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Endometrial Ablation in the US—Present and Future Use
favorable response (53%) were treated with either endometrial ablation or and implementation of surgical procedures in the office can be
hysterectomy after 3–9 months of hormonal therapy. Their findings found at the websites of the American College of Surgeons
suggested that when amenorrhea was the absolute desired end-point, (www.facs.org/patientsafety/patientsafety.html) and the American
hysterectomy as initial therapy was most effective. However, when Society of Anesthesiologists (www.asahq.org/publicationsAndServices/
significant reduction or normalization of menstrual bleeding was an standards/12.pdf). Further, individual state regulatory boards and
acceptable goal, the most cost-effective treatment pathway was to proceed professional liability insurance carriers may provide additional guidelines
to endometrial ablation if hormonal therapy was not effective after three that must be considered when establishing office-based surgical
months. This is not to suggest, however, that we should feel compelled to procedures. Nonetheless, offering minor surgical procedures in the office
use oral contraceptives as initial therapy for all patients with menorrhagia. setting is not a new concept to gynecologists. In addition to the obvious
Indeed, this may be contraindicated in many patients for medical reasons benefits to the physician of efficient time management, office procedures
(e.g. the hypertensive smoker over age 35). In many cases, it seems offer very real benefits to the patient. This provides an opportunity for
appropriate to consider endometrial ablation as a primary treatment option patients to access GEA technology in an office environment with which
for excessive menstrual bleeding. This is especially true in patients with they are familiar, and with the office staff with whom they already feel
ovulatory dysfunctional uterine bleeding or in patients whose menorrhagia comfortable. Thus, endometrial ablation not only provides an effective
treatment for menorrhagia, it also represents a palatable therapeutic
option for an increasing number of patients.
Elective Use
Abnormal uterine bleeding is estimated
As endometrial ablation becomes increasingly more acceptable and
available to patients for treatment of menorrhagia, it is not difficult to
to affect approximately 7 million women
envision that many patients might consider this as an option to reduce or
between the ages of 35 and 55 in the US,
eliminate menstrual bleeding in the absence of a clinical indication. One
only has to look as far as the exponential growth of the cosmetic surgery
only about 35% of whom receive medical
industry to appreciate that patients clamor evermore to physicians for
or surgical therapy.
interventions to treat the ailments that affect the quality of their lives. The
notion that women might elect to reduce or eliminate menstrual bleeding
on an elective basis is supported by the increasing popularity of extended-
use oral contraceptive regimens that dramatically diminish the frequency of
menses. Although the effectiveness of GEA treatment has not been
is related to non-hormonal underlying medical conditions such as von evaluated objectively in the context of normal menstrual bleeding, it is
Willebrand’s disease, thrombocytopenia, anti-coagulation therapy, etc. anticipated that the success and amenorrhea rates should equal or exceed
Additionally, endometrial ablation seems an ideal therapeutic option for the those in the setting of menorrhagia. While not a cosmetic procedure per se,
medically complicated patient in whom hysterectomy carries the potential endometrial ablation certainly has the potential to mitigate undesired
for significant morbidity. bleeding in women who have completed childbearing.
In-office Procedures Future Directions
One impediment influencing access to endometrial ablation may be the Endometrial ablation has become well established as an effective
hospital setting in which it is most typically performed. Along with alternative to hysterectomy for patients with excessive menstrual
mitigating many of the risks and technical challenges associated with bleeding. However, if we are to achieve the very real potential of reducing
performing resectoscopic endometrial ablation techniques, GEA the number of hysterectomies in the US by over 100,000 per year through
technologies provide an opportunity to move these procedures away the use of GEA technologies, we must address at least three challenges.
from the operating theater and into the gynecologist’s office. The First, we must develop a greater appreciation of the scope and recognition
relatively minimal necessary equipment, the relatively simple procedural of abnormal uterine bleeding in our patients. Second, we must create
ergonomics, and the relatively brief treatment cycles make this an ideal greater awareness of endometrial ablation as a viable and effective
office procedure. Indeed, office protocols employing either local treatment option for women who suffer from menorrhagia. Finally, we
anesthesia or light conscious sedation have been described for all of the must provide greater access to endometrial ablation technologies, both in
GEA technologies. Appropriately selected patients tolerate these the operative theater and in the office, through physician and patient
procedures well in this setting. However, we must not forget that these education. In doing so, we would be able to offer endometrial ablation as
are, in fact, surgical procedures, and special attention must be directed a treatment alternative that is minimally invasive and minimally intrusive
to patient safety. Excellent guidelines for patient selection in the lives of our patients. ■
1. Munro, MG, Endometrial Ablation: Where Have We Been? Washington, DC, 2007. women with ovular dysfunctional uterine bleeding, Br J Obstet
Where Are We Going?, Clin Obstet Gynecol, 2006;49(4): 3. Dickersin K, et al., Surgical Treatments Outcomes Project for Gynaecol, 1981;88:434–42.
736–66. Dysfunctional Uterine Bleeding (STOP-DUB): design and methods, 5. He Wade SW, et al., Cost-effectiveness of treatments for
2. ACOG Practice Bulletin Number 81: Endometrial Ablation, Control Clin Trials, 2003;24(5):591–609. dysfunctional uterine bleeding, J Reprod Med, 2006;51:
American College of Obstetricians and Gynecologists, 4. Smith SK, et al., Prostaglandin synthesis in the endometrium of 553–62.
US OBSTETRICS AND GYNECOLOGY 2007 65
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