation procedure, but there appears to be an increased risk of symptomatic cornual hematometra (also referred to as postablation tubal sterilization syndrome [PATSS] [72]). Concomitant endometrial ablation and hysteroscopic permanent contraception was also performed when hysteroscopic permanent contraception devices were available; the primary manufacturer of these devices stopped production in 2018. (See "Hysteroscopic female permanent contraception".)

Proposed etiologies for cornual hematometra include bleeding from active endometrium that is trapped in the uterine cornua and/or uterine contracture with intrauterine scarring. Central hematometra is most likely to occur when the cervical canal is damaged at the time of ablation; this is discussed in detail below. (See 'Complications' below.)

The incidence of PATSS is estimated to be as high as 10 percent [73], and usually develops two to three years after endometrial ablation [74].

The typical presentation is cyclic or intermittent pelvic pain (with or without vaginal bleeding) and a history of endometrial ablation and permanent contraception. Ultrasound has not been reliably sensitive at diagnosing PATSS and magnetic resonance imaging (MRI) during times of symptomatic cramping may be useful using T2 weighted images looking for corneal blood. Central hematometra can usually be seen on imaging (ultrasound or MRI).

Confirmatory diagnosis is made surgically. The definitive treatment of PATSS is hysterectomy [75]. Cervical dilation with hysteroscopic lysis of adhesions is possible but difficult to perform in the cornual regions and is not reliably effective. In addition, some surgeons assess patients with these symptoms laparoscopically and excise the tubal stumps to prevent the distension of the proximal tubal segments during menses. By contrast, central hematometra can usually be treated with cervical dilatation. In some cases, hysteroscopic adhesiolysis is also necessary. (See 'Complications' below.)

Intrauterine device insertion — Endometrial ablation/resection with concomitant insertion of a 52 mg levonorgestrel-releasing IUD (LNG 52 mg IUD) appears to be safe and result in a high rate of amenorrhea [76-81]. In a systematic review of six retrospective studies and one case study, those undergoing endometrial ablation/resection plus LNG 52 mg IUD (427 patients) versus either procedure alone had lower rates of hysterectomy (0 to 11 versus 9 to 24 percent, respectively) and reintervention during the 6 to 55 month follow-up period [82]. Rates of amenorrhea and patient satisfaction appeared higher in the combined treatment group; complication rates were similar between groups.

However, as data are limited and the safety of this combination of procedures is not well established, decisions regarding use of an IUD following endometrial ablation/resection should be individualized.

COMPLICATIONS — The most common complications associated with endometrial ablation are uterine perforation, hemorrhage, hematometra, and pelvic infection.

Uterine perforation – The risk of uterine perforation may be lower in patients undergoing NREA compared with REA, but the risk is overall low. In a meta-analysis of 21 randomized trials, uterine perforation occurred in 0.4 percent of NREA and 1.3 percent of REA procedures [83]. The evaluation and management of uterine perforation are discussed separately. (See "Uterine perforation during gynecologic procedures".)

Hemorrhage – Perioperative hemorrhage has been reported in 1.2 percent of patients undergoing NREA and 3 percent of those undergoing REA [45]. Evaluation and management of hemorrhage are the same as for hysteroscopic procedures. (See "Overview of hysteroscopy", section on 'Hemorrhage'.)

Hematometra – Intrauterine scarring is an expected result of endometrial ablation. When areas of endometrium are adherent and there is endometrial bleeding behind the occlusion, hematometra will occur. The reported rate of hematometra in NREA is 0.9 percent and is 2.4 percent in REA [45].

Hematometra should be suspected in a patient with a history of an endometrial ablation who presents with amenorrhea and cyclic pain, even remote from the procedure [84]. In a retrospective study including 19 patients undergoing hysterectomy for symptoms of postablation pain, hematometra was present in 5 patients (26 percent) [85]. Hematometra can be diagnosed with the visualization of pockets of echogenic fluid in the uterine cavity on transvaginal ultrasound.

Uterine cavity occlusion is likely to occur in the cervical canal or at the most narrow portion of the endometrial cavity, the lower uterine segment. Thus, ablation of the cervix or cervico-uterine junction should be avoided. Complete ablation of the uterine fundus, cornua, and tubal ostia also help avoid accumulation of blood from active endometrium.

Cervical stenosis is treated with cervical dilation. Adhesions in the mid- to upper uterine cavity can be lysed under hysteroscopic guidance. For persistent pain caused by hematometra despite minimally invasive treatment, hysterectomy may be indicated. (See "Intrauterine adhesions: Clinical manifestation and diagnosis".)

Symptomatic cornual hematometra (also referred to as postablation tubal sterilization syndrome [PATSS]) can occur in patients with both endometrial ablation and permanent contraception (ie, tubal occlusion). This is discussed in detail above. (See 'Permanent contraception' above.)

Infection – Fever occurs in the immediate postoperative period in approximately 1 percent of patients who have undergone endometrial ablation [45]. In this meta-analysis, the incidence of infectious complications included endometritis (1.4 to 2.0 percent), pelvic inflammatory disease (1.1 percent), pelvic abscess (0 to 1.1 percent), and myometritis (0 to 0.9 percent) [45]. Evaluation and management of these infections are discussed separately. (See "Endometritis unrelated to pregnancy" and "Pelvic inflammatory disease: Treatment in adults and adolescents" and "Epidemiology, clinical manifestations, and diagnosis of tubo-ovarian abscess".)

Other – NREA compared with REA is associated with lower rates of irrigation fluid overload (0 versus 0.3 percent, OR 0.2, 95% CI 0.04-0.8) and cervical laceration (0.2 versus 2.2 percent, OR 0.2, 95% CI 0.1-0.6) [45]. The risk of fluid overload with REA can be reduced if a bipolar resectoscopic device that will allow the use of saline is chosen.

Major complications are rare. In the United States, the US Food and Drug Administration (FDA) has a reporting system for NREA complications. From 1990 to 2011, bowel injury (128 cases reported from 2005 to 2011) was the complication most commonly reported to the Manufacturer and User Facility Device (MAUDE) database [86-88]. Circulating hot water ablation, in particular, was associated with burns to the vagina and perineum. Other major complications that were rarely reported included: urinary tract injury, perioperative hysterectomy, carbon dioxide embolism, necrotizing fasciitis, and death. It is not possible to calculate the rate of complications from these data, since the total number of procedures performed is not known.

Complications related to operative hysteroscopy are discussed in more detail separately. (See "Overview of hysteroscopy", section on 'Complications'.)

OUTCOMES

NREA versus REA — Outcomes for NREA and REA are discussed here and separate data regarding procedure type are provided, where available. Outcomes for specific procedures (eg, rollerball ablation, cryoablation) are discussed separately. (See "Endometrial ablation: Non-resectoscopic techniques" and "Endometrial ablation or resection: Resectoscopic techniques".)

Improvement in bleeding symptoms – Most patients with successful ablation will have a reduction in menstrual blood flow, but not amenorrhea. As patients may experience irregular bleeding following endometrial ablation, the success of the procedure cannot be determined until 8 to 12 weeks postoperatively. In addition, there is variability across studies in whether menstrual blood loss was measured and the method used (eg, alkaline hematin method, pictorial blood assessment chart) [89-91]; thus, other measures (eg, rates of amenorrhea, patient satisfaction, subsequent surgery) are more commonly used to assess treatment success.

Improvement of bleeding is similar for NREA and REA techniques. In a meta-analysis of randomized trials evaluating outcomes following endometrial ablation, NREA compared with REA techniques resulted in similar reductions in menstrual blood flow (mean rank 2.2 and 2.8, respectively) [92]. Rates of amenorrhea also appear to be similar [45,92]. However, the Minerva device (NREA technique) may have higher rates of amenorrhea compared with REA techniques. In a multi-center randomized trial including 153 patients, patients undergoing Minerva compared with rollerball ablation had higher one-year amenorrhea rates (71.7 versus 49 percent, respectively) [93].

Patient satisfaction – Patient satisfaction rates are high for both types of ablation. In a review of NREA and REA devices, patient satisfaction rates were >86 percent and varied based on specific procedure type [3].

Subsequent surgery – Patients undergoing NREA compared with REA may have lower rates of subsequent surgery, but the certainty of evidence is low. In the meta-analysis of randomized trials, NREA compared with REA resulted in fewer additional surgeries (66 fewer versus 53 fewer; mean rank 2.3 versus 3 [in a ranking from 0 to 5]) [45].

Similarly, in a retrospective study including almost 115,000 patients, patients undergoing radiofrequency compared with REA had a lower likelihood of subsequent surgery (hazard ratio [HR] 0.69, 95% CI 0.63-0.76) within five years [94].

Patients who are less than 45 years old at the time of endometrial ablation appear to be at a higher risk of treatment failure than older patients. This was illustrated in two retrospective studies including 816 and 3681 patients followed for five to eight years after endometrial ablation [29,94,95]. The risk of subsequent hysterectomy or repeat ablation was twofold in patients less than 45 years old versus those 45 years or older (54 versus 27 percent in one study [95]).

Ablation versus other treatments

Medical therapy

Oral therapy – Ablation appears to initially reduce bleeding more than oral medications. In a randomized trial including 187 patients with HMB, those treated with endometrial resection compared with oral medication (at least three cycles, specific medication varied) had fewer days of heavy bleeding (0.8 versus 3.2 days) at four-month follow-up [96]. At five-year follow-up, the rate of hysterectomy was similar between groups; among patients in the original medical therapy group, 10 percent still used medical treatment and 59 percent had surgical treatment other than hysterectomy. Further high-quality data are needed to compare medical therapy with NREA.

Levonorgestrel IUD – The decision to use the 52 mg levonorgestrel-releasing intrauterine device (LNG 52 mg IUD) or endometrial ablation depends upon a patient's preferences regarding treatment factors such as plans for fertility and contraception, convenience, and risks of anesthesia. Comparison between these two treatment options is discussed in detail separately. (See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Management", section on 'Role of surgery'.)

Hysterectomy — Hysterectomy is the definitive management option for heavy menstrual bleeding (HMB). However, for patients who have failed medical management, do not desire future pregnancy, and have a reliable form of contraception, we offer endometrial ablation as an alternative. In general, rates of patient satisfaction are high with both methods [83,97]. While endometrial ablation compared with hysterectomy has a shorter operative time, recovery time, and is associated with a lower risk of sepsis, blood transfusion, and hematoma, there is a risk of reoperation for recurrent symptoms in those managed with endometrial ablation [97-100].

In a meta-analysis including 10 randomized trials and over 1900 patients comparing endometrial resection and ablation (any type) with hysterectomy (open, minimally invasive, or unspecified) for HMB, patients undergoing an endometrial procedure compared with hysterectomy had a [97]:

Higher risk of requiring a second surgery for treatment failure within one year (3 to 13 percent versus 0 to 0.4 percent, eight trials). Treatment failures in the hysterectomy group resulted from patients with continued bleeding after supracervical hysterectomy. No patients required reoperation for treatment failure after total hysterectomy (ie, removal of the uterus and cervix).

Shorter return to normal activity (mean difference -11 to -21 days, two trials).

Similar quality of life at two years, but results favored hysterectomy.

Lower risk of sepsis, blood transfusion, and hematoma when compared with open and unspecified hysterectomy; the risk was similar when compared with minimally invasive hysterectomy.

This meta-analysis reported on short-term outcomes; a higher incidence of reoperation has been reported in large observation studies and in a randomized trial not included in this meta-analysis that followed patients long term [99,100]. In one randomized trial including 153 patients with AUB undergoing either REA or laparoscopic supracervical hysterectomy and followed for a median of 14 years, the risk of reoperation for symptom recurrence was 29 percent for patients treated with REA compared with none in the laparoscopy group (relative risk [RR] 0.39, 95% CI 1.20-1.61) [99]. Similarly, in a subsequent meta-analysis of 53 studies (including 24 randomized trials) and over 48,000 patients managed with NREA, the pooled rate of subsequent hysterectomy was 21.3 percent at 120 months [100]. This is discussed in detail separately. (See "Endometrial ablation: Non-resectoscopic techniques", section on 'Efficacy'.)

In general, studies have found no detrimental effects of hysterectomy on sexual function. However, some data suggest that these effects occur more frequently following hysterectomy than endometrial ablation. This was illustrated in a population-based prospective cohort study of over 9500 patients who underwent either endometrial resection or hysterectomy (total or subtotal) [101]. Oophorectomy versus no oophorectomy at time of hysterectomy was associated with a greater adverse effect on sexual function; therefore, data are included only for patients whose ovaries were conserved. At five-year follow-up, patients who underwent hysterectomy without oophorectomy versus endometrial resection had significantly higher age- and hormone therapy-adjusted rates of severe effects on sexual measures: loss of libido (OR 1.4, 95% CI 1.2-1.7), difficult sexual arousal (OR 1.4, 95% CI 1.2-1.6), and vaginal dryness (OR 1.5, 95% CI 1.2-1.9). (See "Hysterectomy (benign indications): Selection of surgical route".)

FOLLOW-UP

Routine postoperative care — The most common postoperative side effects of endometrial ablation are cramping and vaginal discharge. Light vaginal bleeding or pink-tinged discharge is often present for two to three days. Uterine cramping may persist for 24 to 72 hours. Most patients can resume normal activities in one to three days.

We give patients routine post-hysteroscopy instructions and counsel patients to call if they have severe or persistent pelvic pain or heavy vaginal bleeding. (See "Patient education: Care after gynecologic surgery (Beyond the Basics)".)

In addition, patients who have undergone endometrial ablation must be counseled about the need for contraception. (See 'Pregnancy after ablation' below.)

Recurrent abnormal uterine bleeding

Prevention — Studies suggest that adding progestin therapy after endometrial ablation or resection reduces bleeding and decreases ablation failure rates. The definition of success varies, and may include amenorrhea, relief of bothersome bleeding symptoms, and/or patient satisfaction.

Oral and intramuscular progestins after endometrial resection have been evaluated. In a randomized trial including 71 patients with ovulatory menorrhagia, those undergoing hysteroscopic endometrial resection combined with medroxyprogesterone acetate (MPA; 150 mg intramuscularly, single dose at the time of surgery) compared with resection alone had higher rates of amenorrhea (40 versus 26 percent) and lower rates of subsequent ablation/resection or hysterectomy (3 versus 21 percent) at one-year follow-up [102]. Observational studies have also found that oral and intramuscular medroxyprogesterone following resection was associated with higher rates of amenorrhea and patient satisfaction [103,104].

Use of the 52 mg levonorgestrel-releasing intrauterine device (LNG 52 mg IUD, Mirena or Liletta) concomitant with or following endometrial ablation is described above. (See 'Intrauterine device insertion' above.)

Evaluation — Irregular uterine bleeding or spotting should not be presumed to be a normal outcome of endometrial ablation. Patients with such symptoms should undergo endometrial sampling and/or imaging to evaluate the etiology of the bleeding and exclude endometrial hyperplasia or carcinoma. (See "Overview of the evaluation of the endometrium for malignant or premalignant disease", section on 'Methods of evaluation'.)

However, prior endometrial ablation may interfere with subsequent evaluation of the endometrium [6,10,11,105-116]. The intrauterine adhesions that result from ablation may prevent or delay bleeding (which is the cardinal symptom of endometrial carcinoma), make sampling the endometrium challenging, and/or interfere with histologic evaluation of the endometrial sample [114-118]. In a retrospective study of 303 patients deemed to require endometrial sampling after endometrial ablation, the failure rate for obtaining bleeding assessment was 40 percent [119]. Lower failure rates have been reported. In two cohort studies including patients with a history of Cerene cryoablation or vapor endometrial ablation, subsequent hysteroscopic evaluation was successfully performed in over 90 percent of patients at one and four years, respectively [120,121].

Repeat endometrial ablation — For some patients in whom AUB recurs after ablation, a repeat ablation may be beneficial. Rates of re-ablation of approximately 5 to 20 percent have been reported within three to five years of the initial procedure [96,122-127].

We use only REA for repeat procedures, though repeat NREA procedures have been reported [126]. This is because the uterine cavity is likely to be distorted and hysteroscopic visualization makes it possible to identify and treat remaining areas of endometrium [112,113]. Complication rates (eg, uterine perforation, excessive fluid absorption, genital tract burns) may be higher in repeat compared with primary ablations [122].

Pregnancy after ablation — Despite destruction of the endometrium, pregnancy occurs in approximately 0.7 percent of patients who have undergone endometrial ablation [8]. Conceptions have been reported to occur a median of 1.5 years (range 3 weeks to 13 years) after ablation, and the majority (80 to 90 percent) of such patients reported not using contraception [128].

While successful pregnancies have been reported, there appears to be greater risk of complications in pregnancies that follow ablation [129-132], but data are limited. In a review of 74 cases of pregnancies following various methods of endometrial ablation, outcomes included: pregnancy termination (38 percent), preterm delivery (20 percent), term delivery (20 percent), first-trimester miscarriage (12 percent), second-trimester pregnancy loss (5 percent), and ectopic pregnancy (3 percent) [8]. In another literature review of 70 cases of postablation pregnancies, outcomes included malpresentation (39 percent), abnormal placentation (26 percent), and perinatal mortality (13 percent); 71 percent of patients had a cesarean birth [133]. Further study is needed to evaluate the risk of obstetric complications in postablation pregnancies.

Use of postmenopausal hormone therapy — Patients who have had an endometrial ablation and later choose to use postmenopausal hormone therapy should be given progestins along with estrogen for endometrial carcinoma protection of any untreated endometrial tissue. (See "Menopausal hormone therapy: Benefits and risks", section on 'Protective effect of progestins'.)

SPECIAL CONSIDERATIONS

Nulliparous patients — Nulliparity is not a contraindication to endometrial ablation and nulliparous patients should be counseled similarly to parous patients. Parity was neither an inclusion nor exclusion criteria in the US Food and Drug Administration (FDA) pivotal trials. (See 'Patient selection' above.)

Patients with bleeding disorders or anticoagulation therapy — Most methods of endometrial ablation are appropriate for patients with heavy menstrual bleeding (HMB) due to bleeding disorders or anticoagulant therapy; endometrial resection should be avoided given a theoretical concern of intraoperative hemorrhage due to resection into myometrial vessels.

In our practice, we do not stop anticoagulation in patients undergoing endometrial ablation as the risk of bleeding is very low. For patients taking warfarin, we order an international normalized ratio (INR) approximately one week prior to surgery and then the day of surgery to be sure they are not super-therapeutic. We prefer such patients have an INR under 4.0.

Outcomes appear to be similar for patients with and without coagulopathies. In a retrospective study including patients undergoing NREA, those with coagulopathy (41 patients) compared with normal coagulation (111 patients) had similar rates of subsequent hysterectomy at two years (average) [134]. Perioperative complications were infrequent in both groups; hematometra occurred in one patient with coagulopathy and in none of the controls. Similarly, in a retrospective study including 71 patients with HMB treated with endometrial ablation, those with a suspected bleeding disorder (International Society on Thrombosis and Haemostasis bleeding assessment tool [ISTH-BAT] score ≥6) compared with no bleeding disorder (ISTH-BAT score <6) had similar rates of amenorrhea, dysmenorrhea, and subsequent hysterectomy at up to 10 years of follow-up [135]. BAT scores are discussed in detail separately. (See "Approach to the adult with a suspected bleeding disorder", section on 'Bleeding score'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gynecologic surgery".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Endometrial ablation (The Basics)")

SUMMARY AND RECOMMENDATIONS

Terminology – Endometrial ablation is the surgical destruction of the endometrium for the treatment of abnormal uterine bleeding (AUB). Non-resectoscopic endometrial ablation (NREA) is performed with a disposable device which is inserted into the uterine cavity and delivers energy to uniformly destroy the uterine lining. Resectoscopic endometrial ablation (REA) is performed under hysteroscopic visualization, using resectoscopic instruments to ablate or resect the endometrium. (See 'Terminology' above.)

Patient selection Indications for endometrial ablation include the treatment of chronic heavy menstrual bleeding (HMB) and the treatment of acute bleeding in hemodynamically stable patients in whom medical therapy is contraindicated or unsuccessful. (See 'Indications' above.)

Absolute contraindications – Absolute contraindication to endometrial ablation include pregnancy or desire for future pregnancy, known endometrial hyperplasia or carcinoma, active pelvic infection, and current use of intrauterine device. (See 'Absolute contraindications' above.)

While pregnancy is contraindicated following endometrial ablation, ablation does not prevent pregnancy and contraception is still necessary after ablation in sexually active patients. (See 'Pregnancy after ablation' above.)

Relative contraindications – We do not perform endometrial ablation in postmenopausal patients. Evaluation of the endometrium can be difficult following endometrial ablation and may increase the risk of a missed diagnosis of endometrial carcinoma. (See 'Relative contraindications' above.)

Other relative contraindications include risk factors for endometrial hyperplasia or carcinoma (table 1), myometrial thinning, and uterine anomalies. (See 'Relative contraindications' above.)

Factors associated with treatment failure – Factors associated with treatment failure include large uterine cavity size, adenomyosis, grand multiparity, intracavitary lesions (eg, submucosal fibroid, endometrial polyp), younger age (eg, <30 to 35 years), and acute retro- or anteflexion or retro- or anteversion of the uterus. (See 'Factors associated with treatment failure' above.)

Endometrial sampling and role of endometrial preparation

Endometrial sampling – Endometrial sampling should be performed in all patients prior to ablation. (See 'Endometrial sampling' above.)

Role of endometrial preparation – We prefer techniques that do not require preoperative thinning as endometrial preparation can be expensive, associated with side effects, and can delay surgery. Such techniques include bipolar radiofrequency ablation (NovaSure), combined thermal and bipolar radiofrequency device (Minerva), cryoablation device (Cerene), and endometrial resection. (See 'Endometrial preparation' above.)

Choice of endometrial preparation when used – When endometrial preparation is used prior to endometrial ablation, we suggest gonadotropin-releasing agonists over other agents (Grade 2C). Reasonable alternatives may include pretreatment with oral contraceptives, uterine curettage, or performing the procedure during the follicular phase of the menstrual cycle. (See 'Endometrial preparation' above.)

Choosing the type of ablation – The choice of ablation type must be individualized based on patient characteristics and the surgeon's familiarity with the procedure. (See 'NREA versus REA' above and 'Choosing the type of ablation' above.)

NREA – NREA is performed in most cases of endometrial ablation. While both NREA and REA result in comparable rates of amenorrhea and patient satisfaction, NREA is associated with less frequent use of general anesthesia, a shorter operative duration, and a lower risk of some surgical complications (eg, irrigation fluid overload).

REA – We typically perform REA only for patients with any of the following: uterine cavity shape (eg, acute retro- or anteflexion) or size (eg, >10 weeks) that will not accommodate an NREA device; concomitant procedure (eg, submucous fibroid resection) is planned; history of multiple cesarean births or myometrial procedures; repeat ablation procedure (algorithm 1).

Evaluation of recurrent bleeding – Irregular uterine bleeding or spotting should not be presumed to be a normal outcome of endometrial ablation and patients with such symptoms should undergo evaluation of the endometrium. However, the intrauterine adhesions that result from most ablation techniques may prevent or delay bleeding (which is the cardinal symptom of endometrial carcinoma), make sampling the endometrium challenging, and/or interfere with histologic evaluation of the endometrial sample. (See 'Evaluation' above.)

Role of hysterectomy – For most patients who desire surgical therapy for AUB and who do not desire future pregnancy, we offer both endometrial ablation and hysterectomy. While endometrial ablation has shorter operative and recovery times, hysterectomy is a reasonable option for patients who desire definitive therapy and who are willing to accept the longer surgical and recovery times and possibly an increased risk of sepsis, blood transfusion, and hematoma. (See 'Hysterectomy' above.)

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Topic 3316 Version 44.0

References

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