Hysterectomy Ultimately Needed After 1 in 8 Endometrial Ablations

Hysterectomy rates can be expected to rise slowly in the months and years following endometrial ablation, regardless of ablation device type, a meta-analysis found.

Risk of hysterectomy rose to from 4.3% at 1 year post-endometrial ablation to 12.4% at 5 years in patients with heavy menstrual bleeding (HMB), reported Tamara Oderkerk, MD, of Maxima Medical Center and Maastricht University in the Netherlands, and co-authors.

Across 24,071 study participants, there weren't significant differences in hysterectomy rates by study design type or by specific nonresectoscopic endometrial ablation device, researchers reported in Obstetrics & Gynecology.

They suggested that clinicians counsel their patients about the risk of hysterectomy after endometrial ablation based on these results.

"Due to the broad variation in reported hysterectomy rates, it is difficult to inform patients properly, but providing realistic success and failure rates for endometrial ablation is crucial for their expectations and a well-informed decision-making process," Oderkerk's group noted.

Hysterectomy is an effective treatment for HMB, though less invasive options, such as taking oral contraceptive pills or tranexamic acid, or inserting levonorgestrel-releasing intrauterine system (LNG-IUS), are first-line options.

Endometrial ablation is a less invasive surgical treatment for HMB than hysterectomy. However, needing a hysterectomy after endometrial ablation is an indicator of treatment failure because it indicates that patients have continued to bleed enough to require further surgery.

Previous MedPage Today investigations into NovaSure, a popular endometrial ablation device, highlighted that women historically haven't known the true risks of endometrial ablation for menstrual distress. Some doctors have reconsidered whether it's an intervention they want to recommend, in part because it has been overprescribed in some cases.

Even so, Charlotte Pickett, MD, minimally invasive gynecologic surgeon at the University of California San Diego, said endometrial ablation is an important treatment option for women with HMB who would like to avoid hysterectomy.

"This study is important because it allows doctors to better counsel women on their options for treatment of heavy menstrual bleeding, giving them a better understanding of what to expect with the procedure, the potential risks, and benefits," she commented. The study also better described the timeframe over which women needed additional surgeries, which wasn't well documented before, she told MedPage Today.

Oderkerk and colleagues had identified 53 studies from 1992 through 2017 meeting inclusion criteria for the meta-analysis. Of the included studies, 24 were randomized controlled trials, 23 were prospective studies, and six were retrospective studies.

Most studies were published in 2000 or later (n=45) and took place in America (n=10) or Europe (n= 31). Studies varied in endometrial ablation techniques, with 16 using thermal balloon, 10 using microwave, nine using radiofrequency, eight using combination, and eight using other techniques.

For nearly all participants in the studies, follow-up lasted at least 12 months, with the longest follow-up being 10 years. Most studies were categorized as having intermediate bias (n=29) with some also considered at high risk of bias (n=13) and others low risk (n=11).

The researchers found that some of the more recent studies had lower rates of hysterectomy, which could reflect "a steeper learning curve among gynecologists with a better selection of patients or due to updated ablation techniques."

Pickett noted that although the meta-analysis was well designed, it faced similar data reporting limitations to other meta-analyses.

"Because many of the studies included within it relied on questionnaires to assess who ultimately underwent hysterectomy, it's possible that the number of women needing hysterectomy is underreported," she said.

She added that "this study only tells us about women with clear-cut indications for endometrial ablation who undergo nonresectoscopic techniques" but didn't add to scientific understanding about more complicated scenarios, such as uterine fibroids or structural abnormalities.

Comment