{"paper_id":"8c98f7ff-e878-4912-9d66-a97923015ef6","body_text":"Mukherjee G | Volume 1; Issue 2 (2023) | Mapsci-JGCORM-1(2)-007 | Research Article \nCitation: Mukherjee G, Warty T, Banerjee I, Thakur N, Thakur Y.  Factors Predicting Failure of Endometrial Ablation . \nJ Gynecol Clin Obstet Reprod Med. 2023;1(2):66-72. \nDOI: https://doi.org/10.37191/Mapsci -JGCORM-1(2)-007 \n \n \nJournal of Gynecology, Clinical Obstetrics, and \nReproductive Medicine \nMukherjee G, et al., 2023- J Gynecol Clin Obstet Reprod Med  \nResearch Article \n \n \nFactors Predicting Failure of Endometrial \nAblation \nGargi Mukherjee1*, Tanvi Warty2, Indranil Banerjee1, Niharika \nThakur3 and Yatin Thakur4 \nAbstract \nObjective: To find out the probable reasons for endometrial \nablation failure. \nStudy design:  This retrospective observational study was \nconducted in Basildon and Thurrock University Hospitals. Patients \nundergoing microwave endometrial ablation or radiofrequency \nablation but required additional treatment (medical/surgical) after \nthe procedure were included in the study. The patients  having the \nprocedure between 2012 to 2019 were followed up and included in \nthe study. Patient ’s baseline characteristics including age, BMI, \npresenting complaint, clinical and sonographic findings including \nuterine cavity length, and details of the ablation procedur e were \ncollected. The endometrial biopsy results, further treatment , and \nhistology in patients who underwent hysterectomy were also noted \nand appropriate statistical analysis was conducted. \nResult: Among the 653 patients that underwent endometrial \nablation (either radio-frequency/ microwave), from 2012 to 2019, 100 \npatients had ablation failure. All patients had undergone \nhysteroscopy and had a normal histopathology examination prior to \nundergoing ablation. The most common symptom of failure was a \nrecurrence of heavy bleeding. 67% of patients with ablation failure \nopted for hysterectomy, 15% for repeat ablation , and 18% had \nmedical management. The results showed that increased age, higher \nBMI, a larger uterine cavity , and the presence of fibroids and/or \nadenomyosis are associated with a higher risk of endometrial ablation failure. \nConclusion: This study provides insight into the salient factors contributing to ablation failure which may \nguide future decisions toward better patient selection and counseling for endometrial ablation. \nKeywords:  Endometrial ablation; Failure; Age; Body mass index; Adenomyosis; Fibroid; Hysterectomy.\n1Speciality Registrar, Department of \nObstetrics and Gynaecology, Croydon \nUniversity Hospital, 530, London road, \nCR77 YE, UK \n2Senior House Officer, University Hospital \nLewisham, Lewisham High St, London SE13 \n6LH, UK \n3Foundation doctor year  1-Broomfield \nhospital- Chelmsford -Essex, UK \n4Consultant, Department of Obstetrics and \nGynaecology, Basildon and Thurrock \nUniversity Hospital, Nethermayne, \nBasildon, SS165NL, UK \n*Corresponding Author:  Gargi \nMukherjee, Speciality Registrar, \nDepartment of Obstetrics and \nGynaecology, Croydon University Hospital, \n530, London road, CR77 YE, UK. \nReceived Date: 03-09-2023 \nAccepted Date: 03-20-2023 \nPublished Date: 04-10-2023 \nCopyright© 2023 by Mukherjee G, et al. All \nrights reserved. This is an open-access \narticle distributed under the terms of the \nCreative Commons Attribution License, \nwhich permits unrestricted use, \ndistribution, and reproduction in any \nmedium, provided the original author and \nsource are credited. \n\nMukherjee G | Volume 1; Issue 2 (2023) | Mapsci-JGCORM-1(2)-007 | Research Article \nCitation: Mukherjee G, Warty T, Banerjee I, Thakur N, Thakur Y.  Factors Predicting Failure of Endometrial Ablation . \nJ Gynecol Clin Obstet Reprod Med. 2023;1(2):66-72. \nDOI: https://doi.org/10.37191/Mapsci -JGCORM-1(2)-007 \n \n \nIntroduction \nHeavy menstrual bleeding (HMB) is a broad \nterm that encompasses an excessive loss of \nblood during menstruation which can occur \nalong with dysmenorrhoea. While HMB may \nbe objectively quantified as a loss of 80 ml or \nmore of blood lost during every menstrual \ncycle, clinical diagnosis is centered around \nthe physical, mental, and social impact it has \non the quality of life of the woman; and as \nsuch, can vary remarkably in the perception \nof the amount of blood loss. the management \nof HMB can be co nservative, medical , or \nsurgical. Endometrial ablation is a widely \naccepted and minimally invasive procedure to \ntreat HMB. \nEndometrial ablation involves devices that \naim to remove or destroy the endometrium \neither under direct vision or blindly i.e., first-\ngeneration or second -generation devices \nrespectively. The intended outcomes for both \nare a reduction in actual or perceived \nmenstrual blood loss, a reduction in \ndysmenorrhea, and an improvement in the \noverall quality of life [1]. \nFirst-generation ablation devices, namely the \nresectoscope, while effective, had \ncomplications like uterine perforation, fluid \noverload, and higher failure rates \nnecessitating further procedures [2]. The \nintroduction of global endometrial ablation \nmethods, collectively known as se cond-\ngeneration devices made the procedure \nsignificantly safer while maintaining a good \nsuccess rate [3]. Additionally, they are well‐\nsuited to a daycare setting due to technical \nsimplicity and shorter operating time. \nAlthough endometrial ablation is now \nconsidered a safe and effective modality, a \nsmall proportion of women continue to \nexperience a recurrence of symptoms or to \ndevelop new symptoms requiring additional \nforms of treatment, either medical or surgical \n(repeat ablation or hysterectomy) [4]. There  \nhave been multiple studies [5 -7] that predict \nthe success of the procedure, but very few \nhave focused exclusively on the predictors of \nfailure of the second -generation devices. \nBeelen et al [8] have shown that younger age, \nprior tubal ligation , and pre -existing \ndysmenorrhea were found to be associated \nwith failure of endometrial ablation. Obesity \nhas also been purported to be a cause of \nfailure [9]. Eisele et al [9] showed that bipolar \nradiofrequency endometrial ablation was \nhighly successful in the absenc e of an \nintramural mass (88%). Even smaller \nintramural fibroids or adenomyosis could \nreduce the success rate (76%). The study of \nLonginotti et al  [4] reported that age is an \nimportant predictor for success, especially in \nwomen under the age of 35, who appe ar to \nhave significantly higher failure rates leading \nto future hysterectomies. In light of the \naforementioned studies and the impact HMB \nand its management have on the quality of life \nof women, an analysis of the factors \npredicting success after endometrial ablation \nusing second -generation devices was \nundertaken. \nMaterials and methods \nThis retrospective observational study was \nconducted at Basildon University Hospital. \nThe common modalities of endometrial \nablation offered were Radio -frequency \nAblation (RFA ) (Novasure) or Microwave \n\nMukherjee G | Volume 1; Issue 2 (2023) | Mapsci-JGCORM-1(2)-007 | Research Article \nCitation: Mukherjee G, Warty T, Banerjee I, Thakur N, Thakur Y.  Factors Predicting Failure of Endometrial Ablation . \nJ Gynecol Clin Obstet Reprod Med. 2023;1(2):66-72. \nDOI: https://doi.org/10.37191/Mapsci -JGCORM-1(2)-007 \n \n \nAblation (MA) (Minitouch). The records of all \npatients who underwent endometrial \nablation, either RFA or MA, from 2012 to 2019 \nwere retrieved and followed –up by accessing \nElectronic Medical Records. The follow -up \nperiod spanned from a minimum of 2 years to \na maximum of 5 years, for those patients \nwhose time frames were available. The lower \nacceptable limit for follow -up was based on \nprevious studies which have shown that \nintervention is more likely within the first 2 \nyears after ab lation [1].  The patients who \nrequired further consultation due to \npersistent heavy menstrual bleeding or \ndeveloped new symptoms like \ndysmenorrhoea or pelvic pain which required \nadditional management, either medical (oral \nprogesterone or Mirena insertion) or surgical \n(repeat ablation or hysterectomy), were \nincluded in the study. \nThe factors evaluated in this cohort of \npatients include age, BMI, presenting \ncomplaint, clinical and imaging (transvaginal \nultrasonography was the usual modality) \nfindings, associated medical problems, details \nof the ablation procedure, lengths of the \nutero-cervical canal and the results of the \nendometrial biopsies. The histopathological \nreport of patients who required a \nhysterectomy as definitive treatment were \nalso document ed. The documents were \ntabulated in a password -protected encrypted \nspreadsheet and subsequent analysis was \ndone to evaluate the potential risk factors for \nablation failure. \nResults \nOf the 653 patients who underwent \nendometrial ablation during 2012-2019, either \nradiofrequency or microwave ablation, 100 \npatients required repeat treatment; the \nfailure rate was 15.13, which is comparable \nwith the standard failure rate [10]. \nThe initial presenting complaint of all the \npatients was heavy menstrual bleeding \n(HMB). 35% of these patients reported \nadditional intermenstrual bleeding and 46% \nreported dysmenorrhoea. \nThe average age of the population was 44.5 \nyears with a range of 33–56 years (Median-42 \nyears) (Table 1). The average BMI of the study \npopulation was 30.5 wi th a range of 19 -45 \n(median-30). The common medical disorders \nencountered in this study population were \ndiabetes (12%), hypertension (10%), \nfibromyalgia (2%), depression (1%) , and \nasthma (1%) (Table 2). \nAll patients underwent hysteroscopy and \nendometrial biopsy+/-polypectomy (in all the \ncases where the polyp was visible) before the \nprocedure and the length of the utero-cervical \ncanal (UCL) was measured during ablation; \nthe histopathology report of all the \nendometrial biopsies and polypectomies was \nwithin n ormal limits (Table 3 -4). The most \ncommon symptom of failure was HMB (Table \n5). The majority of patients opted for a \nhysterectomy as the preferred treatment after \nfailure (Table 6). \nThe 15 patients, going through repeated \nablation had an addition al endometrial \nbiopsy of which 7 (46.67%) samples did not \nyield satisfactory tissue for evaluation, while \n8 (53.33%) samples showed the presence of \nproliferative endometrium.  The \nhistopathology results of the 67 patients who \n\nMukherjee G | Volume 1; Issue 2 (2023) | Mapsci-JGCORM-1(2)-007 | Research Article \nCitation: Mukherjee G, Warty T, Banerjee I, Thakur N, Thakur Y.  Factors Predicting Failure of Endometrial Ablation . \nJ Gynecol Clin Obstet Reprod Med. 2023;1(2):66-72. \nDOI: https://doi.org/10.37191/Mapsci -JGCORM-1(2)-007 \n \n \nhave undergone hysterectomy were reviewed, \nand only 21 had normal findings. 46 patients \nhad some coexisting pathology – either \nfibroids/ adenomyosis/endometriosis or a \ncombination of these pathologies (Table 7-8).\nAge Number \n< 40 22 \n 40 78 \nTable 1: The analysis of age. \nBMI Number \n< 24 15 \n 24 85 \nTable 2: The analysis of BMI. \nFibroid uterus 20% \nAdenomyosis 8% \nEndometrial Polyp 7% \nBulky uterus 23% \nFibroid + adenomyosis 3% \nFibroid+ endometrial polyp 5% \nNormal 34% \nTable 3: Ultrasound findings before the procedure. \nUCL Number \n< 8 12 \n 8 88 \nTable 4: Distribution by UCL. \nRecurrence of bleeding 90% \nNew onset pain 17% \nIntermenstrual bleeding 6% \nTable 5: Symptoms of failure. \nHysterectomy 67% \nRepeat ablation 15% \nMedical management 18% \nTable 6: Further treatment accepted. \n\nMukherjee G | Volume 1; Issue 2 (2023) | Mapsci-JGCORM-1(2)-007 | Research Article \nCitation: Mukherjee G, Warty T, Banerjee I, Thakur N, Thakur Y.  Factors Predicting Failure of Endometrial Ablation . \nJ Gynecol Clin Obstet Reprod Med. 2023;1(2):66-72. \nDOI: https://doi.org/10.37191/Mapsci -JGCORM-1(2)-007 \n \n \n \nOpen hysterectomy 68.65% \nLaparoscopic hysterectomy 22.4% \nVaginal hysterectomy 8.95% \nTable 7: Type of hysterectomy performed. \nFibroid 17 (25.4%) \nAdenomyosis 17 (25.4%) \nFibroid + adenomyosis 11 (16.4%) \nEndometriosis 1 (1.5%) \nNormal 21 (31.3%) \nTable 8: Data of Hysterectomy.\nDiscussion \nThe analysis showed that high BMI, larger \nuterine cavity, and the presence of additional \npathologies, like fibroids or adenomyosis, are \nmore commonly associated with failure of \nendometrial ablation using second-\ngeneration devices. \nPrevious studies have shown that higher age \nis associated with better outcomes [7]; a \npossible explanation for this could be - \npatients are closer to the age of menopause \nwhich led to more successful outcomes. \nHowever, the study s howed contradictory \nresults. This may be attributed, in part, to the \nsmall sample size. The other reason could be \nthe presence of other confounding factors like \nhigh BMI, larger cavity size, or the presence of \nfibroids in the older age group. The incidence \nof BMI more than 35 in the population aged \nover 40 years was 37%. This could contribute \nto the increased chance of ablation failure in \nthe population over 40 yrs. Since the sample \nsize is relatively small, the presence of these \nconfounding factors may hav e affected the \nresults. \nThe effect of BMI on the chance of success is \nan important observation in this study. The \nprobable reasons are described below. First, it \nmay be postulated that patients with higher \nBMI have an additional source of endogenous \nestrogen from adipose tissue, which may \ncause an increased rate of proliferation of the \nunabated endometrium. Studies have proven \nthat the uterine cornua, fundus, and the \ninterstitial part of the fallopian tubes are the \nmost common areas where endometrium \npersists even after ablation [11]. Second, the \nprocedure is often technically challenging in \nwomen with high BMI, which can lead to \nincomplete ablation of the endometrium. \nFakih et al [12] corroborate the findings by \nsuggesting that a BMI over 34 showed a trend \ntoward treatment failure. Thus, when \ndiscussing the chances of a successful \nprocedure during the consultation, women \nwith a higher BMI can be counseled regarding \nthe higher rate of recurrence/ failure as \ncompared to their normal BMI counterparts. \n\nMukherjee G | Volume 1; Issue 2 (2023) | Mapsci-JGCORM-1(2)-007 | Research Article \nCitation: Mukherjee G, Warty T, Banerjee I, Thakur N, Thakur Y.  Factors Predicting Failure of Endometrial Ablation . \nJ Gynecol Clin Obstet Reprod Med. 2023;1(2):66-72. \nDOI: https://doi.org/10.37191/Mapsci -JGCORM-1(2)-007 \n \n \nThe size of the uterus i.e., the length of the \nuterocervical canal is another important \nindicator of failure. A larger uterus is more \nlikely to be associated with uterine \npathologies like adenomyosis or uterine \nfibroids. Another independent risk factor is \nthe prese nce of fibroids, irrespective of the \nnumber or location; though submucosal \nfibroids are more commonly responsible for \ndistorting the uterine cavity and reducing the \nchances of success. It has been shown that the \npresence of even small intramural fibroids \ncould reduce the chance of success [9]. \nThe pathophysiology leading to ablation \nfailure in patients with adenomyosis is still \nnot clear. The presence of adenomyosis leads \nto an increase in the size of the endometrial \ncavity – which may cause incomplete ablation \nof the functioning endometrium. \nFurthermore, the functioning endometrium \ninside the myometrium continues to bleed \nleading to the development of new symptoms \nof pain. Most studies that seek to establish a \nrelationship between adenomyosis and \nendometrial ablation failure are retrospective \nand depend on the histopathological \ndiagnosis of hysterectomy specimens. Riley \ndemonstrated that 43% of hysterectomy \nspecimens were associated with adenomyosis \n[10]. In this study, we demonstrated the \npresence of adenom yosis in 41.8% of all \nhysterectomy patients. There was no \nconclusive way to evaluate the prevalence of \nadenomyosis in patients who had successful \noutcomes following endometrial ablation.  \nThe association between fibroids and poor \noutcomes of endometrial ab lation is \ncontroversial. Fibroids tend to distort the \nendometrial cavity which makes the \nendometrial ablation procedure technically \ndifficult and often unsuccessful [13]. \nSimilarly, the presence of endometrial polyps \ncan also reduce the chance of success. \nComino and Torrejon found that the presence \nof leiomyomas and endometrial polyps \nsignificantly increased the risk for \nhysterectomy following ablation. This \nassociation between the presence of \nsubmucous leiomyomas and endometrial \nablation failure was also s hown by Gemer et \nal [15], the study concluded that the presence \nhad a statistically significant positive \npredictive value for the risk of failure. By \ncontrast, Phillips et al [16] in a large \nobservational cohort study of 1000 cases \nfound that the presence of intrauterine \npathologies such as myomas or polyps \nactually decreased the risk of subsequent \nhysterectomy. \nOne way of increasing the success rate can be \nby adding a Mirena coil after endometrial \nablation.  Since previous studies have \nestablished that som e parts of the \nendometrium are still functioning following \nablation, the additional use of a Mirena coil \ncould suppress that functioning \nendometrium and improve the outcome [17]. \nIn a clinical setting, when counseling patients \nabout endometrial ablation, it is important to \nconsider and discuss these factors which may \ncontribute to treatment failure and provide \npatients with adequate and realistic data. \nConclusion \nAppropriate patient selection is a key factor in \nreducing the failure rate of endomet rial \nablation. This study found that BMI, length of \n\nMukherjee G | Volume 1; Issue 2 (2023) | Mapsci-JGCORM-1(2)-007 | Research Article \nCitation: Mukherjee G, Warty T, Banerjee I, Thakur N, Thakur Y.  Factors Predicting Failure of Endometrial Ablation . \nJ Gynecol Clin Obstet Reprod Med. 2023;1(2):66-72. \nDOI: https://doi.org/10.37191/Mapsci -JGCORM-1(2)-007 \n \n \nthe utero –cervical canal , and presence of \nuterine pathologies are key indicators of \nfailure. This information may help doctors \nand patients to make clinically –sound, \nevidence–based and individualized decisions \nto improve the rate of successful outcomes. It \ncould also help surgeons recommend \nadditional treatments, like a Mirena coil, to \nincrease the chances of a successful \nprocedure. However, this study was \nretrospective and included a small cohort of \npatients. Consequently, it could not \nsubstantiate multiple other factors. It would \nbe interesting to assess how the location of \nfibroids affects surgical outcomes. The study \nwas also unable to assess if ethnicity played a \nrole in the outcomes of endometrial ablation. \nFurther large –scale prospective studies may \nhelp substantiate the findings and add to the \nlist of predictors of ablation failure.\nReferences \n1. Stevens KY, Meulenbroeks D, Houterman S, Gijsen T, Weyers S, Schoot  BC. Prediction of Unsuccessful \nEndometrial Ablation: A Retrospective Study. Gynec Surg. 2019;16:1-9. \n2. Arieff AI, Ayus JC. Endometrial Ablation Complicated by Fatal Hyponatremic Encephalopathy. JAMA. 1993 \nSep;270(10):1230-2. PubMed \n3. Cooper JM, Erickson ML. Global Endometrial Ablation Technologies. Obstet Gynecol Clin North Am. \n2000;27(2):385-96. PubMed | CrossRef \n4. Klebanoff J, Makai GE, Patel NR, Hoffman MK. Incidence and Predictors of Failed Second -generation \nEndometrial Ablation. Gynecol Surg. 2017;14(1):26. PubMed | CrossRef \n5. Bongers MY, Mol BW, Brolmann HA. 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Geburtshilfe Frauenheilkd. 2019;79(3):286-292. PubMed | CrossRef \n10. Riley KA, Davies MF, Harkins GJ. Characteristics of Patients Undergoing Hysterectomy for Failed Endometrial \nAblation. JSLS. 2013;17(4):503-7. PubMed | CrossRef \n11. Lisa JR, Gioia JD, Rubin IC. Observations of the Interstitial Portion of the Fallopian Tube. Surg Gynecol Obstet. \n1954;92:159-169. PubMed \n12. Fakih M, Cherfan V, Abdallah E. Success Rate, Quality of Life, and Descriptive Analysis after Generalized \nEndometrial Ablation in an Obese Population. Int J Gynaecol Obstet. 2011;113(2):120-3. PubMed | CrossRef \n13. Ahonkallio SJ, Liakka AK, Martinkainen HK, Santala MJ. Feasibility of Endometrial Assessment after Thermal \nAblation. Eur J Obstet Gynecol Reprod Biol. 2009;147:69-71. PubMed | CrossRef \n14. Comino R, Torrejon R. Hysterectomy after Endometrial Ablation-Resection. J Am Assoc Gynecol Laparosc. 2004; \n11:495-99. PubMed | CrossRef \n15. Gemer O, Kruchkovich J, Huerta M, Kapustian V et al. Perioperative Predictors of Successful Hysteroscopic \nEndometrial Ablation. Gynecol Obstet Invest. 2007;63-205-8. PubMed | CrossRef \n16. Phillips G, Chien P F, Garry R. Risk of Hysterectomy after 1000 Consecutive Endometrial Laser Ablations. Br J \nObstet Gynaecol. 1998; 105:897-903. PubMed | CrossRef \n\nMukherjee G | Volume 1; Issue 2 (2023) | Mapsci-JGCORM-1(2)-007 | Research Article \nCitation: Mukherjee G, Warty T, Banerjee I, Thakur N, Thakur Y.  Factors Predicting Failure of Endometrial Ablation . \nJ Gynecol Clin Obstet Reprod Med. 2023;1(2):66-72. \nDOI: https://doi.org/10.37191/Mapsci -JGCORM-1(2)-007 \n \n \n17. Vaughan D, Byrne P. An Evaluation of the Simultaneous Use of the Levonorgestrel-Releasing Intrauterine Device \n(LNG-IUS, Mirena®) Combined with Endometrial Ablation in the Man agement of Menorrhagia. J Obstet \nGynaecol. 2012;32(4):372-4. PubMed | CrossRef","source_license":"CC0","license_restricted":false}