Endometrial ablation refers to minimally invasive surgical procedures that treat abnormal uterine bleeding in select women who have no desire for fertility. In its guidelines for endometrial ablation, the American College of Obstetricians and Gynecologists (ACOG) compare standard resectoscopic endometrial ablation with nonresectoscopic endometrial ablation techniques and devices. ACOG also reviewed the indications, effectiveness, safety, and limitations of endometrial ablation.

Indications

Endometrial ablation should be used to treat premenopausal women with normal endometrial cavities who have menorrhagia or patient-perceived heavy menstrual bleeding. These should be women who have no desire for future fertility, and they most likely will have been unsuccessful with or are intolerant of medical therapy. Although failure or intolerance of medical therapy and anemia are important considerations, they are not prerequisites for the procedure.

When excessive bleeding or menorrhagia occurs in the context of submucosal myomata, endometrial ablation may be effective. However, this depends on the diameter and location of the myomata as well as the system used for the procedure.

Physicians should advise patients who choose endometrial ablation that the normalization of menstrual blood flow—not necessarily amenorrhea—may be the outcome of the procedure. In addition, ACOG recommends that physicians counsel premenopausal women who are undergoing endometrial ablation to use appropriate contraception.

Evaluation

Physicians should thoroughly evaluate the histology and structure of the endometrial cavity to assess evidence of endometrial hyperplasia or malignancy. They must also ensure that the configuration and length are suitable for endometrial ablation. Women with uterine cancer or endometrial hyperplasia should not undergo endometrial ablation.

Endometrial sampling should be performed to evaluate all women for malignancy or hyperplasia. Transvaginal ultrasonography, hysteroscopy, saline infusion sonohysterography, or a combination of these procedures should be performed to measure the length of the cavity and detect any structural abnormalities or sub-mucosal and intracavitary myomata. If such myomata are identified, physicians should determine the diameter and proportion of the lesion or lesions that extend into the endometrial cavity.

Adverse Events

Resectoscopic endometrial ablation and nonresectoscopic endometrial ablation have been associated with a number of adverse events, including urinary tract infection, vaginal infection, fever, and endometriosis. Adverse events related to fluid overload and electrolyte disturbances are unique to resectoscopic endometrial ablation. However, both approaches have been associated with injury to the vagina or cervix, bleeding, and uterine perforation with the potential to damage surrounding structures.

Summary of Recommendations

The following recommendations are based on good and consistent scientific evidence:

• For women with normal endometrial cavities, non-resectoscopic endometrial ablation and resectoscopic endometrial ablation may be equally successful in the reduction of menstrual flow and in patient satisfaction after one year.

• Resectoscopic endometrial ablation is associated with high patient satisfaction; however, patient satisfaction is even higher with hysterectomy.

The following recommendations are based on limited or inconsistent scientific evidence:

• Hysterectomy rates associated with resectoscopic and nonresectoscopic endometrial ablation are 24 percent or more within four years after the procedure.

• Women with previous or concomitant laparoscopic sterilization who undergo endometrial ablation are at low risk of developing intermittent or cyclic pelvic pain after the procedure.

• Women with normal endometrial cavities have similar patient satisfaction and reduction in menstrual blood flow after endometrial ablation as women who use the levonorgestrelreleasing intrauterine system (Mirena).

The following recommendations are based primarily on consensus and expert opinion:

• Physicians should advise patients who choose endometrial ablation that normalization of menstrual blood flow may be the outcome of the procedure.

• Physicians should counsel premenopausal patients undergoing endometrial ablation to use appropriate contraception.

• Nonresectoscopic endometrial ablation is not recommended in women who have endometrial cavities that exceed device limitations.

• Physicians should test the endometrium of all candidates for endometrial ablation. Physicians also should review the histopathologic results before the procedure.

• Women with uterine cancer or endometrial hyperplasia should not undergo endometrial ablation.

• Performing nonresectoscopic endometrial ablation on patients who have had transmural myomectomy or classic cesarean delivery may increase the risk of damage to surrounding structures. If endometrial ablation is required in these patients, physicians should perform resectoscopic endometrial ablation with laparoscopic monitoring.

• A fluid management and monitoring system that provides “real time” output of fluid balance should be used during resectoscopic endometrial ablation.