QUICK QUERIES Topical Questions, Sound Answers

Endometrial Ablation: What FPs and Their Patients Need to Know

Albert M. Rosengarten, MD, FRCSC Presented at the University of Calgary Family Medicine Update, 2005.

ndometrial ablation (EA) has become a What is the differential Estandard treatment option for menorrhagia diagnosis of excessive uterine (heavy regular periods) and ? (heavy irregular periods). This minimally invasive technique was • Rule out pregnancy-related causes developed in the late 1980s and early 1990s, • Rule out /neoplasia, along with the evolution of hysteroscopy and particularly in: has been performed in Canadian centres for the - peri- and post-menopausal patients, last 10 to 15 years. The principle is to remove - chronic /polycystic ovarian and/or destroy the which is the syndrome (PCOS) source of the bleeding rather than removing the • Dysfunction©al uterine bleeding (DUB):tion whole organ; therefore this offers patients a less - anovutlation, ibu gh tr d, ri is nloa invasive, safer, cheaper option with much quickyer - lack of rhythmil cDor glodbalowvasoconstriction- op cia can e recovery time compared toChysterectomy. emodrulatedsenerdoms etrialasloughus (classically m ed u son However, definite limitations exist and thesme oseenris in polycysr pteicrovarian syndrome and Co Auth y fo need to be understood. The procedurer does haveted. percimenop opausal menometrorrhagia) e o hibi ingle a failure rate and is notarislk-free.e pro t a s• Endometrial lesions such as: r S d us prin fo rise and - polyps, t utho view No Una lay, What is menorrhagia/disp - submucosal fibroids (these can bleed directly and asynchronously) menometrorrhagia? - intramural fibroids (can cause menorrhagia A full discussion of this problem is beyond the by stretching endometrial surface area) scope of this review. However, briefly, FPs need - ( within the to have a practical approach to patients present- ; associated with heavy/painful ing with abnormal menstrual bleeding. periods and uterine pain/tenderness) The average blood loss per menses is about • Systemic causes: e.g., , 40 cc; 80 cc is considered excessive and often therapeutic anticoagulation, hypothyroidism will result in anemia. About 10% of women lose • Cervical source, such as: > 80 cc per period; about half of these women - endocervical polyp, seek medical treatment. Note that one woman’s - neoplasia, menorrhagia can be another’s eumenorrhea - ectropion (can cause post-coital bleeding) (i.e., the symptom is quite subjective). However, • Presence of an intrauterine device patients who feel that their bleeding is excessive (not progestin-releasing) should be offered treatment regardless of “pad/tampon counts” and hemoglobin levels.

The Canadian Journal of CME / April 2007 39 What investigations are • Endometrial ablation recommended? • Hysterectomy • Myomectomy (abdominal/laparoscopic • Complete blood count intramural myomectomy). This is not • Pregnancy test recommended unless future fertility is desired • In selected cases: thyroid-stimulating A hysterectomy is generally a better option hormone; screening • Radiologic embolization of the uterine arteries • Endometrial biopsy (especially in for fibroid-associated menorrhagia patients at risk for endometrial hyperplasia (e.g., polycystic ovarian syndrome) atients with pelvic • Ultrasound to check for fibroids Ppain (beyond • In selected cases: diagnostic hysteroscopy or hysterosonography (ultrasound with ), saline contrast in uterine cavity) to check or for endometrial lesions • Rarely, an MRI to check for adenomyosis adenomyosis, are not good candidates for EA. What are treatment options? Who are candidates for EA? Medical Medical options include the following: Cadidates for EA are patients that: • Oral contraceptive pills (cyclic, or continuous) • Have no desire for future fertility • Progestins (preferably continous use) • Are aged > 35 years; preferably > 40 years • Non-steroidal anti-inflammatory drugs to be (higher failure rate in younger patients) taken with menses • Failed trial of medical therapy • Low-dose danazol (100 mg to 200 mg q.d.) • Are not pregnant • Gonadotropin-releasing hormone agonist • Do not have pelvic inflammatory disease (GNRH) analogs (e.g. leuprolide, goserelin); • Have no atypical endometrial hyperplasia or add-back estrogen/progestin recommended if neoplasia; not at high risk for this in future duration of treatment is longer than six months • Are not expecting total (occurs • Tranexamic acid with menses in minority of patients) • Do not have adenomyosis (higher failure rate) Surgical • Do not have large fibroids (higher failure rate) • Hysteroscopy to rule out endometrial lesions EA does not provide good contraception. There are (polyps, submucosal fibroids). If present, it many case reports of pregnancies that occur post is best to resect them. EA. They are mostly nonviable. Therefore, this • Dilatation and Curettage: only to stop acute issue must be addressed, unless the patient/partner heavy bleeding. This is not a long term option is already sterilized. Laparoscopic tubal steriliza- tion, or in some centres, hysteroscopic sterilization (Essure) is often done at the time of EA. Dr. Albert M. Rosengarten is an Associate Professor of OB/GYN, Patients must understand that there is a small University of Calgary, Calgary, Alberta. risk of endometrial cancer developing after EA, in potentially buried endometrium. The diagnosis can

40 The Canadian Journal of CME / April 2007 QUESTIONS & ANSWERS Topical Questions, Sound Answers Endometrial Ablation

be delayed because of late or absent post- non-conductive fluid medium, usually a hypo- menopausal bleeding. Also, it is more difficult to tonic sugar solution, such as glycine, is used to get good endometrial sampling. Ultrasounds may distend the uterine cavity. An excellent image of be helpful.A hysterectomy may be necessary when the uterine cavity (“womb with a view”) is in doubt. Post-menopausal patients with previous obtained; the patient, if awake, can chose to EA who use hormone replacement therapy must observe the procedure. The endometrium is then take progestin along with estrogen because of pos- systematically resected and/or ablated, to a sible residual endometrial nests. depth below the basal layer, into the myometri- um, so that endometrial regeneration is unlike- he levonorgestrel- ly. A combination of mono-polar electrosurgical Treleasing IUD, loop, roller ball, or roller bar can be used. The technique has been adapted from urological has emerged in the prostate resection. last few years as Most cases can be completed within 30 min- utes. A definite learning curve exists; current one of the main OB/GYN residents are generally well-trained in alternatives to the technique. Patients tend to have minimal to mild post- endometrial ablation. op cramping for a few hours. A blood-tinged discharge can be expected for up to a few Endometrial preparation? weeks. Patients are discharged the same day and Rendering the endometrium thin facilitates the are usually fully recovered by the following day. technique, enabling better visibility, shorter The medical engineering industry has devel- operating time, possibly lower risk of complica- oped a number of non-hysteroscopic EA tech- tions and, arguably, better success rates. This niques, or global EA devices, utilizing energy can best be accomplished by giving GNRH ana- modalities such as: log (e.g. leuprolide or goserelin, one dose about • heat (delivered to the endometrium via four to five weeks pre-operation). Other less balloon, or as free hot water), expensive methods include low-dose danazol • laser, (200 mg to 400 mg q.d. for six or more weeks • bipolar cautery, pre-operation), progestins, or OCPs that are • microwave, withdrawn about seven to 10 days prior to EA. • intrauterine cryotherapy, etc. Alternatively, some gynecologists are comfort- These methods have certain advantages, such as able without any pre-treatment. being technically easier to do; therefore the results are less operator dependent. Some techniques What is the technique? require no endometrial preparation; some have higher amenorrhea rates than the standard hystero- EA is usually done in an OR, under general scopic technique. Some can been done in an out- anesthesia or local, intracervical block with patient setting. On the negative side, all these meth- intravenous sedation. An operative hystero- ods are significantly more expensive than the hys- scope with a video attachment is inserted teroscopic technique. In most series, results and into the after cervical dilatation. A complication rates are similar to hysteroscopic EA.

The Canadian Journal of CME / April 2007 41 Are there complications? Post EA lateral can infrequently be caused by , if there was a pre- • EA has a low risk of complications vious tubal ligation. This can be treated by • Approximately 1% to 2% of patients laparoscopic salpingectomy. hemorrhage (rarely heavy), another 1% to Intramural fibroids and large uteri are asso- 2% may develop an infection. There is less ciated with higher failure rates. Conversely, sub- than 1% risk of uterine perforation. mucosal fibroids that are hysteroscopically Perforations are usually managed via resectable can yield low failure rates. laparoscopy. Serious sequelae are very In many series, about 10% to 15% of patients unlikely but bowel/bladder injuries have having EA will eventually have a hysterectomy. occurred. • Less than 1% risk of excessive fluid Summary absorption of distention medium. This can lead to hyponatremia, very rarely seizures, EA has become well established as a good sur- pulmonary edema. gical alternative to hysterectomy for excessive uterine bleeding in women who have completed What are the results? childbearing and who have failed or declined medical treatment options. These women are The results in patients who recieve EA are: willing to accept (as opposed to • Approximately 25% develop amenorrhea, amenorrhea) and a relatively low failure rate, in 60% hypomenorrhea (i.e., about 85% exchange for the safety, convenience, lack of inva- patient satisfaction, with significant siveness and quicker recovery with little or no post- reduction in menstrual flow) operative pain, compared to hysterectomy. • Approximately 15% failure rate; Appropriate patient selection is paramount in order i.e., continued or recurrent menorrhagia or to achieve optimal success rates. uterine pain leading to further treatment, The levonorgestrel-releasing intrauterine sys- usually hysterectomy; sometimes a second tem (LNG-IUS) IUD has emerged in the last EA is helpful few years as one of the main alternatives to Failures can occur months or years after the proce- endometrial ablation, particularly in younger dure. The failure rate is inversely related to the age women (< 35 to 40 years), women with uterine of the patient. It is rather high (up to 40%) in pain/tenderness and women who need contra- women < 35 years-of-age and declines to approxi- ception or who may wish to conceive later. The mately 5% in women > 45 years-of-age. LNG-IUS IUD can also be a good alternative to Failures are generally associated with adeno- hysterectomy in many cases. myosis. This is usually seen histologically in Hysterectomy, especially less invasive post EA hysterectomy specimens. One may approaches (vaginal or laparoscopic, when fea- question whether the adenomyosis was present sible) is still a good option for women with prior to the EA, or did the EA lead to adenomyosis? menorrhagia, particularly if there is a signifi- Uterine pain can sometimes worsen after EA. Post cant pain component, or if they are not good can- EA uterine pain can also be due to , didates for EA, or if EA fails. Patient satisfaction with cervical stenosis. This can be seen on ultra- rates with hysterectomy are generally high. sound and treated, though not always successfully, with cervical dilatation with or without repeat EA.

42 The Canadian Journal of CME / April 2007