For women with uncontrollable heavy menstrual periods, endometrial ablation, is an attractive option to a hysterectomy. The procedure involves removal of the endometrium (uterine lining) by a variety of techniques. It is a much less invasive procedure that can be performed as an outpatient and even in a doctor’s office. However, postoperative pain can occur, which ultimately results in a hysterectomy—the procedure the woman wanted to avoid in the first place. The study was published in the November edition of the journal Obstetrics & Gynecology by researchers at Drexel University College of Medicine and the Perelman School of Medicine, University of Pennsylvania, both in Philadelphia, Pennsylvania.
The researchers note that endometrial ablation by various methods, including heated water in a balloon, bipolar radiofrequency (an electric current), cryoablation (freezing), microwave energy, and circulating hot fluid. These procedures offer an alternative to hysterectomy for women who are poor surgical candidates or who wish to avoid major surgery. Head-to-head comparisons of first- and second-generation ablation techniques with hysterectomy Hysterectomy guarantees amenorrhea (cessation of menses), it has a longer recovery time, greater cost, and much higher complication rate.
The authors explain that continued bleeding is a common cause for ablation failure, postablation pain is experienced by a significant number of patients, and many of these patients request a hysterectomy. One prior study specifically assessed risk factors for pain after endometrial ablation and found that a history of dysmenorrhea (painful menses), smoking, tubal ligation, and younger age were all associated with developing pain. The aim of the new study was to identify predictive factors that put women at risk of dissatisfaction as a result of pain and subsequent rates that these women request a hysterectomy.
The investigators conducted a retrospective study (backward-looking study) of data from two large academic medical centers. The study group comprised 300 women who underwent endometrial ablation from January 2006 through May 2013. Data collected included baseline characteristics at the time of ablation, pertinent medical history, and ablation technique. The data was subjected to statistical analysis to evaluate risk factors for post-ablation pain or hysterectomy.
The researchers found that, of the 300 women underwent an endometrial ablation during the study period, 270 had follow-up data for analysis. The study found that 23% developed new or worsening pain after ablation and 19% underwent a hysterectomy. A history of dysmenorrhea was associated with a 74% higher risk of developing pain and tubal sterilization was related to more than double the risk. Caucasian women were 45% less likely to develop pain, In regard to hysterectomy, a history of cesarean delivery more than doubled the risk, whereas uterine abnormalities on imaging studies such as ultrasound, including fibroids, adenomyosis, thickened uterine lining, and polyps, quadrupled the risk. A procedure performed in the operating room decreased the risk of hysterectomy by 76%. Hysterectomies for the indication of pain occurred more than three years earlier than for other indications.
The authors concluded that patient characteristics should be considered when counseling patients about the possible outcomes of endometrial ablation. Furthermore, a significant portion of ablations are complicated by post-ablation pain.
Take home message:
Uterine ablation is an attractive option to a hysterectomy; however, this study notes some of the reasons for a subsequent hysterectomy. They include a history of painful menses, tubal ligation, and younger age. Interestingly, an office procedure was significantly more likely to be associated with postoperative pain than a hospital procedure (this could include a procedure performed in an outpatient surgery center). If you suffer from uncontrollable heavy menses, discuss all options thoroughly with your gynecologist.