Is Amenorrhea the Optimal Endometrial Ablation Outcome?

Endometrial ablations were first introduced as a surgical treatment for heavy menstrual bleeding (HMB) in 1886.¹ Starting in the 1980s, global endometrial ablation (GEA) emerged as a less invasive and more convenient methodology to reduce excessive bleeding and painful menstrual cramping.² As GEA technology continued to evolve, especially with heat-based techniques, many OBGYNs shifted their focus to amenorrhea as the optimal treatment outcome.³ However, gynecologists must understand their patient goals and preferences, as well as clinical data, when determining an appropriate treatment plan.

Understanding Patient Goals

In addition to maintaining patient safety, the most important consideration gynecologists should account for when selecting HMB treatment is how to stay aligned with each individual’s goals and preferences. For many patients, this does not include amenorrhea. According to market research, 86% of women with HMB would characterize treatment success as a normal or better period.⁴ While endometrial ablation treatment should aim to reduce HMB to eumenorrhea or hypomenorrhea, the focus should primarily be on improving quality of life. Patients may wish to have a lighter or normal period for several reasons, including:⁵

• Monthly reassurance that they have not become pregnant
• They consider it to be an important part of womanhood
• A regular “cleansing” feeling that promotes connection with one’s health

Setting the Right Expectations

On top of understanding patient goals and preferences, gynecologists should clearly communicate what results patients should expect after endometrial ablation — namely, normal or lighter periods and less cramping. According to ACOG Practice Bulletin 81, although possible, amenorrhea is not the primary outcome of ablation.⁶ In fact, only up to 47% of procedures induce long-term amenorrhea, with many techniques generating much lower rates on average.⁷

The only way to guarantee amenorrhea is by excising the uterus altogether. If patients are looking to stop their periods, then a hysterectomy should be discussed as a definitive treatment option. Setting appropriate expectations for HMB treatment options, including endometrial ablations, should ensure that patients feel confident in the procedural efficacy and satisfied with their results. 

What is the Optimal Endometrial Ablation Outcome?

Instead of eliminating periods altogether, the focus should shift to a holistic treatment approach that specifically addresses the HMB symptoms impacting quality of life. Dysmenorrhea is often a chief complaint among women with menorrhagia; one systematic review and meta-analysis calculated a 71.1% prevalence rate of dysmenorrhea on a global scale.⁸ Severe pelvic cramping not only prevents patients from engaging in social activities, work, and school, but also reduces quality of life and significantly increases the risk of depression and anxiety.⁹

To best meet patient needs, gynecologists can utilize cryotherapy during endometrial ablation to deliver the dysmenorrhea relief their patients are looking for, while also reducing menstrual bleeding to normal levels or often better. The Cerene® Cryotherapy Device provides a safe, effective, and well-tolerated endometrial cryoablation procedure that not only helps 90% of patients return to normal, light, or no periods†, but also generates a significant reduction in dysmenorrhea — 86% of patients treated with Cerene experience a significant reduction in severe menstrual cramping following the procedure.‡

In addition to considering how each GEA modality impacts short-term outcomes, gynecologists should also consider long-term health and clinical options. Uterine cavity access should be considered a primary treatment outcome, as cavity visualization is crucial for future diagnostic evaluation for abnormal uterine bleeding. Postablative scarring can delay the diagnosis of endometrial cancer, as endometrial assessments, including endometrial biopsy and sonohysterography, are difficult to perform with intrauterine adhesions following thermal ablation.11.12 Additionally, intrauterine surgical trauma increases the risk of developing synechiae which, in turn, can generate post-ablation cyclic pelvic pain (CPP) and lead to postablation tubal sterilization syndrome (PATSS) in up to 10% of cases.^13-15 

These long-term ablation complications can be mitigated if patients are treated with cryotherapy. By resulting in minimal postablation intrauterine scarring and adhesion formation, Cerene provides full cavity access in 96% of patients and has no reported signs or symptoms of PATSS 12 months after treatment.^16,17

Dr. Barbara Levy discusses key benefits of Cerene for patients and gynecologists

Prioritizing a patient’s best interest both now and in the future means choosing a treatment modality that prevents unnecessary pain and unintended clinical consequences. With Cerene, you can deliver an endometrial ablation treatment that helps your patients achieve a higher quality of life and find long-term relief from painful, heavy periods.

Learn more at https://cerene.com/healthcare-professionals/ 

† 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

Key Takeaways: 

• Many gynecologists today believe amenorrhea is the most desired outcome for treatment of HMB.. However, most patients are looking for their treatment to provide a normal period or better.
• Gynecologists should set the right expectations about endometrial ablation, as amenorrhea is not a guarantee, and consider other important patient goals, such as a reduction in dysmenorrhea and improvement in quality of life.
• Cerene delivers a safe, effective, and well-tolerated treatment for the relief of HMB through endometrial cryoablation, and is clinically proven to reduce heavy bleeding, relieve severe menstrual cramping, and maintain cavity access in most uterine cavities.

Sources:

1. Wortman, M. (2018). Endometrial Ablation: Past, Present, and Future Part II. Surgical Technology International 33, 161-177.
2. Curlin, H. (2022, November 4). Endometrial ablation in the office setting. Contemporary OB/GYN Journal 67(11). 
3. Data on file. Channel Medsystems Market Research Inspired Health Survey 2023.
4. Data on file. Channel Medsystems Market Research Iris Survey 2014.
5. Cerene. (2023, June 7). Physician Testimonial – Barbara Levy [Video]. Vimeo. https://vimeo.com/833953747 
6. ACOG Committee on Practice Bulletins (2007). ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 81, May 2007. Obstetrics and gynecology, 109(5), 1233–1248.
7. SOGC Clinical Practice Guideline No. 322: Endometrial Ablation in the Management of Abnormal Uterine Bleeding. (2015). Journal of Obstetrics and Gynaecology Canada 37(4), 362-376.
8. Armour, M., Parry, K., Manohar, N., Holmes, K., Ferfolja, T., Curry, C., MacMillan, F., Smith, C.A. (2019). The Prevalence and Academic Impact of Dysmenorrhea in 21,573 Young Women: A Systematic Review and Meta-Analysis. Journal of Women’s Health 28(8). 
9. Sahin, N., Kasap, B., Kirli, U., Yeniceri, N., Topal, Y. (2018). Assessment of anxiety-depression levels and perceptions of quality of life in adolescents with dysmenorrhea. Reproductive Health 15(13). 
10. Curlin, H.L., Cintron, L.C., Anderson, T.L. (2020). A Prospective, Multicenter, Clinical Trial Evaluating the Safety and Effectiveness of the Cerene Device to Treat Heavy Menstrual Bleeding. Journal of Minimally Invasive Gynecology 28(4), 899-908.
11. McCausland, A.M. & McCausland, V.M. (2007). Long-term complications of endometrial ablation: cause, diagnosis, treatment, and prevention. Journal of Minimally Invasive Gynecology 14(4), 399-406.
12. Ahonkallio, S.J., Liakka, A.K., Martikainen, H.K., Santala, M.J. (2009). Feasibility of endometrial assessment after thermal ablation. European Journal of Obstetrics & Gynecology and Reproductive Biology 147, 69-71. 
13. Amin, T.N., Saridogan, E., Jurkovic, D. (2015). Ultrasound and intrauterine adhesions: a novel structured approach to diagnosis and management. Ultrasound in Obstetrics & Gynecology 46(2), 131-139.
14. Tam, T., Elgar, C., Jirschele, K., Lombard, E. (2012). Post-ablation tubal sterilization syndrome following NovaSure endometrial ablation: two case reports. Gynecological Surgery 9, 449-452.
15. Akinlaja, O. & Sherrow, S. (2014). Postablation Tubal Sterilization Syndrome. Austin Journal of Obstetrics and Gynecology 1(1), 2.
16. Curlin, H., Cholkeri-Singh, A., Leal, J. G. G., & Anderson, T. (2022). Hysteroscopic Access and Uterine Cavity Evaluation 12 Months after Endometrial Ablation with the Cerene Cryotherapy Device. Journal of Minimally Invasive Gynecology 29(3), 440-447.