Endometrial ablation (EA) is used as a treatment for abnormal uterine bleeding (AUB) or heavy menstrual bleeding (HMB). The procedure removes a significant portion of the endometrium, the uterus’ inner lining, preventing or reducing the buildup and shedding that occurs during a menstrual cycle (Famuyide, 2017). Endometrial ablation often involves the administration of anesthesia in order to reduce patient discomfort.
The Two Categories of EA
The older approach to EA is called resectoscopic endometrial ablation. It is considered resectoscopic because a thin tube (called a hysteroscope) is inserted through the vagina into the uterus. The endometrium is then removed with a wire loop or vaporized (Famuyide, 2017).
The second, newer approach is called nonresectoscopic endometrial ablation (NREA). As of 2017, six NREA devices were approved by the FDA. Of the NREA devices, microwave and radiofrequency energy devices tend to have the highest rates of amenorrhea, or complete stoppage of menstrual bleeding (Famuyide, 2017).
NREA devices are preferred because of their relative safety and ease of use. However, both resectoscopic and NREA procedures have been shown to produce similar outcomes, substantially reducing menstrual blood loss and associated anemia and improving patient quality of life and sexual function (Famuyide, 2017).
Risks and Alternatives
EA can have operative complications such as uterine perforation, urinary tract infections, vaginal burns and, with resectoscopic procedures, fluid overload and brain swelling (Famuyide, 2017). In the long term, EA causes complications with pregnancy and detection of uterine cancer. Additionally, post-EA pain syndrome occurs in up to 20% of patients, usually due to uterine synechiae (scar tissue that adheres to itself) and hematometra (pooling of blood, often in relation to the synechiae) (Louie et al, 2018). Five years after EA, recurrent bleeding or pelvic pain causes around 16-20% of patients to seek further treatment (Famuyide, 2017).
Alternatives to EA include oral contraceptives, levonorgestrel intrauterine system (LNG-IUS) and hysterectomy (Famuyide, 2017). Oral contraceptives have traditionally been the first line of care; however, a recent study showed that radiofrequency NREA produced superior outcomes with similar costs (Famuyide et al, 2017). LNG-IUS may have greater quality of life improvements and lower costs than EA (Louie et al, 2018), yet it is not popular in the USA, potentially due to the history of intrauterine device failures in the 1970s (the Dalkon Shield). The definitive treatment for HMB is hysterectomy, the removal of the uterus. This is a major surgery, with longer operating and recovery times and increased risk of complications (Famuyide, 2017).
Risks of EA can be managed with careful patient and device selection. For example, NREA devices all have restrictions based on the size of the uterine cavity (Famuyide et al, 2017). EA is most likely to be successful in patients over 45 years of age, who have not had preoperative menstrual pain, and have not had a prior tubal ligation procedure (Famuyide, 2017). Patients must also have completed any desired childbearing, be free of genital infection, and be investigated for any hyperplasia of the endometrium (overgrowth, including cancers) (Famuyide et al, 2017).
Anesthesia Considerations
Success of endometrial ablation can be improved by informed use of anesthesia. Currently, a range of methods are considered acceptable, varying from no anesthesia to paracervical injections to general anesthesia (Klebonoff, 2017).
Pain scores of patients receiving only ibuprofen do not differ significantly from patients receiving local anesthetic. In these cases, procedures may be done with a “rescue” analgesic or sedative on hand, such as nitric oxide (Reinders et al, 2016). If local anesthetic is given, it is recommended to use both paracervical and intrauterine fundal anesthesia. The combination is thought to be important because the cervix and vagina are innervated by different spinal nerves than the uterine body and fundus (Reinders et al, 2020). Finally, a general and local anesthesia combination has been shown to slightly decrease pain in the first hour after endometrial ablation and, importantly, reduce use of opioid pain relievers after surgery (Reinders et al, 2016).
References
Famuyide, A. (2017). Endometrial Ablation. Journal of Minimally Invasive Gynecology, 25(2), 299–307. https://doi.org/10.1016/j.jmig.2017.08.656
Famuyide, A. O., Laughlin-Tommaso, S. K., Shazly, S. A., Hall Long, K., Breitkopf, D. M., Weaver, A. L., McGree, M. E., El-Nashar, S. A., Lemens, M. A., & Hopkins, M. R. (2017). Medical therapy versus radiofrequency endometrial ablation in the initial treatment of heavy menstrual bleeding (iTOM Tri: A clinical and economic analysis. PLOS ONE, 12(11), e0188176. https://doi.org/10.1371/journal.pone.0188176
Klebanoff, J. S., Patel, N. R., & Sloan, N. L. (2017). Utility of anesthetic block for endometrial ablation pain: a randomized controlled trial. American Journal of Obstetrics and Gynecology, 218(2), 225.e1-225.e11. https://doi.org/10.1016/j.ajog.2017.11.571
Louie, M., Wright, K., & Siedhoff, M. T. (2018). The case against endometrial ablation for treatment of heavy menstrual bleeding. Current Opinion in Obstetrics & Gynecology, 30(4), 287–292. https://doi.org/10.1097/gco.0000000000000463
Reinders, I. M. A., Geomini, P. M. A. J., Leemans, J. C., Dieleman, J. P., Timmermans, A., de Lange, M. E., & Bongers, M. Y. (2020). Intrauterine fundal anaesthesia during endometrial ablation in the office: A randomised double-blind, non-inferiority trial. European Journal of Obstetrics & Gynecology and Reproductive Biology, 254, 206–211. https://doi.org/10.1016/j.ejogrb.2020.09.011
Reinders, I., Geomini, P., Timmermans, A., de Lange, M., & Bongers, M. (2016). Local anaesthesia during endometrial ablation: a systematic review. BJOG: An International Journal of Obstetrics & Gynaecology, 124(2), 190–199. https://doi.org/10.1111/1471-0528.14395
