Endometrial ablation is an increasingly popular treatment for women suffering from heavy menstrual bleeding (HMB) due to its effectiveness and the fact that it provides a minimally invasive alternative to hysterectomy—a major surgery with risk of significant complications. However, even with these benefits, research shows that about 20% of patients will undergo a hysterectomy after endometrial ablation.1 This rate is lower with the use of second generation-devices.2 As physicians assess the best option for their patients, it’s important to understand why this is happening and what can be done to prevent it.
In this article, we’ll take a look at:
Endometrial ablation is an appealing option for treating HMB because of the short recovery time, low risk of complications, and reasonable cost associated with the procedure.
The procedure for endometrial ablation takes minutes and can be performed in an outpatient setting with minimal recovery time for patients, making it a much more convenient option for both doctors and patients. Unlike hysterectomy, endometrial ablation does not require removal of the uterus and is not considered major surgery. Some women may still have periods after endometrial ablation although they are typically much lighter.
Hysterectomy Complications: More Than Just Physical
While hysterectomy will completely eliminate HMB and any associated menstrual pain, it’s also a major surgery which can lead to serious complications such as hemorrhage, infection, blood clots and more. These risks are well-documented and are similar for most major surgeries.
However, it isn’t just the physical effects of hysterectomy but also the emotional effects that one needs to consider. One Mayo Clinic study found that hysterectomy was associated with an increased risk of mental health issues.3 According to the 2019 study which reviewed the health records of nearly 2,100 women who underwent hysterectomy without removal of the ovaries from 1980 to 2002, researchers found an absolute risk increase of 6.6% for depression and 4.7% for anxiety over 30 years.4 For those who underwent a hysterectomy at a younger age (18 – 35), the risk of depression was even higher with an absolute risk increase of 12% over 30 years according to the findings.4
For many reasons, reducing the probability of hysterectomy after endometrial ablation should be an obvious and longstanding goal of all healthcare providers.
Age at time of endometrial ablation
Age is the most consistent and significant predictor reported for hysterectomy after endometrial ablation. Research shows that endometrial ablation results are predictable for the first five to seven years after the procedure, but hysterectomy rates tend to trend up after that point.5
The primary reason for this is that ablation rarely destroys all of the basal cells of the endometrium, which can regenerate over time pre-menopause. The average age of menopause in the United States is 51. This means that the younger a patient is when she undergoes endometrial ablation, the more time the endometrium has to grow back and the more opportunities there are for bleeding and HMB to recur.
A Mayo Clinic study of women who underwent endometrial ablation found that being younger at the time of ablation, having significant menstrual pain before ablation, and undergoing tubal ligation before ablation were all associated with an increased risk of requiring hysterectomy after ablation.6
Presence of leiomyomas
In the already-referenced American College of Obstetricians and Gynecologists study on hysterectomy after endometrial ablation, leiomyomas were found in 243 (33.4%) of the 728 hysterectomy cases.5
The authors of that study stated that it’s difficult to compare and assess leiomyomas as a risk factor because of the variable exclusion criteria used for size and/or location of leiomyomas in their centers. A 2004 study that followed 89 women who underwent first-generation endometrial ablation for at least 6 years did find the presence of leiomyomas to be a risk factor for later hysterectomy.7
Patient dissatisfaction post-ablation
Interestingly enough, hysterectomies after endometrial ablation often occur due to poor patient satisfaction post-procedure. We also see that while satisfaction may be relatively high immediately following the procedure, it can wane somewhat in the long-term especially in younger patients. While the reasons for this dissatisfaction can vary greatly from patient to patient, common complaints include continued bleeding as well as the persistence of pain or new onset of severe cyclic pain which has been reported in as many as 20-23% of patients. For these patients, hysterectomy is likely the next best option for treatment.8
We know that the ability to preserve access to the uterine cavity after an endometrial ablation is vital for avoiding hysterectomy because it allows for evaluation of any post-ablation symptoms that may arise. However, in some instances, patients who have undergone endometrial ablation may present a diagnostic challenge due to extensive scarring of the uterine cavity post-procedure.
As stated earlier, bleeding may recur in some patients after having an endometrial ablation. Because these can also be symptoms of much more serious conditions, such as endometrial cancer, physicians must be able to access the cavity in order to provide the proper diagnosis. Unfortunately, studies have found that many of the evaluative tools traditionally used for endometrial cancer detection, including biopsy and transvaginal ultrasound, are often inadequate for assessing women who have previously received certain types of endometrial ablation.9
Therefore, it is reasonable to conclude that the combination of post-ablation symptoms that mimic endometrial cancer along with the prevalence of procedures that limit access to the uterine cavity may lead to more physicians performing hysterectomies even when they may not be medically necessary. In fact, according to John Hopkins Medicine, only approximately 10 percent of the 600,000 hysterectomies performed in the U.S. annually are done to treat cancer (either endometrial, cervical, or ovarian).10
One of the most important factors for maintaining post-ablation cavity access is the type of ablation modality used. Intrauterine scarring and contracture are common following many ablation procedures, especially those found in first-generation ablation devices that utilize heat-based thermal therapy.
Because heat-based thermal ablation uses heat to destroy the cells of endometrium, intrauterine scarring and contracture are not only an expected, but necessary, part of the healing process. Types of these thermal treatments include gas-based, liquid-based, and radio-frequency based. A 2009 study found that endometrial assessment was compromised after previous thermal endometrial ablation with endometrial biopsy failing in 23% of women.11
Fortunately, technological and scientific advancements have enabled the development of new global endometrial ablation (GEA) technologies that allow for post-ablation access to the uterus. One such treatment is cryotherapy. In this and other respects, the availability of cryotherapy for endometrial ablations has the ability to transform how we talk about patient satisfaction and success post-procedure.
Cryotherapy devices operate by freezing the lining of the uterus in order to significantly reduce future menstrual bleeding. In the uterus, cryothermic energy reduces the likelihood of scarring and adhesions while preserving the cavity for future visualization. Researchers followed 230 women who had been treated with the Cerene Cryotherapy Device. When patients underwent a diagnostic hysteroscopy at the Month 12 follow-up visit, they found that the uterine cavity was accessible in 220 of 223 women (98.7%).12
Cerene Cryotherapy Device is an FDA-approved, non-hormonal procedure that is well tolerated and requires no general anesthesia and minimal pain management. With 90% of patients reporting they were satisfied 1-year after treatment with durable results at 3 years, Cerene offers a number of benefits including low risk of re-intervention post-procedure:
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* Patient-reported data are 1 year after treatment with durable results at 3 years.
† Improvement reported one year after treatment for patients reporting severe/very severe period pain.
Barbara Levy, M.D. is a lifelong advocate for advancing the quality of women’s health. Dr. Levy was in private practice in comprehensive holistic women’s health for over 30 years and served as a Medical Director for Women’s and Children’s Services for the Franciscan Health System in Washington State. She has served as a reviewer and editor for several medical journals, including Obstetrics & Gynecology, American Journal of Obstetrics and Gynecology, JAMA, JMIG, Fertility and Sterility. Dr. Levy currently serves as a Board Advisor and consultant to Channel Medsystems.References:
Cerene® Cryotherapy Device is indicated to ablate the endometrial lining of the uterus in premenopausal women with heavy menstrual bleeding due to benign causes for whom childbearing is complete. Pregnancy following the Cerene procedure can be dangerous; therefore, contraception must be used until menopause. The Cerene procedure is not for those who have or suspect uterine cancer; have an active genital, urinary or pelvic infection; or an IUD. There are risks and considerations associated with the use of the Cerene Cryotherapy Device. Temporary side effects may include uterine cramping, vaginal infection, and lightheadedness. For detailed benefit and risk information, consult the Cerene Instructions for Use (IFU) or your healthcare professional. Learn more >