Key points
- Global ablation methods involve destroying the endometrium using specialized devices that do not require an operative hysteroscope or resectoscope.
- The endometrium should be destroyed or resected to the level of the basalis, which is approximately 4 to 6 mm deep.
- In cryoablation, freezing the tissue causes less pain than the heat energy associated with other ablation devices. The procedure typically takes 10 to 20 minutes.
- Not only is bipolar desiccation quick and simple, no endometrial pretreatment is required because the system allows for consistent depths of ablation regardless of endometrial thickness.
- The advantage of hydrothermal ablation is that the circulating hot saline solution contacts the entire endometrial surface regardless of the shape or size of the cavity.
Traditionally, physicians have preferred hysterectomy for the treatment of abnormal uterine bleeding not related to endometrial cancer, representing about 20% of the 590,000 hysterectomie performed annually in the United States.1 The advent of standard endometrial ablation, e.g., surgical resection and rollerball desiccation, offered women less radical alternatives to hysterectomy. However, these “classic” methods are considered by some physicians to be technically difficult because they require the use of an operative hysteroscope—and all of its attendant risks. As a result, many Ob/Gyns continued to opt for hysterectomy when given a choice.
Now there are simpler alternatives: global ablation methods, including the newest—cryoablation, bipolar desiccation, and hydrothermal ablation. These procedures involve destroying the endometrium using specialized devices that do not require an operative hysteroscope or resectoscope. The advantage of these methods is that they are simple, rapid procedures that are easier to perform than standard endometrial ablation. Many surgeons who were uncomfortable utilizing the standard resectoscope can offer this treatment option to women with menorrhagia. In fact, it generally takes clinicians only 5 to 10 procedures to become proficient in endometrial ablation.
While global ablation is not intended to replace hysterectomy—the definitive treatment for most uterine pathology2—it gives patients a choice. Women who want permanent cessation of menses can choose hys-terectomy. Those who want to preserve the uterus or desire an outpatient procedure with minimal morbidity may opt for endometrial ablation. Regardless of the method they choose, patients who participate in the deci-sion-making process are more likely to be satisfied with their outcome.
The thinner the endometrial lining, the more likely ablation will be successful.
Part of this process includes an informed-consent discussion with the patient, including a review of each technique, its risks and complications, and outcomes. The long-term consequences of endometrial ablation remain unknown. The reason: Follow-up data beyond 24 months are minimal. And another question remains unanswered: How many women who have undergone endometrial ablation will develop endometrial carcinoma without symptomatic bleeding? There has been at least 1 report of this phenomenon occurring in a woman who ultimately underwent a hysterectomy for other reasons.3 Other case reports have noted uterine bleeding as the presenting symptom of endometrial carcinoma in women who had undergone ablation.4-6 The bottom line: The risk of asymptomatic endometrial cancer appears to be small in properly selected patients, i.e.,women without a history of endometrial hyperplasia or carcinoma (Table 1).
TABLE 1
Patient selection
INDICATIONS
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CONTRAINDICATIONS
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Preparation
Prior to performing any endometrial ablation, obtain an endometrial sample to rule out premalignant or malignant disease. Also, assess the endometrial cavity using either office hysteroscopy or sonohysterography to exclude the possibility of submucous myomata or polyps, which can be treated with simple resection. These imaging techniques also can reveal abnormally shaped uterine cavities, thus eliminating certain women as candidates for global techniques such as balloon ablation.
For all methods, destroy or resect the endometrium to the level of the basalis, which is approximately 4 to 6 mm deep, depending upon the stage of the menstrual cycle or cycle suppression. It is reasonable to assume that the thinner the endometrial lining, the more likely ablation will be successful. Several methods of producing endometrial atrophy have been used, including dilatation and curettage (D&C) and hormonal suppression with medroxyprogesterone acetate, oral contraceptives (OCs), danocrine, or gonadotropin releasing hormone ago-nists (GnRH-a). I prefer to use leuprolide acetate (7.5 mg for 1 dose) 4 to 5 weeks prior to performing cryoablation or hydrothermal ablation. (Pretreatment of the endometrial lining is not necessary with bipolar desiccation.)