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Hysterectomy: endometrial ablation and resection (part 2) HYSTERECTOMY: ENDOMETRIAL ABLATION AND RESECTION (part 2)
Endometrial resection and ablation were introduced in the late 1970s in the US and are now routine procedures in many hospitals. Many tens of thousands of the procedures are performed worldwide each year. The speed with which the techniques have been taken up by medicine has surprised and shocked many people who say that fundamental questions about their safety, effectiveness and long-term consequences have not been resolved.
Information about the suitability of different groups of women for these procedures is scant. The available evidence suggests that women with a normal sized uterus or those who are on post-menopausal hormone therapy tend to do well, while those with a uterus that is enlarged by fibroids, markedly retroverted (tilted backwards) or who have severe adenomyosis or endometriosis may be unsuitable. Women at risk from a general anaesthetic — such as women who are very overweight, and those with chronic liver, kidney or heart disease — may prefer the option of an endometrial resection or ablation because it is possible to do either under local anaesthesia. Selection of women most likely to benefit from the procedure is extremely important and obviously influences the outcome for them. In this regard, the visualisation of the reproductive organs using ultrasound can be especially helpful in deciding the appropriateness of these procedures.
Endometrial ablation and resection are not risk-free but complication rates appear to be lower than for hysterectomy. Complications include infection (affecting one in every 100 women having the procedure), bleeding (less than one per 100), damage to the bowel or other pelvic structures including major blood vessels (one to two women in every 100 suffers a perforated organ or blood vessel), and fluid overload (one to two per 100).u Studies to date suggest that about two women in every 10 000 having the procedure die as a result of it.
Studies comparing endometrial ablation or resection with abdominal hysterectomy suggest that the former offers benefits in terms of post-operative pain, hospital stay, convalescence, risks and financial cost. Satisfaction among women after having a hysterectomy seems, however, to be significantly higher than among those whose endometrium has been removed (94% compared with 85% in the Maine studies referred to earlier in this chapter). This may reflect the 'failure rate' of endometrial resection or ablation — women who are hoping that their bleeding problems will resolve are likely to feel dissatisfied with the procedure even if they have been warned in advance that it is not a universal success. It might also suggest that the procedure is being oversold or that patient selection is not as good as it could be.
Endometrial resection or ablation is probably the treatment of choice for women who want short-term relief from bleeding problems, and who are keen to minimise the risk of complications, the financial cost of treatment and the time off work. Hysterectomy is probably a better option for women wanting certain and complete relief from bleeding problems. It may also be the preferred option of women with an increased risk of endometrial cancer, which includes women with a family history of the disease, those with polycystic ovaries, those who use oestrogen on its own without added progestogen, and women who are obese or who have diabetes.
Cost is probably one of the major reasons for the rapid uptake of these procedures. In a recent Australian survey the cost of endometrial resection was estimated at $ 1500, which is less than half the cost of an abdominal hysterectomy.12 The cost of endometrial ablation was about $2200 to $2500 depending on the type of equipment used. The relative cost advantage of these techniques over hysterectomy may, however, be eroded if re-treatment and later hysterectomies occur more often than has been reported to date.
A recent article in the popular science magazine New Scientist emphasised that doctors who perform endometrial resection or ablation are on a learning curve. To produce good results they need to be experienced in the technique of hysteroscopy and to have served an apprenticeship in hysteroscopic surgery under a knowledgable supervisor. 'Reports from surgeons suggest that serious complications are most likely to occur while the gynaecologist is still on the 'learning curve', which can last for anything between 10 and 80 operations,' the article said. 'Studies have shown that 50% of perforations of the womb take place in the first five operations a surgeon carries out.' It is important to find out where on this learning curve your surgeon is before agreeing to any procedure.
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