ENDOMETRIAL DESTRUCTIVE PROCEDURES
Although medical therapy is generally used first, more than half of women with menorrhagia undergo hysterectomy within 5 years of referral to a gynecologist. In at least a third of these, an anatomically normal uterus is removed. As alternatives to hysterectomy, less invasive procedures have been devised that either destroy or resect the endometrium and lead to amenorrhea in a manner similar to Asherman syndrome.
Currently acceptable procedures for endometrial resection or ablation employ laser, radiofrequency, electrical, or thermal energies (Oehler, 2003). They are considered as either first- or second-generation techniques according to their temporal introduction into use and their need for hysteroscopic guidance. A number of studies that compared first- and second-generation techniques have shown them equally effective.
After resection or ablation, 70 to 80 percent of women experience significantly decreased flow, and 15 to 35 percent of these develop amenorrhea. Increasing treatment failures due to endometrial regeneration accrue with time following the procedure. For example, in a long-term surveillance of 301 women following ablation, Martyn and coworkers (1998)reported that the cumulative failure rate increased from 13 percent at 2 years to 27 percent at 5 years. In these women, the amenorrhea rate remained relatively constant at approximately 40 percent. Vilos (2004) noted that subsequent hysterectomy approximated 12 percent by 5 years following ablation.
Although success rates for treatment of heavy bleeding are not as high as with hysterectomy, patient satisfaction rates are surprisingly comparable. Moreover, resection and ablation procedures have significantly lower complication rates when compared with hysterectomy.
Following ablation, later evaluation of the endometrium for recurrent abnormal bleeding can be challenging. Uterine cavity anatomy is often distorted by synechiae and uterine wall agglutination. The failure rate of endometrial sampling has been reported to be as high as 33 percent. Moreover, endometrial stripe evaluation by transvaginal sonography or hysteroscopic examination may be limited. Accordingly, endometrial ablation is not routinely recommended for patients at high risk for endometrial cancer
Very little known disorder called POST ABLATION SYNDROME in which blood no longer escapes the uterus because of scars or a stenosed cervix.
Postablation tubal sterilization syndrome: Some women who have undergone tubal ligation prior to endometrial ablation experience cyclic or intermittent pelvic pain. The proposed etiology is bleeding from active endometrium that is trapped in the uterine cornua. The incidence of this complication is as high as 10 percent in some reports. Prevention, diagnosis, and management of these symptoms are the same as for presentations of hematometra. In addition, some surgeons assess women with these symptoms laparoscopically and excise the tubal stumps to prevent the distension of the proximal tubal segments during menses.