[CG] Endometrial ablation

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Heavy menstrual bleeding (HMB) is an important cause of morbidity affecting 1 in 5 of the population and leads to 21% of gynaecology referrals from general practitioners. Endometrial ablation is an effective treatment for HMB and can be performed under local anaesthesia as an office procedure or under general anaesthesia in theatre.

History

  • Date of LMP
  • Frequency and duration of menses
  • Previous treatments for menorrhagia
  • Previous caesarean sections or uterine surgery
  • Contraception - ablation should not be used as a method of contraception and women must be willing to make appropriate contraceptive provision

Examination

  • Pelvic examination
  • BMI if being considered for ablation under GA

Investigations

  • All women undergoing endometrial ablation should have an endometrial biopsy, ideally in advance of the procedure (well tolerated endometrial biopsy is an indication that ablation is suitable to be carried out under local anaesthetic in a clinic setting rather general anaesthetic in theatre)
  • All women undergoing endometrial ablation should have a pelvic ultrasound prior to the procedure to determine uterine size and morphology and to assess the endometrial cavity. A measurement of any previous LUSCS scar should be made (scar thickness < 8 mm – consider treating only endometrium above level of scar).
  • If there is doubt regarding suitability of the cavity for an ablation, then consideration should be given to performing hysteroscopy to confirm suitability before dating for the procedure.
  • Hysteroscopic assessment of the endometrial cavity must be made prior to the procedure. This should be performed immediately following dilation of the cervix, prior to insertion of the ablation device. This is essential to exclude perforation or creation of a false passage.

Contra-indications to endometrial ablation

  • Woman wishes to retain her fertility
  • Genital tract malignancy
  • Unexplained vaginal bleeding
  • Acute pelvic infection
  • Uterine abnormalities e.g. septate uterus
  • Previous classical caesarean section
  • Other contra-indications will depend on the technique employed e.g. regularity of the uterine cavity, presence and size of fibroids. The surgeon should be familiar with the manufacturer’s guidelines for all products that are used and their limitations.

Ablation technique

This guideline refers only to second generation ablation techniques in use in GG&C. It does not refer to first generation techniques such as TCRE and rollerball ablation. The ablation method used will depend on local expertise and availability of equipment.

Novasure®

This uses impedance controlled bipolar energy to cause ablation using a gold mesh electrode to conform to the contours of the uterine cavity. Depth of ablation is 2-3mm at the cornu and 5-7mm in the main body of the uterus. Treatment time is 90-120 seconds. There is an added safety feature using carbon dioxide to test for uterine perforation before treatment. Safety and efficacy have not been assessed in uterine cavities with a sounded length of greater than 10cm.

Complications of second generation devices

Minor complications are common and include pain and nausea. Serious complications are relatively rare but have been reported e.g. uterine perforation and damage to adjacent structures e.g. bowel. Patients should receive an information leaflet giving instructions about post-operative pain and how to access out-of-hours emergency gynaecology services.

Patients who require readmission following an ablation procedure should be assessed by senior staff to rule out intra-abdominal injury. Where there is any doubt, laparoscopy or laparotomy should be performed.

Antibiotic Prophylaxis

Antibiotic prophylaxis is not required.

Patient information

Appendix: Ablation proforma

Last reviewed: 30 April 2018

Next review: 30 April 2023

Author(s): Claire Higgins

Approved By: Dr. R. Jamieson