Treatment of Endometrial Ablation Failure

Endometrial ablation has been an important minimally invasive tool in the management of abnormal uterine bleeding for women who have completed childbearing. Over 300,000 global endometrial ablation (GEA) procedures are performed in the United States each year [1]. These methods include the following [2]:

  • NovaSure®
  • ThermaChoice
  • Hydrothermal ablation
  • Her Option (cryoendometrial ablation)

Global Endometrial Ablation Devices

Endometrial Ablation - NovaSure, Hydrothermal Ablation, ThermaChoice BalloonWhat is now understood is that one in four of these women will undergo a hysterectomy within 4 years of the procedure [3-7]. Many others will suffer some form of delayed complication that may be managed in other ways including hormone therapy or the use of analgesics in order to manage symptoms such as pain.

Our experience in the past 20 years has demonstrated to us that many of the hysterectomies following a global endometrial ablation (GEA) are avoidable. This article is intended to explain why some women develop symptoms following endometrial ablation and how—in many cases—hysterectomy can be avoided.

Why do these women end up with hysterectomies?

In our own practice we have observed the following reasons that women have been asked to undergo hysterectomies.

  1. Persistent bleeding—their bleeding never really improved significantly in the first place
  2. Development of moderate to severe pain following endometrial ablation—months to years later.
  3. The delayed onset of heavy vaginal bleeding after an initial good response to endometrial ablation
  4. The inability to adequately biopsy or evaluate the uterine cavity in the presence of postmenopausal or abnormal perimenopausal bleeding

Is a 25% hysterectomy rate after endometrial ablation an unreasonably bad outcome?

The good news is that these methods do prevent 75% of hysterectomies. But that may be little comfort if you’re one of the women for whom these procedures have produced a less than desirable outcome.   Let’s look at why these procedures fail.

Why do endometrial ablation procedures fail?

In general these methods all have the potential to leave areas of endometrium (lining tissue of the uterus) behind. In some instances the lining hasn’t been destroyed—these women experience little if any relief even for the first cycle following their endometrial ablation. In other cases the procedure may have worked well for months or even years when women develop recurrent menstrual bleeding, severe pelvic pain and cramps or a combination of these symptoms. In still other instances the endometrial ablation may have been performed despite the presence of fibroids—which need to be removed before an ablation can be successfully performed.

Central HematometraIn our practice, which treats many endometrial ablation failures, the most common complaint referred to our practice is the occurrence of cyclic (meaning approximately once a month) pelvic pain or cramps—often, but not always accompanied by bleeding. Some women have even compared this pain to “labor pain”. The pain often occurs because of a hematometra (a collection of blood within the uterine cavity) that is unable to pass the cervix. The pressure inside the hematometra builds up as the uterus contracts in an attempt to pass it.

Why do hematometras occur?

In general hematometras occur because blood is being produced somewhere in the uterine cavity but it is unable to pass easily from the cervix. The reason for this “backup” of blood within the uterine cavity is related to scarring that occurs in the lower portion of the uterus near the cervix. It doesn’t take a great deal of blood (less than a teaspoon) to “back up” before it produces symptoms of pelvic pain.

What is the treatment of these hematometra?

The treatment involves several steps including:

  • Dilating the cervix under ultrasound guidance
  • Locating and removing areas where the lining is growing—unless this step is performed the problem will only reoccur.
  • Exploring other portions of the uterus where lining has the potential to grow—and removing them as well.

How long have you been performing reoperative hysteroscopic surgery?

We have been performing reoperative hysteroscopic surgery for the past 20 years. We first reported our results in 2001 [8] for women who had undergone “first generation” endometrial ablation procedures. In the past 15 years, however, there have been a proliferation of GEA devices such as the NovaSure, ThermaChoice and Hydrothermal ablation methods. We are now seeing an increasing number of women who a presenting with the delayed complications of these methods.

How is reoperative hysteroscopic surgery (RHS) performed?

RHS is a technique involving a hysteroscope. Unlike the methods noted above which do not depending on looking inside the uterus, reoperative hysteroscopic surgery allows us to look directly inside the uterus to remove areas where lining tissue has either re-grown or been inadequately destroyed.

Before & After - Pelvic Pain - Endometrial AblationThese are before and after pictures of the same patient. This woman had a previous endometrial ablation. The picture on the left shows the appearance of a relatively small uterine cavity with areas of endometrial regrowth.   Notice that after further exploration we found (see right hand picture) an entire separate cavity that had been sealed off from the rest of the uterus. This patient’s main issue was cyclic pelvic pain. 

By identifying these areas we can remove them. An important safety feature of this procedure—to minimize the possibility of accidental uterine perforation is the simultaneous use of ultrasound guidance.

Rochester NY Procedure Room - REOPERATIVE HYSTEROSCOPIC SURGERYYou can see in the figure below that our operating suite is equipped with two ‘side-by-side’ monitors. This allows us to look inside the uterine cavity while monitoring the progress of the procedure using non-invasive ultrasound. These two separate techniques used together have provided a great deal of safety and excellent results.

How successful is RHS in treating my problem and avoiding hysterectomy?

Our experience with reoperative hysteroscopic surgery is now well in excess of 200 cases. Our center is, to my knowledge, the only one in the United States that offers this technique [9]. Our experience –to date—suggests that we avoid hysterectomy in approximately 90% of women using minimally invasive technique.

Where is the procedure performed?

Most of our procedures are performed in an office setting under intravenous sedation—much as might be done for a colonoscopy. Some women require the use of a hospital outpatient department.

How long does the procedure take?

The procedures vary in length but most can be performed within 30-35 minutes. Our focus is on safety and achieving good outcomes.

Are any preparations done prior to the procedure?

If you are a candidate for reoperative hysteroscopic surgery you will be seen the day prior (in most cases) for the insertion of a laminaria. A laminaria is a rolled up dehydrate piece of seaweed—no that’s not a typo. I functions by absorbing moisture from the cervix and vagina slowly expanding overnight. Its purpose is to allow your cervix to dilate adequately so that we can introduce our instruments the following day. Many women prefer a mild sedative for this procedure as well. It is available on request.

Is there anything else I should know?

It’s always good to bring a trusted friend, spouse, partner or relative with you for your consultation. There’s a great deal of information to absorb in a relatively short period of time. Having another set of ears always helps.

Remember that whenever you have sedation we ask you to refrain from solid food for at least 4 hours prior to receiving any intravenous medications.

You cannot drive yourself home after surgery or any other procedure involving the use of intravenous sedation.

If you are having sedation someone will need to drive you here, remain with you while you’re in the office and drive you home.

Bring a list of questions!

References

1. http://investors.hologic.com/index.php?s=43&item=420  Queried 4/28/13

3. Amso NN. Clinical and health service implications of second generation endometrial ablation

devices. Curr Opin Obstet Gynecol. 2006;18:457-63.

4. Shavell VI, Diamond MP, Senter JP, Kruger ML, Johns AD. Hysterectomy subsequent to endometrial ablation. J Minim Invasive Gynecol. 2012;19:459-64.

5. Longinotti MK, Jacobson G, Hung Y, Learman LA. Probability of Hysterectomy After Endometrial Ablation. Obstet Gynecol. 2008; 112: 1214-20.

6. Munro MG. ACOG Practice Bulletin: Endometrial Ablation. Obstet Gynecol. 2007; 109:1233.

7. McCausland AM, McCausland VM. Long-Term Complications of Minimally Invasive Endometrial Ablation Devices. J Gynecol Surg. 2010; 26: 133-49.

8. Wortman M, Daggett A. Reoperative Hysteroscopic Surgery in the Management of Patients Who Fail Endometrial Ablation and Resection. J Am Assoc Gynecol Laparosc. 2001; 8: 272-7.

9. Wortman M. Ultrasound-guided Reoperative Hysteroscopy: Managing Endometrial Ablation Failures. Surg Technol Int. 2012. XXII;165-171.