SOGC CLINICAL PRACTICE GUIDELINE

No. 322, April 2015

Endometrial Ablation in the Management

of Abnormal Uterine Bleeding
Abstract
This clinical practice guideline has been reviewed by the
Clinical Practice–Gynaecology Committee and approved by Background: Abnormal uterine bleeding (AUB) is the direct cause
the Executive and Board of the Society of Obstetricians and of a significant health care burden for women, their families,
Gynaecologists of Canada. and society as a whole. Up to 30% of women will seek medical
assistance for the problem during their reproductive years.
PRINCIPAL AUTHORS
Objective: To provide current evidence-based guidelines on the
Philippe Laberge, MD, Quebec QC techniques and technologies used in endometrial ablation (EA),
a minimally invasive technique for the management of AUB of
Nicholas Leyland, MD, Ancaster ON
benign origin.
Ally Murji, MD, Toronto ON
Methods: Members of the guideline committee were selected on the
Claude Fortin, MD, Montreal QC basis of individual expertise to represent a range of practical and
Paul Martyn, MD, Sydney, Australia academic experience in terms of both location in Canada and
type of practice, as well as subspecialty expertise and general
George Vilos, MD, London ON background in gynaecology. The committee reviewed all available
evidence in the English medical literature, including published
CLINICAL PRACTICE–GYNAECOLOGY COMMITTEE guidelines, and evaluated surgical and patient outcomes for the
Nicholas Leyland, MD (Co-chair), Hamilton ON various EA techniques. Recommendations were established by
consensus.
Wendy Wolfman, MD (Co-chair), Toronto ON
Evidence: Published literature was retrieved through searches of
Catherine Allaire, MD, Vancouver BC MEDLINE and The Cochrane Library in 2013 and 2014 using
Alaa Awadalla, MD, Winnipeg MB appropriate controlled vocabulary and key words (endometrial
ablation, hysteroscopy, menorrhagia, heavy menstrual bleeding,
Sheila Dunn, MD, Toronto ON
AUB, hysterectomy). Results were restricted to systematic
Mark Heywood, MD, Vancouver BC reviews, randomized control trials/controlled clinical trials, and
observational studies written in English from January 2000 to
Madeleine Lemyre, MD, Quebec QC
November 2014. Searches were updated on a regular basis and
Violaine Marcoux, MD, Montreal QC incorporated in the guideline to December 2014.
Frank Potestio, MD, Thunder Bay ON Grey (unpublished) literature was identifies through searching the
David Rittenberg, MD, Halifax NS websites of health technology assessment and health technology-
related agencies, clinical practice guideline collections, clinical
Sukhbir Singh, MD, Ottawa ON trial registries, and national and international medical specialty
Grace Yeung, MD, London ON societies.

Disclosure statements have been received from all contributors. Values: The quality of evidence in this document was rated using the
criteria described in the Report of the Canadian Task Force on
The literature searches and bibliographic support for this Preventive Health Care (Table 1).
guideline were undertaken by Becky Skidmore, Medical
Research Analyst, Society of Obstetricians and Gynaecologists Results: This document reviews the evidence regarding the
of Canada. available techniques and technologies for EA, preoperative and
postoperative care, operative set-up, anaesthesia, and practical
considerations for practice.
Keywords: Endometrial ablation, hysteroscopy, menorrhagia,
heavy menstrual bleeding, abnormal uterine bleeding,
hysterectomy.
J Obstet Gynaecol Can 2015;37(4):362–376

This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information
should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate
amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be
reproduced in any form without prior written permission of the SOGC.

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 Endometrial Ablation in the Management of Abnormal Uterine Bleeding

Table 1. Key to evidence statements and grading of recommendations, using the ranking of the Canadian Task Force
on Preventive Health Care
Quality of evidence assessment* Classification of recommendations†
I: Evidence obtained from at least one properly randomized A. There is good evidence to recommend the clinical preventive action
controlled trial
II-1: Evidence from well-designed controlled trials without B. There is fair evidence to recommend the clinical preventive action
randomization
II-2: Evidence from well-designed cohort (prospective or C. The existing evidence is conflicting and does not allow to make a
retrospective) or case–control studies, preferably from recommendation for or against use of the clinical preventive action;
more than one centre or research group however, other factors may influence decision-making
II-3: Evidence obtained from comparisons between times or D. There is fair evidence to recommend against the clinical preventive action
places with or without the intervention. Dramatic results in
uncontrolled experiments (such as the results of treatment with E. There is good evidence to recommend against the clinical preventive
penicillin in the 1940s) could also be included in this category action

III: Opinions of respected authorities, based on clinical experience, L. There is insufficient evidence (in quantity or quality) to make
descriptive studies, or reports of expert committees a recommendation; however, other factors may influence
decision-making
*The quality of evidence reported in here has been adapted from The Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health
Care.51
†Recommendations included in these guidelines have been adapted from the Classification of Recommendations criteria described in the Canadian Task Force
on Preventive Health Care.51

Benefits, harms, and costs: Implementation of the guideline allow the use of local rather than general anaesthesia. However,
recommendations will improve the provision of EA as an effective both techniques have comparable patient satisfaction and
treatment of AUB. Following these recommendations would allow reduction of heavy menstrual bleeding. (I)
the surgical procedure to be performed safely and maximize
4. Both resectoscopic and non-resectoscopic endometrial ablation
success for patients.
(EA) have low complication rates. Uterine perforation, fluid
Conclusions: EA is a safe and effective minimally invasive option for overload, hematometra, and cervical lacerations are more
the treatment of AUB of benign etiology. common with resectoscopic EA; perioperative nausea/vomiting,
uterine cramping, and pain are more common with non-
Summary Statements resectoscopic EA. (I)
1. Endometrial ablation is a safe and effective minimally invasive 5. All non-resectoscopic endometrial ablation devices available in
surgical procedure that has become a well-established alternative Canada have demonstrated effectiveness in decreasing menstrual
to medical treatment or hysterectomy to treat abnormal uterine flow and result in high patient satisfaction. The choice of which
bleeding in select cases. (I) device to use depends primarily on surgical judgement and the
2. Endometrial preparation can be used to facilitate resectoscopic availability of resources. (I)
endometrial ablation (EA) and can be considered for some non- 6. The use of local anaesthetic and blocks, oral analgesia, and
resectoscopic techniques. For resectoscopic EA, preoperative conscious sedation allows for the provision of non-resectoscopic
endometrial thinning results in higher short-term amenorrhea EA in lower resource-intense environments including regulated
rates, decreased irrigant fluid absorption, and shorter operative non-hospital settings. (II-2)
time than no treatment. (I)
7. Low-risk patients with satisfactory pain tolerance are good
3. Non-resectoscopic techniques are technically easier to perform candidates to undergo endometrial ablation in settings outside the
than resectoscopic techniques, have shorter operative times, and operating room or in free-standing surgical centres. (II-2)
8. Both resectoscopic and non-resectoscopic endometrial ablation
are relatively safe procedures with low complication rates. The
ABBREVIATIONS complications perforation with potential injury to contiguous
AUB abnormal uterine bleeding structures, hemorrhage, and infection. (II-2)

CS Caesarean section 9. Combined hysteroscopic sterilization and endometrial ablation

can be safe and efficacious while favouring a minimally invasive
D&C dilatation and curettage approach. (II-2)
EA endometrial ablation
FDA United States Food and Drug Administration Recommendations

GnRH gonadotropin releasing hormone 1. Preoperative assessment should be comprehensive to rule out
any contraindication to endometrial ablation. (II-2A)
HSG hysterosalpingogram
2. Patients should be counselled about the need for permanent
LNG-IUS levonorgestrel intrauterine system contraception following endometrial ablation. (II-2B)
NSAIDS non-steroidal anti-inflammatories
3. Recommended evaluations for abnormal uterine bleeding,
RCT randomized control trial including but not limited to endometrial sampling and an

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SOGC clinical practice guideline

assessment of the uterine cavity, are necessary components of

the preoperative assessment. (II-2B)
performed in 2000. EA is now more prevalent than vaginal
hysterectomy in Quebec. However, the impact of EA on
4. Clinicians should be vigilant for complications unique to
resectoscopic endometrial ablation such as those related to fluid hysterectomy rates remains uncertain. American statistics
distention media and electrosurgical injuries. (III-A) from 6 states show EA being used as an “additive medical
5. For resectoscopic endometrial ablation, a strict protocol should be technology rather than a substitute” for hysterectomy.1 In
followed for fluid monitoring and management to minimize the risk the United Kingdom, there has been a significant reduction
of complications of distension medium overload. (III-A) in hysterectomy rates over the past 20 years, explained in
6. If uterine perforation is suspected to have occurred during cervical part by both improved medical treatment and increased
dilatation or with the resectoscope (without electrosurgery),
the procedure should be abandoned and the patient should be
use of EA techniques.2,3 EA improves treatment access for
closely monitored for signs of intraperitoneal hemorrhage or those women who have AUB and provides an alternative
visceral injury. If the perforation occurs with electrosurgery or if the to major procedures such as hysterectomy.
mechanism of perforation is uncertain, abdominal exploration is
warranted to obtain hemostasis and rule out visceral injury. (III-B) In the past 10 years alone there have been more than 600
7. With resectoscopic endometrial ablation, if uterine perforation publications on the subject of EA. This guideline reviews
has been ruled out acute hemorrhage may be managed by using
intrauterine Foley balloon tamponade, injecting intracervical
the indications and contraindications for performing
vasopressors, or administering rectal misoprostol. (III-B) EA (Table 2) and compares resectoscopic and non-
8. If repeat endometrial ablation (EA) is considered following non- resectoscopic techniques. The document also includes
resectoscopic or resectoscopic EA, it should be performed by discussions of operative set-up, anaesthesia, preoperative
a hysteroscopic surgeon with direct visualization of the cavity. and postoperative care, and some special considerations
Patients should be counselled about the increased risk of
complications with repeat EA. (II-2A)
in clinical practice. A patient information sheet has been
included to help patients better understand the benefits
9. If significant intracavitary pathology is present, resectoscopic
endometrial ablation combined with hysteroscopic myomectomy and limitations of this procedure (Appendix).
or polypectomy should be considered in a non-fertility sparing
setting. (II-3A)
COMPARISON OF EA TO OTHER THERAPIES

INTRODUCTION EA Versus LNG-IUS

The LNG-IUS is a simple treatment option for women with

E ndometrial ablation refers to a number of minimally

invasive surgical procedures designed to treat AUB,
which is defined as changes in frequency of menses,
AUB and is more cost-effective than any surgical technique,
including EA. In one meta-analysis of 6 randomized trials,
LNG-IUS and EA had similar patient efficacy up to 2 years
duration of flow, or amount of blood loss. EA consists of after treatment.4 A Cochrane review concluded that EA
targeted destruction or removal of the endothelial surface and LNG-IUS had similar patient satisfaction, although
of the uterine cavity in selected women who have no desire EA was associated with a greater reduction in menstrual
for future fertility. The procedure was designed to treat bleeding.5 During the first 6 months of use, the LNG-
heavy menstrual bleeding refractory to medical therapy IUS may be associated with a number of progestogenic
and not caused by structural uterine pathology. It is a less side effects including but not limited to irregular bleeding,
invasive alternative to hysterectomy. breast tenderness, and headache.

Although endometrial destruction through the endocervical CLINICAL TIP

canal dates back to 1937, this technique became more This option (LNG-IUS) should be discussed prior to any surgical
widely adopted in 1981 with laser EA, followed by rollerball option for women with AUB and a normal cavity.
and loop resection in the late 1980s. In the last 20 years,
non-resectoscopic ablation techniques have become EA Versus Hysterectomy
available. They use different energy sources to achieve In a review of 9 prospective randomized clinical trials,
endometrial destruction of the endometrium, including hysterectomy was associated with improved control of pain
heated liquid (either free circulating or confined within and bleeding.6 In another study at 4 years’ follow-up 98%
a balloon), radiofrequency electricity, and tissue freezing. of women in the hysterectomy group versus 85% in the EA
Currently, 6 of these systems are available in Canada. The group were satisfied.7 However, hysterectomy was associated
use of microwave energy has been discontinued in Canada. with a higher risk of adverse events, severe complications,
and longer hospital stay. In a large retrospective study with
According to the Association of Obstetricians and 11 years’ follow-up, risk of surgery for subsequent pelvic
Gynecologists of Quebec, 3646 cases of EA were floor repair and stress urinary incontinence associated with
performed in Quebec in 2012, more than twice those EA was lower than with hysterectomy.8 Although the direct

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 Endometrial Ablation in the Management of Abnormal Uterine Bleeding

costs of EA are about half that of hysterectomy, it seems Table 2. Indications and contraindications to EA
that the costs of the 2 procedures become equivalent at 4 Indications
years because some women with EA will need additional • AUB of benign origin
treatment. Age < 40 years, prior tubal ligation, and • EA may be considered as a primary intervention in
preoperative dysmenorrhea are independent predictors of circumstances such as intolerance to or failure of medical
EA failure and subsequent re-intervention.9,10 therapy, or patient preference
• EA may be considered for patients who refuse or are poor
Summary Statement surgical candidates for hysterectomy
1. Endometrial ablation is a safe and effective Absolute contraindications
minimally invasive surgical procedure that has • Pregnancy
become a well-established alternative to medical • Desire to preserve fertility
treatment or hysterectomy to treat abnormal uterine • Known or suspected endometrial hyperplasia or cancer
bleeding in select cases. (I) • Cervical cancer
• Active pelvic infection
Recommendation • Specific contraindications related to non-resectoscopic
1. Preoperative assessment should be comprehensive techniques*
to rule out any contraindication to endometrial *See “Special Considerations”

ablation. (II-2A)
amenorrhea rates at 12-month follow-up were 39% for
PREOPERATIVE AND POSTOPERATIVE CARE endometrial preparation with GnRH agonists compared
with 34% for danazol, 26% for medroxyprogesterone
Preoperative Care acetate, and 18% for D&C.14
The work-up of patients with AUB and the algorithm for
decision-making have been previously described.11 The use of endometrial preparation prior to non-resectoscopic
EA will depend on the product monograph for each individual
Patients must not desire future fertility as serious maternal– device. Meta-analysis of a few randomized trials on second-
fetal complications have been reported in pregnancies generation devices (radiofrequency ablation and balloon
following EA (uterine rupture causing maternal death, devices) suggest that preoperative endometrial thinning does
limb defects, premature labour).12 Therefore, women must not improve postoperative rates of amenorrhea.13
be counselled that EA is not considered a sterilization
method. Women must also be appropriately counselled No RCTs have yet supported or refuted the role of
about realistic expectations of ablation outcomes. The antibiotic prophylaxis before EA by any technique.15
goal of EA is to reduce bleeding symptoms; amenorrhea,
although possible, cannot be guaranteed. Postoperative Care
Patients can usually be discharged within 1 to 3 hours
Endometrial preparation can be considered preoperatively of EA depending on the type of anaesthesia used. They
as a thin endometrium can improve visualization for the can resume their normal activities progressively, but are
resectoscopic techniques and improve patient outcomes. advised to abstain from sexual intercourse for one week.
A thin endometrium can be achieved by scheduling Pain can be managed with NSAIDS or opiates, and will
the procedure in the immediate post-menstrual phase, usually resolve within 24 hours. Light vaginal bleeding or
performing curettage prior to the procedure or administering pinkish discharge is usual and can last up to several weeks
of preoperative hormonal therapy. A systematic review following the procedure. Patients are counselled to seek
suggested that preoperative endometrial thinning with GnRH medical care if they have fever, intense pain, or profuse
agonists and danazol resulted in higher rates of amenorrhea vaginal bleeding.
at 12 and 24 months than placebo/no treatment.13 Whether
or not this difference is maintained beyond 24 months is Summary Statement
uncertain. GnRH agonists and danazol also had a beneficial 2. Endometrial preparation can be used to facilitate
effect on the intrauterine operating environment with resectoscopic endometrial ablation (EA) and can be
respect to shorter operating time and reduced absorption of considered for some non-resectoscopic techniques.
distention media. The disadvantages of these agents include For resectoscopic EA, preoperative endometrial
the costs and side effects. Randomized data assessing the thinning results in higher short-term amenorrhea
value of progestins in preoperative endometrial thinning rates, decreased irrigant fluid absorption, and
prior to EA are scarce. In a study of resectoscopic EA, shorter operative time than no treatment. (I)

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SOGC clinical practice guideline

Recommendations further endometrial proliferation. Operative hysteroscopy,

first described by Neuwirth in 1976, involved resection
2. Patients should be counselled about the need for
of submucosal myomas using a modified urological
permanent contraception following endometrial
resectoscope.18 Laser ablation was described by Goldrath
ablation. (II-2B)
in 1981,19 but lost favour due to its expense and
3. Recommended evaluations for abnormal uterine
unreliability. Loop electrode and rollerball ablation using
bleeding, including but not limited to endometrial
bipolar or monopolar radiofrequency electrosurgery were
sampling and an assessment of the uterine cavity,
subsequently described by DeCherney and Polan in 1983
are necessary components of the preoperative
and Lin et al. in 1988, as reported in a previous summary
assessment. (II-2B)
of ablation techniques.20

CLINICAL TIP Patients are placed in supported lithotomy position

Required investigations prior to EA include: and the cervix dilated to at least 10 mm. Most operative
• pregnancy test, hysteroscopic systems employ a 9 mm (27 French)
• Papanicolaou test within 2 years, scope. Hysteroscopes are usually rigid, with operative
• cervical cultures if clinically appropriate, hysteroscopy using 12, 15, or 30 degrees of angulation.
• endometrial sampling, and After uterine distension is achieved, the cavity is inspected
• assessment of uterine cavity for Müllerian anomalies or and endometrial lesions or abnormalities are mapped.
intracavitary pathology using transvaginal ultrasound, Importantly, intrauterine landmarks (tubal ostia, internal
contrast infusion sonography, or diagnostic hysteroscopy.
cervical os, and/or the characteristic appearance of the
(See also SOGC Clinical Practice Guideline No. 292, Abnormal
Uterine Bleeding in Pre-Menopausal Women.11) endometrium) are identified to confirm that the cavity has
Because it is often difficult to interpret residual menstrual discharge been entered and ensure that the operator has not created a
post procedure, the efficacy of the EA should be assessed no false passage. Focal lesions are biopsied, resected, and sent
earlier than 6 to 12 weeks postoperatively. separately to the pathology laboratory.

The rollerball is used at the fundus and ostial regions with

COMPARISON OF RESECTOSCOPIC AND
NON-RESECTOSCOPIC EA TECHNIQUES a touch technique applying no pressure. The treatment
endpoint is a visual change in the endometrium to a yellow-
The first-generation techniques introduced in the 1980s brown honeycomb appearance indicating myometrial
consisted of targeted endometrial destruction under direct tissue has been reached. Tissue destruction to a depth of
hysteroscopic visualization. These techniques included 4 to 6 mm will usually destroy the basal endometrial layer.
laser ablation and electrosurgical endometrial resection The uterine walls can be ablated with the ball electrode
or ablation. Despite their efficacy, the first-generation or resected using the loop electrode, which also provides
methods had certain disadvantages. They required a skilled a specimen for histology. The electrode should always
hysteroscopic surgeon and an operating room environment. be visible, in contact with tissue, and moving toward
Their uncommon but serious complications of fluid the surgeon when activated. Prolonged activation of the
overload and uterine perforation led to the advent of electrode should be avoided to prevent capacitive coupling
simpler, less user-dependant alternatives. and other causes of electrosurgical injuries. The surgeon
should avoid ablating beyond the cervico-uterine junction
These second-generation techniques, also known as non- to avoid cervical stenosis.
resectoscopic ablation, use a variety of energy sources to
non-selectively destroy the endometrial lining. The advantage Endometrial polyps and small submucosal fibroids
of these newer technologies is that they require shorter can be resected using the resectoscope, but larger
surgical time and less specialized training, and they can be (> 3 cm) myoma resection requires advanced operative
performed in the outpatient setting. They also help to avert hysteroscopy skills. Endometrial resection may result in
complications associated with the use of fluid distention more fluid absorption, which is associated with longer
media while achieving similar clinical outcomes.16 For operating times.16
these reasons non-resectoscopic procedures have become
increasing popular.17 Use of a fluid management system is recommended.
Bipolar resectoscopic systems require the use of normal
Resectoscopic EA saline as a distention medium, thereby eliminating concerns
Resectoscopic endometrial resection/ablation is an about hyponatremia; however, large quantities of normal
attempt to destroy the basal endometrial layer to prevent saline can still result in fluid overload complications.

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 Endometrial Ablation in the Management of Abnormal Uterine Bleeding

Efficacy of Resectoscopic EA serum sodium, it is less likely to cause cerebral edema than
Early studies reported high rates of improvement in heavy the absorption of hypotonic media.
menstrual bleeding and high rates of patient satisfaction.
O’Connor and Magos reported a 20% repeat surgery rate Fluid absorption increases significantly when intrauterine
including a 9% hysterectomy rate over 5 years follow-up in a pressure exceeds mean arterial pressure. For every 100 mL
group of 525 patients undergoing endometrial resection.21 of non-electrolyte solution absorbed, serum sodium falls
Martyn and Allan reported similar results with a repeat by 1 meq. Electronic fluid management systems provide an
surgery rate of 19.2% including an 11.6% hysterectomy accurate measurement of fluid deficits and can safeguard
rate at 5 years of follow-up.22 The presence of fibroids and against complications of excess absorption. Excess absorption
dysmenorrhea did not increase the risk of failure. of isotonic solutions may be less dangerous than absorption
of hypotonic solutions because there is a smaller chance of
A meta-analysis of 21 randomized trials comparing cerebral edema. Excessive fluid absorption may be prevented
different resectoscopic techniques of endometrial by pre-treatment of the endometrium,14 intracervical
destruction showed no difference in rates of amenorrhea injection of pressor agents (vasopressin, epinephrine) and the
and subsequent hysterectomy.16 First-generation techniques use of distension pressure less than that of the patient’s mean
showed improvement in bleeding in 72.5% to 79.5% at arterial pressure. Electronic fluid monitoring systems, which
1-year follow-up and high patient satisfaction rates. allow regulation of the flow rate, infusion pressure, outflow
suction, and fluid deficit may be more accurate in calculating
Advantages and Disadvantages of Resectoscopic EA fluid deficits than traditional gravity infusion systems and
Compared with the non-resectoscopic techniques, the manual estimation of fluid deficit.
resectoscopic EA offers certain advantages. It allows for
accurate assessment of uterine pathology with directed Non-resectoscopic EA
biopsies, documentation with photography, and concurrent Currently various energy sources are used in 6 non-
treatment of intracavitary pathology. It can also be used resectoscopic EA devices approved by Health Canada:
in patients who have had previous EA or transmyometrial bipolar radiofrequency ablation(NovaSure), cryotherapy
surgery. However, resectoscopic EA is a skill-dependent (Her Option),23 heated fluid freely circulated in the uterine
procedure that requires an operative room environment cavity (Hydro ThermAblator), and fluid contained in a
and has a higher complication rate than non-resectoscopic balloon (Thermachoice, Thermablate EAS, and Cavaterm).
methods. Specifications of each of these devices are compared in
Table 3. Future technologies such as the Aurora ablation
Distending Media for Resectoscopic EA system (radiofrequency energy and heated Argon gas
Distending media provide uterine distension and irrigate forming plasma energy) have promising preliminary results.24
blood and tissue fragments from the surgical field. A non-
electrolyte solution is required for monopolar resectoscopic In the absence of large differences in effectiveness and
surgery, but normal saline can be used with bipolar systems. with low complication rates for each of the devices, the
The following are common distending media: choice of which to use depends primarily on the following
practical issues and patient factors:
Conductive solutions (electrolytic/crystalloids)
•• availability of scientific evidence
•• Normal saline (290 mOsm/L): isotonic/isonatremic
•• cost effectiveness
Non-conductive (non-ionic, non-electolytic) •• surgeon preference
•• mannitol (275 mOsm/L): isotonic/hyponatremic, •• ease of use in outpatient/clinic setting
induces diuresis
•• requirement of endometrial preparation
•• glycine 1.5% (200 mOsm/L): hypotonic/hyponatremic;
acidic with a pH of 6.1 •• uterine cavity characteristics (size, cavitary pathology)
•• sorbitol 3.3% (165 mOsm/L): hypotonic/
CLINICAL TIP
hyponatremic
• For safety and appropriate intracavitary device placement,
•• cystosol (mannitol 0.54% and sorbitol 2.7%): pre- and post -procedural diagnostic hysteroscopy or
isotonic/hyponatremic intraprocedural ultrasound guidance may be considered.

• The balloon technologies involve coagulation of the

Osmotically active particles must be added to hypotonic endometrium that eventually leads to fibrosis. The maximum
solutions to prevent complications from fluid absorption. effect of this process is seen at 6 months post procedure rather
Although absorption of isotonic fluids may also lower than the 2 to 4 weeks seen with other technologies.

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 Table 3. Comparison of non-resectoscopic endometrial ablation devices
Mechanism Device Treatment
of action size (mm) time (min) Advantages Disadvantages Procedural points
Novasure Bipolar 7.2 1 to 2 Rapid treatment time Cavity limitations After cervical dilatation to Hegar 8 (25 fr), the device
radiofrequency (mostly suitable for is inserted against the fundus then slightly retracted.
No endometrial preparation
normal cavities) It is deployed after proper seating. Pending a CO2
required
Cost of disposable perforation detection check, negative pressure is
High amenorrhea and applied and power is delivered until 50 Ohms of
equipment

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satisfactioes tissue impedance is reached. Blood/steam from the
Seating the device cavity is removed during the procedure.
requires practice
SOGC clinical practice guideline

Her Option Cryo-ablation 5.5 10 to 18 Minimal anaesthesia Long treatment time After cervical dilatation to Hegar 5–5½ (15 fr), a
at −90°C disposable 4.5mm cryoprobe is used to form an
Minimal or no cervical Variability of outcome
dilatation data23 elliptical freezing zone starting at both cornua.
Concurrent trans-abdominal ultrasound allows
Able to treat larger cavities Requires ultrasound visualization of the freezing process. Frequently
guidance and hormonal additional applications are necessary to treat the
endometrial preparation lower uterine body.
Hydro- Saline at 90°C 7.8 3 to heat Direct visualization of Requires hormonal After cervical dilatation, a disposable sheath that
Therm- circulated freely fluid, 10 treatment effect endometrial preparation adapts to a 2.7–3.0 mm hysteroscope is inserted.
Ablator to treat The fluid is heated to target temperature for 3 min
Able to treat irregular Safety: fluid leaks may
followed by a 10 min treatment time under direct
cavities (fibroids) cause burns
visualization. Loss of more than 10 mL of fluid
Short learning curve Long treatment time (through the cervix or the Fallopian tubes) will shut
the system off automatically.
Hot liquid-filled silicone balloon devices
Therma- 5% dextrose 5.5 8 Short learning curve Cramping from balloon The cervix is dilated, the cavity is measured, and the
choice III at 87°C distention pear-shaped balloon catheter is inserted. Automated
Long-term safety and
treatment maintains a pressure of 180 to 185
effectiveness data Long treatment time
mmHg. Safety features monitor and prevent excess
temperature and pressure. Endometrial preparation
(hormonal/mechanical) is optional.
Thermablate Glycerine 6 2.2 Short learning curve RCT results not yet Fluid takes 8 min to heat prior to catheter insertion.
EAS at 173°C available During the treatment, the balloon undergoes serial of
Rapid treatment time
pressurizations (200 mmHg) and depressurizations.
Fluid pressure is monitored by transducers that
react to contractions or relaxations of the uterus.
Endometrial preparation (hormonal/mechanical)
is optional.
Cavaterm 1.5% Glycine 8 10 Simple to use Cramping During the treatment, the fluid is maintained at
at 75°C to 80°C approximately 200 mmHg. A safety mechanism
Adjustable balloon length Long treatment time
will stop the procedure if it exceeds 250 mmHg.
Endometrial preparation (hormonal/mechanical)
is optional.
 Endometrial Ablation in the Management of Abnormal Uterine Bleeding

Comparing the Efficacy of Non-resectoscopic Devices compared resectoscopic and non-resectoscopic techniques
Patient satisfaction and re-intervention rates may be and reported similar amenorrhea rates at 1 year (37% vs.
more clinically meaningful than absolute amenorrhea 28%) and at 2 to 5 years (53% vs. 48%).16 Because women
rates in comparing outcomes of procedures using non- who suffer from menorraghia are likely to be satisfied with
resectoscopic devices. All of these devices work well and either hypomenorrhea or normal menses, satisfaction rates
lead to high levels of patient satisfaction, as demonstrated for both types of ablations are high.32 In the Cochrane
by the FDA’s pivotal trials that showed satisfaction rates of meta-analysis, satisfaction rates were also comparable at 1
86% to 99% at 1 year.25 year (91% vs. 88%) and at 2 to 5 years (93% vs. 87%).16 In
an updated analysis of 25 RCTs with over 4000 patients,
Direct comparisons of non-resectoscopic devices are the rates of amenorrhea and patient satisfaction were not
scarce, and differences between trials with respect to significantly different, even up to 10 years after surgery.33
outcome measures, preoperative endometrial preparation, The surgical re-intervention rate (repeat ablation and/or
practice settings, and follow-up times make it challenging hysterectomy) for AUB has been reported to be similar
to compare outcomes accurately. NovaSure radiofrequency between techniques (21% vs. 25% at 2 to 5 years).16
ablation has been the most studied in randomized trials However, analysis of studies with longer follow-up shows
comparing it with Hydro ThermAblator and the hot liquid that non-resectoscopic EA has a lower re-intervention rate
balloons Thermachoice and Cavaterm. (RR 0.6, 95% CI 0.38 to 0.96) than resectoscopic EA.33

NovaSure versus Hydro ThermAblator Although clinical outcomes between techniques were
At 12 months’ follow-up, NovaSure had significantly higher comparable, non-resectoscopic procedures required
rates of patient satisfaction (87% vs. 68%) and amenorrhea shorter surgical time, were more likely to be performed
(47% vs 24%) than Hydro ThermAblator.26 This benefit under local anaesthesia, and resulted in patients’ quicker
persisted at 5 years, with NovaSure having significantly return to normal activity.32,33 The overall perioperative
higher satisfaction rates (81% vs. 48%), higher amenorrhea complication rate was low with both techniques (< 2.5%
rates (55% vs. 37%), and fewer surgical re-interventions each), but the non-resectoscopic procedures had a
(15% vs. 35%).27 lower incidence of uterine perforation, fluid overload,
hematometra and cervical laceration.32,33 These advantages
NovaSure versus Thermachoice were offset by increased nausea/vomiting and uterine
At the 5-year follow-up, both groups had similar cramping in the perioperative period.33 A higher incidence
improvements in health-related quality of life measures of equipment failure of second-generation devices was
and no significant differences in amenorrhea rates (48% reported in earlier trials, but this is becoming less of a
vs. 32%) and surgical re-interventions (10% vs. 13%).28 concern with updated models.

NovaSure versus Cavaterm Summary Statements

In a small randomized trial of 57 patients at 1-year 3. Non-resectoscopic techniques are technically easier
follow-up, there was no difference in patient satisfaction to perform than resectoscopic techniques, have
(92% vs. 83%) or re-intervention rates between groups. shorter operative times, and allow the use of local
Amenorrhea rates, however, were significantly higher with rather than general anaesthesia. However, both
NovaSure (42% vs. 12%).29 techniques have comparable patient satisfaction and
reduction of heavy menstrual bleeding. (I)
A network meta-analysis reported that bipolar radio 4. Both resectoscopic and non-resectoscopic
frequency EA resulted in higher rates of amenorrhea endometrial ablation (EA) have low complication
than thermal balloon at 12 months.30 This has also been rates. Uterine perforation, fluid overload,
confirmed by other systematic reviews.31 However, there hematometra, and cervical lacerations are more
was no difference between techniques in patient satisfaction common with resectoscopic EA; perioperative
or number of women still experiencing heavy bleeding. nausea/vomiting, uterine cramping, and pain are
more common with non-resectoscopic EA. (I)
5. All non-resectoscopic endometrial ablation devices
EFFECTIVENESS OF RESECTOSCOPIC
available in Canada have demonstrated effectiveness
VERSUS NON-RESECTOSCOPIC TECHNIQUES
in decreasing menstrual flow and result in high
Primary outcome measures when evaluating EA procedures patient satisfaction. The choice of which device to
include rates of amenorrhea, patient satisfaction, and use depends primarily on surgical judgement and
surgical re-intervention. A Cochrane Database review the availability of resources. (I)

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SOGC clinical practice guideline

ANAESTHESIA AND OPERATIVE SET-UP COMPLICATIONS OF ENDOMETRIAL ABLATION

Resectoscopic ablation is frequently performed under The most common adverse events following EA are
general or regional anaesthesia in the operating room. pelvic pain, cramping, and nausea/vomiting. These will
However, in the appropriate setting, it can also be safely and generally resolve within 12 to 24 hours of the procedure.
effectively performed using a local paracervical block with Other problems that can develop post-procedure are
intravenous sedation. hematometrium, pyometrium, or endometritis. More
severe complications are rare with both techniques of
Local, regional, or general anaesthesia can be used for non-
EA, but can include injury to contiguous pelvic structures
resectoscopic EA. A main advantage of non-resectoscopic
proce­dures is that they may be conducted under local such as pelvic blood vessels, the bowel, and urinary tract
anaesthesia in a lower resource-intense environment than the anatomic components. Procedural complications such as
operating room. Performing such procedures in the operating severe pain, bleeding, uterine perforation, and infection
room rather than through a hysteroscopic procedure in may require emergent surgical management.16
another setting adds significant instrumentation costs but no The FDA has a reporting system for non-resectoscopic
value to the patient. ablation complications, and bowel injury is the most
In addition to local anaesthesia by paracervical block, oral common complication reported to its Manufacturer and
or intravenous conscious sedation may be used depending User Facility Device (MAUDE) database.36 Other major
on patient pain tolerance and surgeon preference. NSAIDS complications reported more infrequently are urinary
can be administered preoperatively and are moderately tract injuries, immediate hysterectomy, gas embolism,
effective in diminishing uterine contractions during and necrotizing fasciitis, and death. The incidence of such
after the procedure.34 complications is unavailable from such databases as
the denominator (total number of cases) is not known.
Procedure Room Versus Operating Room Setting However, the majority of these adverse events were
In the United States non-resectoscopic EA is frequently an associated with non-compliance with the manufacturers’
office-based procedure, and provider payment processes instructions for use. To mitigate the risk of injury with
promote these less resource-intense environments.35 non-resectoscopic procedures, surgeons may consider
Currently no mechanisms in the Canadian health care system post-dilatation hysteroscopy or concurrent ultrasound
compensate providers for non-resectoscopic EA in such a surveillance during the procedure.
setting. EA performed in a hospital-based procedure room or
a free-standing surgical centre rather than an operating room Serious Complications of EA
offers the advantages of a patient-centred environment, Uterine perforation has been reported in 0.3% of non-
easier scheduling, and reduced costs per case. Appropriate resectoscopic EA procedures and 1.3% of resectoscopic
low-risk patient selection and a satisfactory pain management ablations or resections.16 If uterine perforation is suspected
strategy are critical in this environment. Procedure rooms to have occurred during cervical dilatation or with the
must have appropriate emergency equipment available and resectoscope (without electrosurgery), the procedure should
all personnel must be trained in appropriate adverse event be abandoned and the patient should be closely monitored
protocols. A systematic review comparing non-resectoscopic for signs of intraperitoneal hemorrhage or visceral injury.
EA performed in the outpatient setting to resectoscopic EA If the perforation occurs while using electrosurgery or if
in the operating room, showed varying amounts of cost- the mechanism of perforation is uncertain, abdominal
savings.31 In the Canadian setting, an estimated savings of exploration is warranted to obtain hemostasis and rule out
$562 per patient receiving EA has been attributed to the visceral injury.
introduction of balloon devices in the outpatient setting.31
Perioperative hemorrhage has been reported in 1.2% of women
Summary Statements
undergoing non-resectoscopic ablation and 3.0% of those
6. The use of local anaesthetic and blocks, oral undergoing resectoscopic ablation.16
analgesia, and conscious sedation allows for the
provision of non-resectoscopic EA in lower Hematometra have been reported in 0.9% of women
resource-intense environments including regulated undergoing non-resectoscopic ablation and in 2.4 of
non-hospital settings. (II-2) those undergoing in resectoscopic ablation.16 Although
7. Low-risk patients with satisfactory pain tolerance intrauterine scarring is an expected result of EA,
are good candidates to undergo endometrial hematometra will occur when areas of the endometrium
ablation in settings outside the operating room or are adherent and there is endometrial bleeding behind
free-standing surgical centres. (II-2) the occlusion. Hematometra and cervical stenosis may be

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managed by cervical dilation, hysteroscopic adhesiolysis Complications Specific to Resectoscopic EA

and drainage, or hormonal endometrial suppression. Resectoscopic EA has potential complications specific to
For persistent pain despite minimally invasive treatment, this surgical modality. Careful fluid management is critical
hysterectomy may be indicated. to the safe use of hysteroscopic EA. In addition, surgeons
must possess a comprehensive understanding of potential
Postablation tubal sterilization syndrome has been reported to electrosurgical injuries during hysteroscopic EA.
occur at a rate as high as 10%.37 Some women who have
undergone tubal ligation prior to EA experience cyclic or Safe hysteroscopic surgery requires careful fluid
intermittent pelvic pain. The proposed etiology is bleeding management to avoid excessive intravasation of
from active endometrium trapped in the uterine cornua. hysteroscopic distension media. Adherence to a strict
This can be managed laparoscopically by excision of the protocol of fluid monitoring and management criteria
tubal stumps or hysterectomy. will minimize the risk of complications of distension
medium overload such as cardiovascular compromise
Pelvic infections and fever occur in the immediate postoperative and pulmonary edema, electrolyte abnormalities, and
period in approximately 1% of women who have encephalopathy. Table 4 provides an approach to prudent
undergone EA.16 In a meta-analysis, the incidence of management of hysteroscopic distention fluid issues.
infectious complications included endometritis (1.4 to
2.0%), myometritis (0 to 0.9%), pelvic inflammatory Electrosurgical injuries with monopolar operative
disease (1.1%), and pelvic abscess (0 to 1.1%).16 hysteroscopy can occur due to capacitive coupling and
defective insulation and result in cervical, vaginal, or
Long-term recurrent AUB after EA may be caused by perineal burns. There is an increased risk of this occurring
endometrial proliferation, adenomyosis, or (rarely) when the tip of the resectoscope is in the cervical
pre-malignant or malignant condition of the uterus. canal, when the cervix is over-dilated, or when there are
Investigation should include an endometrial biopsy if electrode insulation defects. There is a greater degree of
more than 1 year has passed since the procedure. Because capacitive coupling injury with higher voltage outputs,
dense intrauterine synechiae sometimes follow EA, which may occur with use of coagulation mode, long
endometrial biopsy, even D&C, may often be impossible.38 uninterrupted periods of electrode activation, and non-
Transvaginal ultrasound can also be used to exclude contact with tissue.41 Risks of capacitive coupling can
abnormal proliferation of the endometrium. When be reduced by preventing cervical over-dilatation, using
adequate sampling of the endometrium cannot be obtained the lower voltage “cut” current, avoiding prolonged and
and AUB persists, with ultrasonic evidence of a thickened uninterrupted activation, checking for insulation defects,
endometrium, hysterectomy is generally indicated for both ensuring contact with tissue during activation, and using a
curative and diagnostic purposes.38 weighted speculum during the procedure to disperse any
stray currents.
CLINICAL TIP
• For resectoscopic EA, if uterine perforation has been ruled out, Summary Statement
acute hemorrhage may be managed with intrauterine Foley
balloon tamponade, intracervical vasopressors injection, or
8. Both resectoscopic and non-resectoscopic endometrial
rectal misoprostol administration. ablation are relatively safe procedures with low
• Hematometra should be suspected in a patient with a history complication rates. The complications perforation
of an EA who presents with amenorrhea and cyclic pain, with potential injury to contiguous structures,
even remote from the procedure.39 This can be diagnosed by
hemorrhage, and infection. (II-2)
transvaginal ultrasound and prevented by ensuring complete
ablation of the uterine fundus, cornua, and tubal ostia while
avoiding ablation of the cervix or cervico-uterine junction. Recommendations
• Tips for administering paracervical block40: 4. Clinicians should be vigilant for complications
–– Infiltration of the cervix carries the risks of intravascular unique to resectoscopic endometrial ablation such
injection and toxicity of the local anaesthetic. These as those related to fluid distention media and
risks can be minimized by infiltrating slowly, using lower
concentrations of local anaesthetic, frequently aspirating, electrosurgical injuries. (III-A)
and monitoring for symptoms of intravasation (tinnitus, 5. For resectoscopic endometrial ablation, a strict
blurring of vision, peri-oral/facial numbness). If the local
anaesthetic contains epinephrine, patients may experience
protocol should be followed for fluid monitoring and
palpitations, tachycardia, or feelings of anxiety. Basic management to minimize the risk of complications
resuscitative equipment should be available. of distension medium overload. (III-A)
–– Allow the block to take effect by waiting 10 to 15 minutes 6. If uterine perforation is suspected to have occurred
prior to proceeding with cervical dilatation. during cervical dilatation or with the resectoscope

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Table 4. Management of hysteroscopic distention fluid losses

Measurement of Intake and Output (I&O) During Hysteroscopy
a. I&O should be measured accurately, ideally by an electronic fluid management system, for all operative hysteroscopy procedures.
b. I&O values for all distention media should be monitored and fluid deficits reported to the surgeon and anaesthesiologist.
c. The circulating nurse should seek assistance, and additional staff if required, to monitor fluid I&O.
d. Final I&O values or fluid deficit should be recorded on the operative record.
e. Final I&O values should be reported to the surgeon and anaesthesiologist at the end of the procedure.
Excess Fluid Deficit for Non-conductive Solutions
At a fluid deficit of 500 cc:
• Ensure anaesthesiologist and surgeon are aware of the deficit in return of uterine distension fluid.
At a fluid deficit of 1000 cc:
• The procedure should be completed as expeditiously as possible.
• Consider placing Foley catheter in bladder for accurate monitoring of urine output.
• Consider fluid restriction and IV to keep vein open.
• Consider IV diuretic ( e.g. furosemide) administration.
At a fluid deficit of 1500 cc:
• The procedure should be discontinued immediately.
• Serum electrolyte values should be obtained and abnormalities managed appropriately.
• Observe patient for signs of fluid overload and encephalopathym, changes in level of consciousness, seizure activity, pulmonary edema,
and tachypnea.
• Admit patient for observation and management of complications.
• If normal saline is used as the distending medium, consider completing and terminating the procedure at volumes of 2000 cc and
2500 cc, respectively.

(without electrosurgery), the procedure should If repeat EA is considered, a hysteroscopic approach

be abandoned and the patient should be closely using the resectoscope is recommended. With the
monitored for signs of intraperitoneal hemorrhage possible exception of the HydroThermAblator,40 a non-
or visceral injury. If the perforation occurs with resectoscopic blind procedure is generally contraindicated
electrosurgery or if the mechanism of perforation in this clinical scenario, as is a global EA technique under
is uncertain, abdominal exploration is warranted to hysteroscopic visualization. Complication rates of repeat
obtain hemostasis and rule out visceral injury. (III-B) EA are statistically higher than primary procedures. The
7. With resectoscopic endometrial ablation, if uterine risks of perforation, higher fluid absorption, and bleeding
perforation has been ruled out acute hemorrhage have been reported to be in the order of 9.3% to 11%
may be managed by using intrauterine Foley balloon compared with 2.05% for primary ablation.42 Repeat
tamponade, injecting intracervical vasopressors, or ablation should therefore be performed by skilled surgeons
administering rectal misoprostol. (III-B) with experience in hysteroscopic surgery. When repeat
procedures are performed in patients with the appropriate
SPECIAL CONSIDERATIONS indications, success rates of avoiding hysterectomy have
been reported to be about 55% to 60%.43
Repeat Ablation
Irrespective of technique, EA has a success rate of 73% Concomitant Hysteroscopic (Essure)
to 85%. Therefore, EA failures raise the issue of repeat Tubal Sterilization
ablation or hysterectomy. The decision for repeat ablation Hysteroscopic sterilization has rapidly replaced laparoscopic
versus another approach will depend on the surgeon’s skill sterilization in the United States but has not yet been widely
and the patient’s consent, appropriately informed about accepted in Canada. Essure is highly successful, with a
possible complications. If the initial EA was deemed a reported 5-year effectiveness of 99.8% and most failures
failure because it did not reduce menstrual flow and if the related to deviations from protocol.44 Over the last few
symptoms are highly suggestive of adenomyosis, definitive years there have been multiple reports on the concomitant
management should be considered. use of Essure and different ablation techniques, most

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often non-resectoscopic procedures such as NovaSure, < 4 cm reported an amenorrhea rate of 39% with the
Thermachoice, Thermablate, HydroThermAblator.45 HydroThermAblator treatment. However, amenorrhea rates
In most cases, both procedures were reported to be were significantly higher for patients with normal cavities
successful for the ablation and placement of the implants (62% at 30 months’ follow-up).48 Rates of re-intervention
at rate of 83% to 89%. The NovaSure requires placement were also significantly higher in patients with distorted
of implants after the procedure, while balloon thermal cavities.48 Women with types 1 and 2 submucosal fibroids
transfer and circulating saline could be performed before < 3 cm who were followed prospectively following treatment
or after hysteroscopic tubal sterilization. with NovaSure had amenorrhea rates of 69% at 1 year.49
Thermachoice also demonstrated a decrease in menstrual
Problems with combined Essure placement arise from the flow in 4 women with submucosal myomas < 3 cm.50
FDA’s mandatory requirement of confirming postoperative
tubal occlusion by HSG at 3 months. Obliteration of the Despite encouraging results showing that non-
uterine cavity following EA may make confirmation of tubal resectoscopic EA may be beneficial in treating AUB in
occlusions by HSG difficult. However, in other countries women with small (< 3 cm) submucosal fibroids, further
including Canada, HSG is not mandatory following research is still required. Where possible, hysteroscopic
hysteroscopic sterilization and many articles advocate myomectomy/polypectomy combined with resectoscopic
using three-dimensional US and X-ray to confirm bilateral EA should be used to treat women with symptomatic
placement and the non-migration of the tubal inserts.46 intracavitary pathology.

Previous Caesarean Section Summary Statement

The literature regarding EA in patients with previous CS 9. Combined hysteroscopic sterilization and
consists primarily of small retrospective cohorts studies. endometrial ablation can be safe and efficacious
For resectoscopic EA, there are generally no restrictions while favouring a minimally invasive approach. (II-2)
following previous CS. However, caution should be
exercised over the CS scar as myometrial thinning may Recommendations
predispose it to perforation or thermal injury. For a patient 8. If repeat endometrial ablation (EA) is considered
with previous transmural myomectomy, obtaining adequate following non-resectoscopic or resectoscopic EA,
visualization of the cavity using a pressure pump should it should be performed by a hysteroscopic surgeon
allow for safe treatment. with direct visualization of the cavity. Patients
should be counselled about the increased risk of
For the available non-resectoscopic technologies, no complications with repeat EA. (II-2A)
restriction on the minimum myometrial thickness has 9. If significant intracavitary pathology is present,
been mentioned. However, caution is recommended with resectoscopic endometrial ablation combined with
patients who have had more than 2 CS. Non-resectoscopic hysteroscopic myomectomy or polypectomy should
EA is contraindicated in patients with previous classical be considered in a non-fertility sparing setting. (II-3A)
Caesarean section or transmural myomectomies. Five-
year data on satisfaction, treatment failure, and operative
complications of non-resectoscopic EA in patients with REFERENCES
previous CS are similar to those in patients without 1. Farquhar CM, Naoom S, Steiner CA. The impact of endometrial ablation
previous CS.47 on hysterectomy rates in women with benign uterine conditions in the
United States. Int J Technol Assess Health Care 2002;18:625–34.
Intracavitary Pathology and Non-Resectoscopic EA 2. Reid PC. Endometrial ablation in England—coming of age? An
Intracavitary fibroids and polyps were excluded from examination of hospital episode statistics 1989/1990 to 2004/2005.
the original randomized controlled trials evaluating Eur J Obstet Gynecol Reprod Biol 2007;135:191–4.

non-resectoscopic EA techniques. These procedures 3. Cooper K, Lee A, Chien P, Raja E, Timmaraju V, Bhattacharya S.
Outcomes following hysterectomy or endometrial ablation for heavy
were originally designed to treat normal uterine cavities. menstrual bleeding: retrospective analysis of hospital episode statistics in
Subsequently, various attempts have been made to examine Scotland. BJOG. 2011;118(10):1171–9.
the utility of these technologies in distorted cavities with 4. Kaunitz AM, Meredith S, Inki P, Kubba A, Sanchez-Ramos L.
submucosal fibroids. The HydroThermAblator, which relies Levonorgestrel-releasing intrauterine system and endometrial ablation in
heavy menstrual bleeding: a systematic review and meta-analysis. Obstet
on freely circulating heated fluid under direct visualization, Gynecol 2009;113:1104–16.
may be suited to treat distorted cavities as it does not rely
5. Lethaby AE, Cooke I, Rees M. Progesterone or progestogen-releasing
on the fixed shape of a mesh or balloon. A prospective intrauterine systems for heavy menstrual bleeding. Cochrane Database
study of patients with type 0 or type 1 submucosal fibroids Syst Rev 2005;(4):CD002126.

APRIL JOGC AVRIL 2015 l 373

SOGC clinical practice guideline

6. Matteson KA, Abed H, Wheeler TL, Sung VW, Rahn DD, Schaffer JI, et al. 25. Sharp HT. Assessment of new technology in the treatment of
A systematic review comparing hysterectomy with less-invasive treatments idiopathic menorrhagia and uterine leiomyomata. Obstet Gynecol
for abnormal uterine bleeding. J Minim Invasive Gynecol 2012;19:13–28. 2006;108:990–1003.
7. Munro MG, Dickersin K, Clark MA, Langenberg P, Scherer RW, Frick KD, 26. Penninx JPM, Mol BW, Engels R, van Rumste MME, Kleijn C,
et al. The Surgical Treatments Outcomes Project for Dysfunctional Uterine Koks CAM, et al. Bipolar radiofrequency endometrial ablation compared
Bleeding: summary of an Agency for Health Research and Quality- with hydrothermablation for dysfunctional uterine bleeding: a randomized
sponsored randomized trial of endometrial ablation versus hysterectomy for controlled trial. Obstet Gynecol 2010;116:819–26.
women with heavy menstrual bleeding. Menopause 2011;18:445–52. 27. Penninx JPM, Herman MC, Mol BW, Bongers MY. Five-year follow-up
8. Bhattacharya S, Middleton LJ, Tsourapas A, Lee AJ, Champaneria R, after comparing bipolar endometrial ablation with hydrothermablation for
Daniels JP, et al. Hysterectomy, endometrial ablation and Mirena® for heavy menorrhagia. Obstet Gynecol 2011;118:1287–92.
menstrual bleeding: a systematic review of clinical effectiveness and cost- 28. Kleijn JH, Engels R, Bourdrez P, Mol BWJ, Bongers MY. Five-year
effectiveness analysis. Health Technol Assess. 2011;15(19):iii–xvi–1–252. follow up of a randomised controlled trial comparing NovaSure and
9. Longinotti MK, Jacobson GF, Hung Y-Y, Learman LA. Probability ThermaChoice endometrial ablation. BJOG. 2008;115:193–8.
of hysterectomy after endometrial ablation. Obstet Gynecol 29. Abbott J, Hawe J, Hunter D, Garry R. A double-blind randomized
2008;112:1214–20. trial comparing the Cavaterm and the NovaSure endometrial ablation
10. El-Nashar SA, Hopkins MR, Creedon DJ, St Sauver JL, Weaver AL, systems for the treatment of dysfunctional uterine bleeding. Fertil Steril
McGree ME, et al. Prediction of treatment outcomes after global 2003;80:203–8.
endometrial ablation. Obstet Gynecol 2009;113:97–106. 30. Daniels JP, Middleton LJ, Champaneria R, Khan KS, Cooper K,
11. Singh S, Best C, Dunn S, Leyland N, Wolfman WL; SOGC Clinical Mol BWJ, et al. Second generation endometrial ablation techniques for
Practice–Gynaecology Committee. Abnormal uterine bleeding in heavy menstrual bleeding: network meta-analysis. BMJ 2012;344:e2564.
pre-menopausal women. SOGC Clinical Practice Guideline, No. 292, 31. Kroft J, Liu G. First- versus second-generation endometrial ablation
May 2013. J Obstet Gynaecol Can 2013;35:473–9. devices for treatment of menorrhagia: a systematic review, meta-
12. Laberge PY. Serious and deadly complications from pregnancy after analysis and appraisal of economic evaluations. J Obstet Gynaecol Can.
endometrial ablation: two case reports and review of the literature. 2013;35:1010–9.
J Gynecol Obstet Biol Reprod (Paris) 2008;37:609–13. 32. Middleton LJ, Champaneria R, Daniels JP, Bhattacharya S, Cooper KG,
13. Tan YH, Lethaby A. Pre-operative endometrial thinning agents before Hilken NH, et al. Hysterectomy, endometrial destruction, and
endometrial destruction for heavy menstrual bleeding. Cochrane Database levonorgestrel releasing intrauterine system (Mirena) for heavy menstrual
Syst Rev 2013;11:CD010241. bleeding: systematic review and meta-analysis of data from individual
patients. BMJ 2010;341:c3929.
14. Shawki O, Peters A, Abraham-Hebert S. Hysteroscopic endometrial
destruction, optimum method for preoperative endometrial preparation: 33. Lethaby A, Penninx J, Hickey M, Garry R, Marjoribanks J. Endometrial
a prospective, randomized, multicenter evaluation. JSLS 2002;6:23–7. resection and ablation techniques for heavy menstrual bleeding. Cochrane
Database Syst Rev. 2013;8:CD001501.
15. Thinkhamrop J, Laopaiboon M, Lumbiganon P. Prophylactic antibiotics
for transcervical intrauterine procedures. Cochrane Database Syst Rev 34. Ahmad G, O’Flynn H, Attarbashi S, Duffy JM, Watson A. Pain relief for
2007;(3):CD005637. outpatient hysteroscopy. Cochrane Database Syst Rev. 2010;(11):CD007710.

16. Lethaby A, Hickey M, Garry R, Penninx J. Endometrial resection/ 35. Glasser MH. Practical tips for office hysteroscopy and second-generation
ablation techniques for heavy menstrual bleeding. Cochrane Database “global” endometrial ablation. J Minim Invasive Gynecol 2009;16:384–99.
Syst Rev 2009;(4):CD001501. 36. Gardner S, Schultz DG. Complications associated with global
17. Deb S, Flora K, Atiomo W. A survey of preferences and practices of endometrial ablation: the utility of the MAUDE database. Obstet
endometrial ablation/resection for menorrhagia in the United Kingdom. Gynecol 2004;103(5 Pt 1):995–6.
Fertil Steril 2008;90:1812–7. 37. McCausland A, McCausland V. Frequency of symptomatic cornual
18. Neuwirth RS, Amin HK. Excision of submucus fibroids with hematometra and postablation tubal sterilization syndrome after total
hysteroscopic control. Am J Obstetr Gynecol 1976;126:95–9. rollerball endometrial ablation: a 10-year follow-up. Am J Obstet Gynecol
2002;186:1274–80; discussion 1280–3.
19. Goldrath MH, Fuller TA, Segal S. Laser photovaporization of
38. Gadzinski JA, Sheran J, Garbe G, Fitzgerald G, Mueller E, Wagner S.
endometrium for the treatment of menorrhagia. Am J Obstet Gynecol
Obstet Gynecol 2014;123(Suppl 1):124S. doi: 10.1097/01.
1981;140:14–9.
AOG.0000447083.64986.03.
20. Vilos GA. Hysteroscopic and nonhysteroscopic endometrial ablation.
39. McCausland A, McCausland V. Long-term complications of endometrial
Obstet Gynecol Clin North Am 2004;31:687–704, xi.
ablation: cause, diagnosis, treatment, and prevention. J Minim Invasive
21. O’Connor H, Magos A. Endometrial resection for the treatment of Gynecol 2007;14:399–406.
menorrhagia. N Engl J Med 1996;335:151–6.
40. Glasser MH, Heinlein PK, Hung Y-Y. Office endometrial ablation with
22. Martyn P, Allan B. Long-term follow-up of endometrial ablation. local anaesthesia using the HydroThermAblator system: comparison of
J Am Assoc Gynecol Laparosc 1998;5:115–8. outcomes in patients with submucous myomas with those with normal
23. Townsend DE, Duleba AJ, Wilkes MM. Durability of treatment effects cavities in 246 cases performed over 5(1/2) years. J Minim Invasive
after endometrial cryoablation versus rollerball electroablation for Gynecol 2009;16:700–7.
abnormal uterine bleeding: two-year results of a multicenter randomized 41. Munro MG. Mechanisms of thermal injury to the lower genital tract
trial. Am J Obstet Gynecol 2003;188:699–701. with radiofrequency resectoscopic surgery. J Minim Invasive Gynecol
2006;13:36–42.
24. Sabbah R, Laberge P, Fortin C, Thiel J, Garza-Leal J, Fullop T, et al.
A multi-center, single-arm, international clinical study of the safety and 42. MacLean-Fraser E, Penava D, Vilos GA. Perioperative complication rates
efficacy of the AURORA endometrial ablation system. Preliminary clinical of primary and repeat hysteroscopic endometrial ablations. J Am Assoc
results. J Minim Invasive Gynecol 2011;18:S82. Gynecol Laparosc 2002;9:175–7.

374 l APRIL JOGC AVRIL 2015

 Endometrial Ablation in the Management of Abnormal Uterine Bleeding

43. Hansen BB, Dreisler E, Stampe Sørensen S. Outcome of repeated 48. Glasser MH, Heinlein PK, Hung Y-Y. Office endometrial ablation with
hysteroscopic resection of the endometrium. J Minim Invasive Gynecol local anaesthesia using the HydroThermAblator system: comparison of
2008;15:704–6. outcomes in patients with submucous myomas with those with normal
cavities in 246 cases performed over 5(1/2) years. J Minim Invasive
44. Connor VF. Essure: a review six years later. J Minim Invasive Gynecol Gynecol 2009;16:700–7.
2009;16:282–90.
49. Sabbah R, Desaulniers G. Use of the NovaSure impedance controlled
45. Donnadieu AC, Deffieux X, Gervaise A, Faivre E, Frydman R, endometrial ablation system in patients with intracavitary disease:
Fernandez H. Essure sterilization associated with endometrial 12-month follow-up results of a prospective, single-arm clinical study.
ablation. Int J Gynaecol Obstet 2007;97:139–42. J Minim Invasive Gynecol 2006;13:467–71.
46. Mircea CN, Goojha C, Thiel JA. Concomitant NovaSure endometrial 50. Soysal ME, Soysal SK, Vicdan K. Thermal balloon ablation in
ablation and Essure tubal sterilization: a review of 100 cases. J Obstet myoma-induced menorrhagia under local anaesthesia. Gynecol
Gynaecol Can 2011;33:361–6. Obstet Invest 2001;51:128–33.
47. Khan Z, El-Nashar SA, Hopkins MR, Famuyide AO. Efficacy and safety 51. Woolf SH, Battista RN, Angerson GM, Logan AG, Eel W. Canadian Task
of global endometrial ablation after cesarean delivery: a cohort study. Am Force on Preventive Health Care. New grades for recommendations from the
J Obstet Gynecol2011;205:450.e1–4. Canadian Task Force on Preventive Health Care. CMAJ 2003;169:207–8.

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APPENDIX
ENDOMETRIAL ABLATION PATIENT INFORMATION SHEET

Endometrial ablation is an alternative surgical procedure for heavy menstrual bleeding. It attempts to destroy or remove the
endometrium—the lining of your uterus. This can replace hysterectomy in many cases.
This is a day surgery procedure. The technique varies depending on the method used to destroy the endometrium.
Most EA procedures can be done in an outpatient surgical centre while others must be performed in an operating room. Factors such
as the size of your uterus, presence of fibroid tumours, and experience of the surgeon will help determine which endometrial ablation
method is best for you.
While medications are typically recommended as first line treatment for heavy menstrual bleeding, endometrial ablation may be an
option if medications don’t help or you decline to try them.
Endometrial ablation is not recommended for women who: Endometrial ablation risks may include:
• wish to become pregnant in the future, • perforation of the uterine wall,
• have cancer of the uterus, • damage to nearby organs, and/or
• have large fibroid tumours in the uterus, and/or • pain, bleeding, or infection.
• have had recent pelvic infection.

Future pregnancy
Many women stop having periods after endometrial ablation, but pregnancy is still possible in some women. Most of these pregnancies
will have an abnormal outcome. Women who wish to become pregnant in the future should not consider endometrial ablation.
Some women may choose to undergo a sterilization procedure at the time of endometrial ablation or consider other forms of reliable
contraception to prevent pregnancy. Concomitant laparoscopic tubal ligation would usually require general anaesthetic.

Preparation for surgery

• Check for abnormal endometrial cells. Your doctor may take a small sample of the lining of your uterus using a small
endometrial biopsy instrument. This is done in the office before surgery.
• Thin your endometrium. Endometrial ablation is often performed more successfully when the uterine lining is thin. This can be
accomplished with preoperative medications or by undergoing a D and C (dilation and curettage) on the day of surgery.
• Discuss method of anaesthesia. Most procedures can be performed with conscious sedation and local anaesthetic block.
In some instances general anaesthesia is required.

The procedure
Endometrial ablation can be performed in your doctor’s office, but some types of endometrial ablation are performed in a hospital
operating room, especially if you will need general anaesthesia.
The cervix is dilated to allow for the passage of the instruments used in endometrial ablation. Endometrial ablation procedures vary by
the method used to destroy your endometrium.
• Electrosurgery. This method uses a small hysteroscope to view the uterine cavity during the procedure. An electrode is used to
resect or destroy the lining of the uterus.
• Free-flowing hot fluid. Saline fluid heated to 80°C to 90°C is circulated within the uterus for about 10 minutes.
• Heated balloon. A balloon device is inserted through your cervix and then inflated with fluid heated to 87°C for about 2 to
10 minutes.
• Bipolar radiofrequency. This uses a bipolar wire mesh electrode that contacts the uterine cavity. The instrument transmits high
frequency electrical energy that vaporizes the endometrial tissue in about 90 seconds.

After the procedure

After endometrial ablation, you may experience:
• Cramps. You may have menstrual-like cramps for a few days.
• Vaginal discharge. A watery discharge, mixed with blood, may occur for a few weeks. The discharge is typically heaviest for the
first few days after the procedure.
• Frequent urination. You may need to pass urine more often during the first 24 hours after endometrial ablation.
Avoid intercourse for one week after surgery.
All endometrial ablation techniques show similar improvement in bleeding pattern. It may take a few months to see the final results of
surgery, but endometrial ablation causes marked reduction in menstrual blood loss in over 80% of patients. Most women will have lighter
periods or spotting, and some will stop having periods entirely.
You should continue to use contraception.

376 l APRIL JOGC AVRIL 2015