PB 81: Endometrial ablation

Question 1

Indications for endometrial ablation?

Answer 1

Treatment of menorrhagia or patient-perceived heavy menstrual bleeding in premenopausal women with normal endometrial cavities without desire for future fertility

Not prerequisites but important considerations: presence of anemia, failure of or intolerance to medical therapy

Question 2

What are the systems available for endometrial ablation?

Answer 2

Urological resectoscope: uses radiofrequency alternating current and a loop electrode or electrosurgical tissue desiccation with ball or barrel electrode

Cryotherapy: Her Option - pass device into each cornu

Heated free fluid: Hydro ThermAblator - uses heated normal saline to 90 deg C, depth of necrosis 3-4mm

Microwave: 2 devices

Radiofrequency electricity: NovaSure

Thermal balloon: ThermaChoice

Question 3

How do endometrial ablation outcomes compare with medical therapy?

Answer 3

Ablation better than oral medical therapy: in RCT - by 5y, 10% of medical tx pts kept on medicine, 77% went to surgery; in patients who got ablation, 27% needed further surgery

Ablation and levonorgestrel releasing system are equivalent in satisfaction: ablation is better for bleeding at 1 year but no difference by 2-3 years out

Question 4

Is one type of endometrial ablation superior to the other?

Answer 4

For women with normal endometrial cavities, resectoscopic and nonresectoscopic ablation systems are equal with respect to reduction in menstrual flow and patient satisfaction at 1 year after index surgery

Question 5

What are common side effects of endometrial ablation?

Answer 5

Resectoscopic methods: unique for fluid overload and electrolyte disturbances

Both resectoscopic and nonresectoscopic: bleeding, injury of cervix and vagina, uterine perforation

Question 6

What is distention media fluid overload?

Answer 6

Distension media needed for resectoscopic monopolar instruments or standard radiofrequency electrosurgical operative hysteroscopy - needs to be electrolyte-free and low viscosity: 3% sorbitol, 1.5% glycine, 5% mannitol, combined mannitol and sorbitol solutions (all hypotonic)

With sufficient absorption, get dilutional hyponatremia and hypoosmolality –> subsequent brain edema, permanent neurological damage, and death

Worse outcomes in premenopausal women because of inhibitory impact of estrogen and progesterone on brain’s sodium pump (so women more vulnerable to cerebral edema)