Second generation endometrial ablation techniques: an audit of clinical practice
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- Madhu, C.K., Nattey, J. & Naeem, T. Arch Gynecol Obstet (2009) 280: 599. doi:10.1007/s00404-009-0982-7
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To audit the practice and effectiveness of second generation endometrial ablation techniques (microwave and thermal balloon ablation).
Design and methods
An audit of microwave and balloon endometrial ablation procedures was completed and performed during a 2-year period, in two district hospitals of Calderdale and Huddersfield NHS Trust, UK. Patients were followed up with for a maximum of 1 year postoperatively, or were referred again from their GPs, with symptoms. A questionnaire was also completed to evaluate patient satisfaction.
About 136 and 59 women underwent balloon and microwave endometrial ablation, respectively (Total = 195), for heavy periods. By the end of year 1, 16% of patients were amenorrhoeic and 60% had lighter periods. About 15% of women did not have any relief of symptoms and needed a hysterectomy by 3 years. There were no statistically significant differences in the endometrial ablation techniques. There was no significant effect of age, body mass index, utero-cervical length, or the ablation technique on the results or the hysterectomy rates. A satisfaction survey showed that 75% of women felt better after the procedure and would recommend it to a close friend.
Second generation ablation techniques are safe and effective methods of treating dysfunctional uterine bleeding, and are easy to use. They have reduced the incidence of hysterectomies and also have financial implications for healthcare providers.
KeywordsSecond generation endometrial ablation techniquesMicrowave endometrial ablationThermal balloon endometrial ablationMenorrhagiaPatient satisfaction
Heavy menstrual bleeding is one of most common gynaecological problems. It can affect a woman’s physical, social, emotional and/or material quality of life . In the early 1990s, it was estimated that at least 60% of women with heavy periods had a hysterectomy . This number is rapidly decreasing as a result of conservative surgical procedures. The first generation endometrial ablation techniques, introduced in the 1980s, like laser or loop resection and roller ball ablation, needed more surgical skills and expertise. Since the 1990s, second generation endometrial ablation techniques, such as Thermal balloon endometrial ablation (TBEA) and Microwave endometrial ablation (MEA), have been introduced and are rapidly replacing some first generation methods. They are easier, safer and equally effective to use compared to the previous generation .
This audit was aimed towards evaluating the practice and efficacy of these techniques. It was also an attempt to find out patient satisfaction.
Materials and methods
The department of obstetrics and gynaecology, Calderdale and Huddersfield NHS trust, UK, completed this audit. This was a retrospective audit and looked into 195 case notes of patients, who underwent either TBEA or MEA over a period of 30 months. (January 2003–August 2005) procedures were not randomised but chosen based on consultant choice and availability. Patients were identified from the gynaecology theatre database.
Patients, who had period problems, went to their GPs at the first instance and were treated with tranexamic acid, mefenamic acid and/or progesterones (including mirena). If such medical treatment failed or if they were refused treatment, then they were referred to secondary care. A thorough history was taken, and a clinical and gynaecological examination was conducted. Investigations were requested, if indicated. Investigations included a full blood count, ultrasound scan, hysteroscopy, or endometrial biopsy. Women with abnormal endometrial findings were excluded, and no pre-treatment was given with GnRH analogues. Trainees under supervision and/or consultants completed all the procedures. Intra-operative details and complications were recorded. Postoperative recovery and complications were also noted. Procedures were conducted as a day case or as inpatients (for medical and/or anaesthetic indications), under general anaesthesia. Analgesia was prescribed as required postoperatively.
A questionnaire was also designed to evaluate the impact of the procedure on quality of life. Questionnaires were designed by the audit team and were not validated. These questionnaires were sent out by post and collected by the audit department. Ethical committee approval was not taken as this was an audit and evaluating service provision.
Thermachoice® (Gynecare) , a uterine balloon therapy system, was used in 136 patients. Under general anaesthesia and aseptic precautions, the uterus is sounded to obtain the utero-cervical length. The balloon catheter is inserted through the cervix into the uterus. The balloon is then filled with sterile D5 W until the pressure reaches 160–180 mm Hg. The cycle is then initiated and the temperature in the balloon rises to 87°C. The therapy lasts for 8 min and is automatically deactivated. When the controller indicates completion, the balloon is deflated, and the catheter withdrawn and discarded.
Microwave endometrial ablation (MEA™, Microsulis)  was used in 59 patients. It utilizes an 8.5 mm diameter probe that delivers microwaves at a frequency of 9.2 GHz. The power delivered to the tissue is around 20 W. After cervical dilatation, the utero-cervical length is confirmed that it is between 5 and 12 cm. The probe is then inserted gently into the cavity, and the graduated measurements on the probe must agree with the measured cavity length before treatment can commence. The cavity is then treated, moving the probe from side to side, whilst gradually withdrawing the probe to treat the whole cavity. The yellow band on the probe corresponds to the internal os of the cervix, when treatment is stopped. A therapeutic temperature range of 75 and 80°C results in endometrial and superficial myometrial death.
A Total of 195 cases were reviewed. About 136 of them had had a balloon ablation, with 59 having had microwave endometrial ablation. All the patients presented with heavy periods. About 57% of them had irregular periods and 23% had painful periods at presentation. About 140 (72%) of the patients were more than 40 years of age. About 42 (22%) patients were obese with a body mass index (BMI) of more than 30.76 (39%) patients were overweight with a BMI of 25–30, and the rest had a BMI of less than 25. These differences were not statistically significant.
About 179 (87%) women had some form of failed treatment with progesterone, tranexamic acid, mefenamic acid, or mirena. The rest had no treatment and opted for endometrial ablation at the first instance. A pelvic ultrasound scan was completed on 52 (27%) patients for clinical indications. Fibroid uterus was the most common finding seen in eight patients, while the rest of them had normal findings. Endometrium was evaluated by hysteroscopy and/or endometrial biopsy. About 12 (6%) patients had endometrial polyps. The rest of the findings were within normal limits. About 172 (88%) cases were done as a day case procedure. The remaining 22 cases needed in-patient admission for medical and/or anaesthetic reasons. Trainees in gynaecology completed 50% of all the TBEA cases, whilst under consultant supervision. Consultants completed all the cases of MEA. About 108 (54%) cases had an utero-cervical length (UCL) of less than 8 cm. About 81 (42%) had a UCL of 8–12 cm. There was no record of UCL in six patients. Antibiotics were not routinely used, but 18 (9%) were given an intra-operative antibiotic, prophylaxis, at the clinicians request. There were no intra-operative or postoperative complications noted.
There was no routine policy for follow-up and this varied amongst clinicians. Some patients had follow-up in the gynaecology outpatient’s clinic, whilst others were followed by their general practitioners and if there were concerns, were referred back. 190 patients were followed up within 12 months of the postoperative period. Five patients did not have any follow-up. About 144 patients (75.2%) felt better symptomatically and were discharged. About 31 (16.3%) were amenorrhoic and 113 (59.5%) had lighter periods. About 46 patients (25.2%) still complained of heavy and/or irregular periods and opted to wait or to have a repeat procedure, or a hysterectomy. Three patients had a repeat BETA and one had a repeat MEA. About 29 (15%) patients in the group that followed had a hysterectomy for menorrhagia, by the end of 3 years from the procedure. Out of the 29 hysterectomies carried out, 19 (14% failure rate) patients had had a BETA and 10 (17% failure rate) patients had had an MEA. Histopathological examination of specimens showed no abnormality in 17 (59%), adenomyosis in seven (24%), and fibroid in four (14%). Further evaluation of such failures, revealed that 66% (n = 19) of patients were aged more than 40 years. BMI in the failure group were <25 (n = 8), 25–30 (n = 12) and >30 (n = 9); differences were statistically, not significant. Utero-cervical lengths were <8 cm (n = 16) and 8–12 cm (n = 13); differences were statistically, not significant.
Patient symptoms before and after the procedure (questionnaire)
Patient symptoms before the operation
Quite a lot
Patient symptoms following operation
There have been many developments in the field of endometrial ablation, and various methods exist to destroy the endometrium that induces iatrogenic Asherman’s syndrome. The first generation techniques have been reviewed extensively and results were very effective . The drawbacks are in the expertise used and patient morbidity. Second generation endometrial techniques were thus developed to avoid these drawbacks. Various techniques such as cryotherapy, fluid balloon, microwave and hydrothermablation are being introduced. These techniques are easier to use with less complications, with results being comparable to first generation techniques [1, 2, 5–8]. Economic modelling also suggests second generation techniques to be more cost effective than first generation ones .
At the end of 1 year, 16% of our patients were amenorrhoic and 60% had lighter periods. At the end of 3–5 years, 15% of patients had had a hysterectomy for period problems. Failure rates with TBEA and MEA were 14 and 17%, respectively. This difference was not statistically significant (P = 0.7505). Histopathological examination of the hysterectomy specimens showed adenomyosis (24%) and fibroids (14%), as the most common pathologies. No pathologies were found in the rest, implying the unknown nature of dysfunctional uterine bleeding.
Hodgson et al.  followed up patients following MEA for 3 years, and reported an amenorrhoea rate of 37% and lighter periods in 26% of patients. Overall the satisfaction rate was 84%. A number of review articles and meta analyses showed similar results [7, 8]. One review quoted an amenorrhoea rate of 65% and a hysterectomy rate after 5 years at 16% . A review of TBEA alone, or in comparison, showed a reduction in menstrual blood loss by 94%, and an amenorrhoea rate of 24% [7, 8]. The satisfaction rate was 94% .
A systematic review  of MEA and TBEA showed significantly shorter operating times than the first generation techniques, with fewer peri-operative adverse effects. They did not find any differences between the first and second generation techniques in terms of amenorrhoea, bleeding patterns, and patient satisfaction or quality of life.
About 81% of this study’s patients were happy with the procedure and 75% would recommend the procedure to a close friend, indicating a high patient satisfaction rate. The main drawback of the questionnaire used was that it was not validated. A number of studies have shown high patient satisfaction rates with second generation ablation techniques [5–9].
A procedure should be safe, easy to use and have fewer complications without compromising the result. Patient satisfaction should also be an important factor to determine the successful outcome of a procedure. Second generation endometrial ablation techniques seem to be fulfilling most of the criteria. Our audit showed similar results to various other studies, and has shown that second generation endometrial ablation techniques, both TBEA and MEA, were safe and effective. They also rated high in patient satisfaction.
Sincere thanks to Christine Ackroyd and all the staff of the Audit Department and the Department of Obstetrics and Gynaecology, Calderdale and Huddersfield NHS trust for their cooperation in completing this audit.
Conflict of interest statement
The authors declare no conflicts of interest.