CHAPTER 156 Endometrial Ablation
For over a century, physicians have attempted a variety of methods to control abnormal uterine bleeding as an alternative to hysterectomy. It is estimated that nearly 50% of women will have significant, heavy menstrual bleeding during their lifetime, particularly during the fifth and sixth decades of life. In the late 1880s there was a report of a physician placing a uterine sound into the endometrial cavity of patients and attaching the sound to a series of batteries. It was noted that women who did not have uterine fibroids had significant improvement in their heavy bleeding. However, because of the lack of suitable equipment and delivery systems, interest in endometrial ablation for the treatment of abnormal bleeding was essentially nonexistent. The technique of dilation and curettage (D&C) was introduced and became the gold standard for the treatment of abnormal bleeding, even though this procedure continues to be ineffective in controlling abnormal uterine bleeding. More recently, different methods of hormone manipulation have been used with limited success.
Modern methods of achieving endometrial coagulation by heat had their beginning when Goldrath successfully used the neodymium-doped yttrium-aluminum garnet (Nd:YAG) laser in the early 1980s. His technique was quickly followed by other methods in which a urologic resectoscope was used to remove the endometrial lining. Resection was soon followed by rollerball endometrial ablation, in which the lining is not removed, but is destroyed by cauterization. For the past decade, the Nd:YAG laser, uterine resection, and rollerball ablation have been the primary methods used to control abnormal bleeding when hysterectomy was not desired and hormones were ineffective.
Endometrial ablation is safe, effective, efficient, and readily learned. It allows patients to address problematic vaginal bleeding from the endometrium while allowing them to keep their uterus. Methodologies that use hysteroscopy for visualization of the uterus are considered invasive. The newer techniques that do not require the use of hysteroscopy are termed minimally invasive nonhysteroscopic methods for endometrial ablation. This chapter covers the more contemporary approaches to endometrial ablation with a brief historical discussion of the classic techniques of rollerball, hysteroscopic methods of resection, and laser. At the end of the discussion, a table highlighting the U.S. Food and Drug Administration (FDA) comparative data on the five second-generation approaches is provided (Table 156-1). These data reflect the FDA Manufacturer and User Facility Device Experience (MAUDE) database review.
TABLE 156-1 Comparative Data from 2001 U.S. Food and Drug Administration Trial of Five Second-Generation Endometrial Ablation Devices

Advantages
Indications
The ideal candidate for endometrial ablation meets all of the following criteria. However, there are differences in indications and contraindications depending on which technique is used.
Prerequisite Conditions
Contraindications
Absolute
Relative
Equipment and Supplies
Because there are different systems that use supplies specific to the particular procedure, the following equipment/supply list provides the most often required supplies to perform the majority of the procedures. A list of equipment/supplies germane to each procedure is listed with each particular section.
Precautions
Endometrial ablation does not exclude the possible future development of endometrial cancer or pregnancy. Although the risks of these are low, patients should be made aware of this before undergoing the procedure. If a patient is on estrogen therapy after endometrial ablation, progestin supplementation is still necessary to prevent the development of atypical endometrium.
If the patient is still of childbearing age and pregnancy is a distinct although distant possibility, contraceptive measures should be taken to ensure pregnancy is prevented.
Preprocedure Patient Education and Forms
Endometrial ablation is such a life-altering procedure that it is the surgeon’s obligation to provide the patient with all of the information needed to understand all of the possible outcomes (see the example patient education form online at www.expertconsult.com). Some key elements of discussion are to emphasize that ablation may induce sterility but does not guarantee that pregnancy will not occur. Another element is that sexual desire should not be affected by the procedure. Because the endometrium is the only focus of treatment, and not the ovaries, hormonal cycles will continue if the patient is premenopausal.
Preprocedure Patient Preparation
Preoperative preparation in this manner can decrease surgical time, lessen fluid absorption, and improve safety and surgical outcome for the patient.
Appropriate anesthesia for these procedures varies with the procedure, patient, physician, and clinical setting. Paracervical block, sedation, regional anesthesia, general anesthesia, or a combination of these should be considered.
Procedure
The following descriptions summarize the procedures in the most succinct manner. However, the focus is on the more contemporary techniques, with as much detail as possible. Inclusion of the rollerball and laser ablation is of more historical rather than practical value given the advent of the more contemporary ablative techniques. Some of the new-generation techniques for endometrial ablation do not require the use of the hysteroscope and are termed minimally invasive nonhysteroscopic methods for endometrial ablation. Discussion of long-term success rates regarding issues such as amenorrhea, patient satisfaction, and the eventual need for hysterectomy is well covered in the references provided in the Bibliography.
Anesthesia
The anesthesia provided for the rollerball and laser procedures is usually general anesthesia, but with the new procedural approaches, paracervical block along with oral analgesics may be all that is required to effect adequate clinical comfort. The paracervical block is used in several of the new techniques (see Chapter 173, Paracervical Block).
Technique of Hysteroscopic Endometrial Ablation with Rollerball
A rigid (0-, 12-, or 30-degree viewing angle) hysteroscopic resectoscope (see Fig. 156-1) is necessary for this procedure.
For the surgeon to adequately visualize the entire uterine cavity, it must be distended with liquid. Operative hysteroscopy usually uses a low-viscosity medium that continuously flows into and out of the uterus, clearing out surgical debris and blood and improving the surgeon’s field of view. An inflow pressure of 80 to 110 mm Hg ensures optimal distention and continuous irrigation. An automated irrigation delivery system may be used, or a bag of distending medium is hung 1 m above the patient and produces distention through gravity. Distention media used during endometrial ablation include hypotonic agents such as glycine (1.5%), sorbitol (3%), or mannitol; isotonic agents such as normal saline; or the high-viscosity agent, dextran 70 (a viscous solution of 32% dextrose). Infused and collected fluid volumes are measured every 5 minutes, and consideration should be given to terminating the procedure if the fluid accumulation exceeds 1 to 1.5 L.
Procedure
Under sterile conditions, perform a standard bimanual pelvic examination to ascertain uterine position.
Complications
The media used to distend the uterine cavity during hysteroscopy can cause fluid overload, allergic reactions, and other toxic reactions. Fluid overload is associated with prolonged operating times and the use of high distending pressures.
Postprocedure Management
Consideration should be given to the use of postoperative antiemetics and pain medication. Options for pain control include nonsteroidal anti-inflammatory drugs (NSAIDs), opiates, and acetaminophen. The patient should be instructed to have a return appointment at the surgeon’s office within 1 to 2 weeks and be apprised of possible postoperative complications such as prolonged bleeding, vaginal discharge, infection, and abdominal discomfort.
Endometrial Laser Ablation
A resective hysteroscope with Nd:YAG laser attachment is necessary for this procedure.
Endometrial laser ablation is performed as an inpatient or outpatient procedure under general or regional anesthesia. A distention medium, usually normal saline, is delivered into the uterus by peristaltic pump, sphygmomanometer, or gravity, and uterine pressure is maintained between 80 and 100 mm Hg. The amount of medium is measured so that the development of fluid overload can be monitored. The Nd:YAG 600-µm fiber can produce 17,000 W/cm2 at 60-W power when maximally focused. Characteristic front-scatter, coagulation, and bubbling occur during the process. A 1200-mm microfiber at same power will produce 4200 W/cm2.
Procedure

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