Hysterectomy risk up following endometrial ablation

Hysterectomy rates could exponentially increase following endometrial ablation regardless of the ablation device used as shown in a meta-analysis.

The risk of hysterectomy after endometrial ablation rose from 4.3 percent after 1 year to 12.4 percent after 5 years in patients with heavy menstrual bleeding (HMB), said study author Dr Tamara Oderkerk from Maxima Medical Center and Maastricht University in the Netherlands.

There were no significant differences in hysterectomy rates by study design type or among the different nonresectoscopic endometrial ablation devices across 24,071 patients included in the study.

“Clinicians may therefore need to counsel patients about the risk of hysterectomy after endometrial ablation,” Oderker added.

50 studies, 48,071 patients

She and her team searched the EMBASE, MEDLINE, ClinicalTrials.gov, and Cochrane databases for eligible articles to be included in the meta-analysis, using combinations of search terms for endometrial ablation and hysterectomy.

Fifty studies met the inclusion criteria, 24 of which were randomized controlled trials, 23 were prospective studies, and six were retrospective studies. Overall, 48,071 patients underwent endometrial ablation between 1991 and 2017. [Obstet Gynecol 2023;142:51-60]

The studies differed in endometrial ablation techniques used. Sixteen used thermal balloons, 10 used microwaves, nine relied on radiofrequency, eight were of combination strategies, and eight had other techniques.

Follow-up lasted between 12 and 120 months. Following ablation, hysterectomy rates were 4.3 percent at 1 year, 11.1 percent at 1.5 years, 8 percent at 2 years, 10.2 percent at 3 years, 7.6 percent at 4 years, and 12.4 percent at 5 years.

Two studies reported a mean hysterectomy rate of 21.3 percent at 10 years following ablation.

Uterine sparing but not without complications

For women who do not desire definitive management with a hysterectomy, endometrial ablation is an option.

The endometrium is thermally destroyed but the uterus is preserved in endometrial ablation. It is a less invasive approach to HMB than a hysterectomy, where the uterus is removed. Each approach has its own advantages and risk profile though.

Endometrial ablation does not require surgical incisions and may be easier to perform. But some women develop cyclic pelvic pain which can last for months or years after the procedure. This may be a potential indication of late-onset endometrial ablation failure. In fact, about 20 percent of women who underwent ablation will ultimately require a hysterectomy. [BJOG 2011;118:1171-1179]

Hysterectomy: What to expect

A meta-analysis of randomized trials showed that total hysterectomy is superior to endometrial ablation in terms of clinical and cost-effectiveness. However, it takes longer to perform and requires a longer recovery period. [Lancet 2019;394:1425-1436]

Total hysterectomy could also predispose women to bladder symptoms, such as urinary incontinence. [Lancet 2000;356:535-539]

As for the risk of hysterectomy after endometrial ablation, Oderkerk said it may be difficult to inform patients properly due to the broad variation of reported hysterectomy rates in the study. “However, providing realistic success and failure rates for endometrial ablation is crucial for women’s expectations and a well-informed decision-making process,” she added.

“This is an important study as it allows clinicians to better counsel women of their options for treating HMB,” commented Dr Charlotte Pickett from the University of California San Diego in California, US. “The results gave women a better understanding of what to expect with the procedure, including the potential risks and benefits,” she added.