Guideline No. 453: Endometrial Ablation in the Management of Abnormal Uterine Bleeding

Objective

To provide an update of the current evidence-based guideline on the techniques and technologies used in endometrial ablation, a minimally invasive technique for the management of abnormal uterine bleeding of benign origin.

Target Population

Women of reproductive age with abnormal uterine bleeding and benign pathology with or without structural abnormalities.

Benefits, Harms, and Costs

Implementation of the guideline recommendations will improve the provision of endometrial ablation as an effective treatment for abnormal uterine bleeding. Following these recommendations would allow the surgical procedure to be performed safely and maximize success for patients.

Evidence

The guideline was updated with published literature retrieved through searches of Medline and the Cochrane Library from January 2014 to April 2023, using appropriate controlled vocabulary and keywords (endometrial ablation, hysteroscopy, menorrhagia, heavy menstrual bleeding, abnormal uterine bleeding, hysterectomy). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies written in English.

Grey (unpublished) literature was retrieved from the Association of Obstetricians and Gynecologists of Quebec (AOGQ) in 2023.

Validation Methods

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

Intended Audience

Obstetricians, gynaecologists, and primary care providers.

Social Media Abstract

This is an updated version of the 2015 SOGC Endometrial Ablation guideline. The authors discuss special considerations, update evidence, and make new fluid deficit recommendations.

SUMMARY STATEMENTS

• 1.

  Endometrial ablation is a safe and effective minimally invasive surgical procedure that has become a well-established alternative to medical treatment or hysterectomy for abnormal uterine bleeding in select cases (high).

• 2.

  Medical preparation to thin the endometrium can be used to facilitate resectoscopic endometrial ablation and can be considered for some non-resectoscopic techniques. For resectoscopic endometrial ablation, preoperative endometrial thinning results in higher short-term rates of amenorrhea, decreased distension media fluid absorption, and shorter operative time when compared with no treatment (high).

• 3.

  Non-resectoscopic techniques are technically easier to perform than resectoscopic techniques, have shorter operative times, and can be done in procedure rooms rather than formal operating rooms. Both techniques have comparable results with respect to patient satisfaction and reduction of heavy menstrual bleeding (high).

• 4.

  Both resectoscopic and non-resectoscopic endometrial ablation have low complication rates. Uterine perforation, fluid overload, hematometra, and cervical lacerations are more common with resectoscopic endometrial ablation; perioperative nausea/vomiting, uterine cramping, and pain are more common with non-resectoscopic endometrial ablation (high).

• 5.

  All non-resectoscopic endometrial ablation devices available in Canada have demonstrated effectiveness in decreasing menstrual flow and result in high patient satisfaction. Device selection depends primarily on surgical judgement and the availability of resources. In general, non-resectoscopic endometrial ablation devices require the confirmation of a relatively normal endometrial cavity before device selection (high).

• 6.

  The use of local anaesthetic and blocks, oral analgesia, and conscious sedation allows for the provision of non-resectoscopic endometrial ablation in less resource-intensive environments, including regulated non-hospital settings (moderate).

• 7.

  Low-risk patients with satisfactory pain tolerance are good candidates to undergo endometrial ablation in settings outside the operating room or in free-standing surgical centres (moderate).

• 8.

  Endometrial ablation procedures do not increase the risk of cancer, do not cause delayed diagnosis of endometrial cancer, and may decrease the overall risk of endometrial cancer (high).

RECOMMENDATIONS

• 1.

  Preoperative assessment should be comprehensive to rule out any contraindications to endometrial ablation or to plan for concurrent management of fibroids, cavitary anomalies, or polyps (good practice point).

• 2.

  Patients should be counselled about the need for effective contraception following endometrial ablation (good practice point).

• 3.

  Recommended evaluations for abnormal uterine bleeding, including but not limited to endometrial sampling and an assessment of the uterine cavity, are necessary components of the preoperative assessment (good practice point).

• 4.

  Clinicians should be knowledgeable about complications specific to resectoscopic endometrial ablation, such as those related to fluid distension media and electrosurgical injury (good practice point).

• 5.

  For resectoscopic endometrial ablation, a strict protocol should be followed for fluid monitoring and management to minimize the risks associated with distension medium overload. The maximum threshold for hypotonic solution, such as glycine, is 1000 mL. The threshold for isotonic solutions, like sodium chloride, is up to 2500 mL in the absence of cardiopulmonary/renal disease (strong, high).

• 6.

  If uterine perforation is suspected to have occurred during cervical dilatation or with the resectoscope (without electrosurgery), the procedure should be discontinued immediately, and the patient should be closely monitored for signs of intraperitoneal hemorrhage or visceral injury. If the perforation occurs with electrosurgery or if the mechanism of perforation is uncertain, abdominal and pelvic exploration is warranted to obtain hemostasis and rule out potential visceral injuries (strong, high).

• 7.

  With resectoscopic endometrial ablation, if uterine perforation has been ruled out, acute hemorrhage may be managed by using one or more of these techniques: intrauterine Foley balloon tamponade, intracervical vasopressors injection, administration of rectal misoprostol, and systemic administration of tranexamic acid (conditional, moderate).

• 8.

  If repeat endometrial ablation is considered following non-resectoscopic or resectoscopic endometrial ablation, it should be performed by a skilled hysteroscopic surgeon with direct visualization of the cavity. Patients should be counselled about the increased risk of complications with repeat endometrial ablation (strong, moderate).

• 9.

  When considering endometrial ablation in patients with a history of cesarean delivery, resectoscopic techniques that allow direct visualization of the cavity and myometrial defect (isthmocele) should be used (good practice point).

• 10.

  Endometrial ablation may be considered in the setting of abnormal uterine bleeding related to adenomyosis. However, patients should be counselled that preoperative pain is an independent risk factor for endometrial ablation failure and subsequent hysterectomy, whether related to adenomyosis or other potentially comorbid conditions including endometriosis (strong, moderate).

• 11.

  Concomitant insertion of a levonorgestrel intrauterine system at the time of endometrial ablation may improve outcomes, but this practice is under investigation and has not been definitively established in any population (conditional, low).

• 12.

  If significant intracavitary abnormalities are present, resectoscopic endometrial ablation combined with hysteroscopic metroplasty, myomectomy, or polypectomy should be considered. The sequential use of a hysteroscopic tissue removal system and non-resectoscopic endometrial ablation device is not recommended owing to concerns regarding safety and significant additional cost (good practice point).

• 13.

  Residency training programs will need to continue to inculcate hysteroscopic skills as non-resectoscopic techniques cannot always be used for cases with cavity pathologies and anomalies. They are also associated with significant additional case costs (good practice point).

• 14.

  The presence of persistent abnormal uterine bleeding or uterine pain following endometrial ablation warrants a thorough investigation. If endometrial sampling cannot be performed, an ultrasound evaluation of endometrial thickness should be performed and hysterectomy considered (good practice point).