Endometrial Ablation Periprocedural Care

Updated: Nov 30, 2016
  • Author: Stephanie Deter Pickett, MD; Chief Editor: Michel E Rivlin, MD  more...
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Periprocedural Care

Patient Education and Consent

Informed consent must be obtained. Patients should be counseled that endometrial ablation is not considered a form of sterilization and that subsequent pregnancies, though atypical, have been reported and are associated with a wide range of complications, including spontaneous abortion, abnormal placentation, preterm labor, preterm delivery, uterine rupture, and antepartum hemorrhage. [33, 34, 35, 36]

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Preprocedural Planning

Obtain a careful history, and perform a physical examination. Remove any indwelling intrauterine device (IUD) that may be present (this can be done at the same time as the procedure).

Preoperative endometrial preparation

Endometrial ablation is most effective when the endometrium is resected to the level of the basalis, which is approximately 4-6 mm deep. [37] Endometrial thinning before ablation has been shown to improve both the operating conditions and the initial postoperative outcome. The bipolar ablation device is the only global endometrial ablation (GEA) device that has been shown to work with equal effectiveness with or without pretreatment.

Danazol, medroxyprogesterone, and gonadotropin-releasing hormone (GnRH) agonists have been used to pretreat the endometrium and obtain atrophy. Best results are seen after 6 weeks of drug therapy. [37] GnRH analogues produce more consistent endometrial thinning. Notably, pretreatment with GnRH agonists or danazol before resectoscopic endometrial ablation (REA) results in higher amenorrhea rates at 12 months, shorter procedures, greater reported ease of surgery, and lower postoperative dysmenorrhea rates. [38]

Dilation and curettage can be performed immediately before ablation to thin the endometrial lining by mechanical means. This is particularly recommended with the thermal balloon device.

Finally, timing the procedure to the follicular phase of the menstrual cycle can be used in place of the aforementioned methods.

Preoperative cervical preparation

Preoperative cervical preparation regimens include both intraoperative cervical dilation and the use of preoperative oral or vaginal regimens aimed at cervical softening or dilation. These outpatient regimens typically involve the use of misoprostol either the evening before the procedure, the morning of the procedure, or both. Because of the minimally invasive nature of endometrial ablation procedures, aggressive dilation regimens are generally not required.

Antibiotic prophylaxis

At present, no randomized controlled data support routine use of prophylactic antibiotics for REA and GEA procedures. Furthermore, observational data reveal an extremely low risk of infection. Accordingly, the American Congress of Obstetricians and Gynecologists (ACOG) does not recommend the routine use of prophylactic antibiotics for endometrial ablation. [39] However, the use of preoperative antibiotics, especially in the office setting, is not uncommon.

Sterilization at time of ablation

Because endometrial ablation is not itself a method of permanent sterilization, patients sometimes elect to undergo concomitant elective tubal sterilization when undergoing endometrial ablation. The sterilization procedure may be performed laparoscopically either before or after the ablation. In addition, some GEA techniques have been successfully performed in conjunction with hysteroscopically guided intratubal placement of microinserts (Essure; Conceptus, Inc, Mountain View, CA) for sterilization.

Because these microinserts may transmit heat through the tubes, the operator should strongly consider delaying their placement until after completion of the ablation. It is worth noting that Conceptus has issued a warning against concomitant performance of ablation and Essure placement, on the grounds that postoperative development of uterine synechiae may compromise subsequent tubal occlusion testing (hysterosalpingography). [40]

In view of the lack of long-term data involving these concomitant hysteroscopic procedures, caution is advised in the implementation of such techniques.

Office-based ablation

All of the GEA devices described in this article may be used in the outpatient office setting. Many regimens for analgesia are available in this setting, including pain medications ranging from preoperative nonsteroidal anti-inflammatory drugs (NSAIDs) to oral or intramuscular narcotics and adjunct medications ranging from oral anxiolytics to intravenous (IV) sedatives. Anesthesia may range from local anesthesia to monitored anesthesia care by an anesthesiologist.

Even in settings outside the operating room, physicians must maintain the appropriate emergency and operative equipment and protocols for handling rare complications such as anaphylaxis or allergic reactions, significant vagal reactions, hemorrhage, uterine perforation, and pelvic organ injury.

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Preprocedural Evaluation

Laboratory testing

Urine human chorionic gonadotropin (hCG) testing can detect hCG levels as low as 20 mIU/mL (International Reference Preparation). The test becomes positive approximately 1 week after conception. Perform the test preoperatively on the day of surgery.

Endometrial ablation should not be performed in the presence of active pelvic infection; accordingly, gonorrhea and chlamydia testing is necessary.

Ultrasonography and hysteroscopy

Either pelvic ultrasonography or hysteroscopy is recommended to evaluate the uterine anatomy and measure uterine length before or at the time of the ablation. Ultrasonography may be used to assess for and measure intracavitary or submucosal myomas (see the images below).

Volume contrast imaging showing sagittal view of t Volume contrast imaging showing sagittal view of the uterus and endometrium (left) and coronal view of the endometrium with an endometrial polyp in the fundal region (arrow). Images courtesy of Noah Lazebnik, MD.
The orthogonal views (sagittal, axial and coronal) The orthogonal views (sagittal, axial and coronal), as well as the rendered 3D image of the endometrium, taken by vaginal 3-D ultrasound transducer. Images courtesy of Noah Lazebnik, MD.

Hysteroscopy is more commonly used before endometrial ablation to assess the length of the uterine cavity and to evaluate the internal architecture of the uterus. It can also visualize polyps, abnormally shaped cavities, and leiomyomas. The presence of these may be limitations to certain ablation techniques.

Endometrial biopsy

Endometrial biopsy is used to exclude endometrial hyperplasia and malignancy. For premenopausal patients in particular, endometrial biopsy can easily be accomplished in the office setting in most cases, and the results can be reviewed before ablation is scheduled. However, in patients unable to tolerate office biopsy or in clinical scenarios not amenable to sampling in the office, dilation and curettage with possible hysteroscopy is warranted to rule out premalignant and malignant conditions of the endometrium.

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Equipment

When no other abnormalities are present, preoperative imaging with transvaginal ultrasonography may be sufficient for achieving an accurate assessment of overall uterine size and shape. In cases of suspected uterine abnormalities, saline-infusion sonohysterography or office hysteroscopy may be used to characterize the uterine cavity and aid in proper selection of the ablation device.

Proper selection of a device for endometrial ablation should take into account the following factors:

  • Cavity size and shape
  • Previous uterine surgery
  • Location of procedure
  • Results of the preoperative evaluation

For many patients, medical therapy often controls abnormal uterine bleeding. However, failure of such therapy or inability to tolerate it is not an absolute prerequisite for endometrial ablation. [2] Patients with abnormal uterine bleeding secondary to systemic disease should be managed medically; the use of endometrial ablation in these patients requires further study.

Equipment for resectoscopic procedures

REA procedures include rollerball fulguration, laser fulguration, vaporization, and endomyometrial resection. All are performed under direct visualization and require a modified urologic resectoscope that uses radiofrequency (RF) alternating current (AC). [2] Resection via a loop electrode, [41] fulguration or desiccation via a barrel or ball-shaped electrode, [37] and vaporization via a pointed-tip electrode have been commonly performed through the resectoscope. [14, 42]

Equipment for global (nonresectoscopic) procedures

Devices that have been approved for use in GEA procedures include the following:

  • Thermal balloon ablation device (ThermaChoice; Ethicon, Somerville, NJ)
  • Hydrothermal ablation (HTA) device (Hydro ThermAblator and Genesys HTA; Boston Scientific, San Diego, CA)
  • Bipolar energy ablation device (NovaSure; Hologic, Bedford, MA)
  • Cryotherapy ablation device (Her Option; Cooper Surgical, Trumbull, CT)
  • Microwave endometrial ablation device (Hologic, Bedford, MA)

Thermal balloon ablation

With the ThermaChoice, a single-use silicon balloon-tipped catheter probe-handpiece measuring 4-5 mm is connected via a cable to a dedicated control unit. The heating element is contained within the balloon, and a separate port attached to the handpiece allows instillation of 5% dextrose in water (D5W) into the balloon. The control unit aborts the procedure if the temperature of the fluid in the balloon does not reach the appropriate level during the preheating phase.

Hydrothermal ablation

The Hydro ThermAblator includes a single-use 7.8-mm outer-diameter (OD) sheath that attaches to a variety of standard 3-mm OD hysteroscopes, which, in turn, provide intraoperative direct visualization of the procedure. Attached to the hysteroscope is a closed fluid circuit that uses normal saline; this is managed by the control unit. The control unit automatically aborts the procedure if more than 10 mL of fluid is lost, regardless of route.

Bipolar energy ablation

The NovaSure includes a single-use 7.2-mm OD probe-handpiece that is attached to a microprocessor-based control unit. A bipolar gold mesh electrode array is located on the end of the probe, wrapped around 2 extendable curved arms that deploy through retraction of the sheath. The probe is equipped with standardized deployment lengths (eg, depth of cavity), which the operator manually sets before inserting the probe on the basis of an initial sounding of the uterus.

In addition, the NovaSure insufflates carbon dioxide into the cavity, in fixed volume, to determine the integrity of the cavity. The current generation of the device does not allow activation of the ablation phase if the cavity does not pass this integrity test.

The NovaSure also employs a closed circuit to apply suction to the endometrial cavity for the evacuation of steam, debris, and blood during the ablation phase.

Cryoablation

Her Option includes a single-use 4.5-mm OD probe-handpiece that is attached via a cable to a control unit. The probe is inserted into the endometrial cavity, and 2-4 "freeze" locations are typically employed. The probe creates an elliptical ice ball measuring approximately 3.5 cm by 5 cm. The procedure is performed under abdominal ultrasonographic guidance; although this may require extra personnel, it gives the operator valuable visual feedback for proper treatment of the entire cavity.

Microwave endometrialablation

The microwave endometrial ablation device includes an 8-mm OD single-use probe as well as a reusable probe, either of which can be attached to a 9.2-GHz, 30-W control unit via a reusable cable. The probe is manually moved about the entire endometrium while the operator receives temperature monitoring data via the control unit. A marker located 4 cm from the tip of the probe helps the operator identify the cervicouterine junction and thus avoid inadvertent ablation of the cervix.

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Patient Preparation

Anesthesia

Several different anesthetic regimens may be used for endometrial ablation; the choice should be individualized on the basis of the patient’s characteristics and condition and the location of the procedure. Possibilities for anesthesia include the following:

  • No anesthesia
  • Paracervical block, with or without sedation
  • Regional anesthesia

Positioning

The patient can be placed in either the low or the high dorsal lithotomy position. Proper positioning techniques should be observed to minimize the risk of femoral or peroneal nerve injury; however, because these procedures are generally of short duration, they are already associated with a lower risk than longer procedures such as hysterectomy. Multipositional stirrups (eg, Yellowfin or Allen) generally support the legs better than traditional "candy cane" stirrups do, especially for patients with an increased body mass index.

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