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Endometrial Ablation - Indications and Complications

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This is part of the Gynsurgery guidelines used in an educational setting for residents in Ob-Gyn.


Indications

  1. Postmenopausal bleeding and negative endometrial sampling and hysteroscopy (no polyps) but persistent bleeding and failed HRT or HRT contraindicated/refused
  2. Premenopausal age >35 with metrorrhagia with negative endometrial sampling and treated for abnormal bleeding hormonally for >=3 months with no resolution of abnormal bleeding (normal TSH and coagulation studies) and childbearing no longer desirable or possible and willing to accept normalization of menstrual flow as the outcome and not having significant pain with their bleeding episodes (possible adenomyosis)
  3. Premenopausal age 25-35 with menorrhagia or patient perceived heavy menstrual bleeding and treated for abnormal bleeding hormonally (either oral or IUCD) for >=3 months with no resolution of abnormal bleeding (normal TSH and coagulation studies) and childbearing no longer desirable or possible and willing to accept normalization of menstrual flow as the outcome and not having significant pain with their bleeding episodes (possible adenomyosis)

Contraindications

  1. Current or planned pregnancy
  2. Known or possible endometrial hyperplasia or carcinoma
  3. Active genital or urinary tract infection at time of procedure
  4. Active pelvic inflammatory disease
  5. Intrauterine device concurrently in place


Complications (2.5 - 10%)

  1. Cervical laceration
    1. Use graduated dilatators to dilate cervix to internal uterine os to size of hysteroscope or intrauterine instrument to be used
    2. Avoid excess downward traction on cervical tenaculum
  2. Uterine perforation
    1. At exam under anesthesia, determine version and flexion position of the uterus
    2. Put downward traction on cervical tenaculum to straighten out cervical-uterine axis
    3. Avoid excessive cephalad pressure with dilator
  3. Excessive Bleeding
    1. Introduce instruments into the uterus in the midline sagittal plane
  4. Ablation technique specific malfunction problems
    1. Follow instrument specific instructions precisely
  5. Postoperative hematometra
    1. Perform procedure in proliferative phase of cycle
    2. Suppress endometrial thickness preoperatively with LHRF agonists, progestins, OCPs or by concurrent suction currettage
    3. Assess that uterine size does not exceed device maximum (10-14cm)
  6. Infection (UTI, vaginitis, endometritis, bacteremia, fever) (4-8%)
    1. Preoperatively, culture for G.C. and Chlamydia if any discolored cervical mucous
    2. Preoperatively, culture urine if any symptoms of urinary frequency, urgency, dysuria or nocturia
    3. Avoid contaminating intrauterine instruments with vaginal blood and secretions
  7. Fluid distension media problems glycine solution with resectoscopic technique(hyponatremic fluid overload)
    1. Keep track of distension fluid used and returned; discrepancy to be less than 250ml
    2. Maintain intrauterine pressure at or below the patient’s mean arterial pressure
    3. Try to keep procedure less than 45 minutes
    4. Avoid preoperative overhydration
  8. Thermal injury (<=1%)
    1. Check weighted specula and other instruments for excessive heat
    2. Use instruments for ablation according to manufacturers’ instructions
  9. Interruption of an intrauterine pregnancy
    1. Test preoperatively within 48 hours of surgery for pregnancy in any reproductive age woman
    2. Avoid performing procedure in the luteal phase of menses in women without sterilization or using effective contraception
  10. Bladder, bowel or omental injury (<1%)
    1. Avoid uterine perforation
    2. If instrument penetration is suspicious for or strongly indicates uterine perforation, discontinue procedure
  11. Failure of procedure to normalize or stop menstrual bleeding (amenorrhea rate 15-55%, 5 yr satisfaction rate <65-75%)
    1. Perform procedure in proliferative phase of cycle
    2. Suppress endometrial thickness preoperatively with LHRF agonists, progestins, OCPs or by concurrent suction currettage
    3. Assess that uterine size does not exceed device maximum (10-14cm)
  12. Persistent uterine pain after procedure (<=10%)
    1. Assess degree of menstrual bleeding associated pain preoperatively
    2. If previous tubal ligation convey increased chance of pain

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