Endometrial Ablation

Here’s your RoshReview Question of the Week!

A 41-year-old G3P2103 woman is scheduled to undergo nonresectoscopic endometrial ablation for a history of heavy menstrual bleeding. She previously tried combined oral contraceptives but was not satisfied with medical management. An endometrial biopsy was completed and benign. Which of the following do you inform her is the most common complication when counseling her about the risks of the procedure?

• Abdominal pain

• Endometritis

• Hematometra

• Urinary tract injury

Check to see if your answer is correct at the links above!

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Read along with ACOG PB 81

What is an Endometrial Ablation? 

• History and Rationale 

  • Minimally invasive surgical procedure designed to treat heavy uterine bleeding in select women who DO NOT WANT FUTURE FERTILITY 

  • Developed originally in 1937 

    • 1967 - cryoendometrial ablation where you “supercooled” the endometrial lining

    • Becomes more prevalent in the 1980s when hysteroscopy became more widely available 

• How is it done today? - many ways! 

  • Laser and resectoscopic endometrial ablation 

    • Done under hysteroscopic visualization 

    • Uses a resectoscope with 4 current techniques 

      • Endometrial desiccation with electrosurgical rollerball or rollerbarrel - basically heats the tissue up to 60-90 degrees and destroys the endometrium 

      • Resection with monopolar or bipolar loop electrode - will also resect endometrium to level of myometrium (basically same way that we take care of fibroids from within)  

      • Radiofrequency vaporization - high energy to rapidly heat the intracellular water to 100 degrees C → vaporization of tissue, but no tissue is removed 

      • Laser vaporization - same as above 

  • Nonresectoscopic techniques (in the US) - can be nice because these can sometimes be less uncomfortable and can be performed in the office 

    • Bipolar radiofrequency (Novasure) - 3-dimensional bipolar mesh probe that delivers radiofrequency current until specific tissue impedance is reached 

    • Cryotherapy (Her Option, Cerene) - probe inserted into the uterus and cooled via liquid nitrogen or differential gas exchange 

    • Circulating hot water (Hydro ThermAblator or HTA-ablation) - only one of the non-resectoscopic techniques that uses hysteroscopy.

      • Sheath is inserted into the uterus → heated saline is administered for 10 minutes, and fluid should be at 90 degrees C

    • Combined thermal and bipolar frequency (Minerva) 

      • Heat applied to endometrium via silicone membrane with circulating ionized argon gas (advertised as “plasma”) 

    • Vapor ablation (Mara) - no longer FDA approved 

  • After the endometrium is burned, it can scar down, leading to difficulty entering the uterine cavity again 

  • Anesthesia 

    • Most trials describing non-resectoscopic ablation devices have used local anesthesia and parenteral conscious sedation

    • Can use cervical and paracervical block if desired to do procedures in the office - however need to select if patient is a good candidate for in office procedure (ie. low risk for complications) 

Candidacy for Endometrial Ablation  

• Who is the right candidate? 

  • Treatment is indicated for heavy bleeding in premenopausal women with no desire for future fertility 

    • An important caveat: this should be for those with heavy OVULATORY menstrual bleeding 

    • Should not be first line to treat for abnormal uterine bleeding due to anovulation 

      • This is because you should figure out the cause of that abnormal bleeding otherwise and treat the cause (ie. if due to PCOS, treat for PCOS) 

      • That is not to say that a patient with PCOS cannot have an ablation - however, you need to make sure that you are treating the causes of the PCOS.

  • Usually, these are patients who have tried other medical therapies and have failed or who should not have medical therapies

  • It is importance to counsel that patients should accept normalization of menstruation, not complete amenorrhea 

    • Not a treatment for those who do not want to have menstruation 

    • Variability across studies in amount of menstrual bleeding after ablation

    • In a meta-analysis, both non-resectoscopic and resectoscopic ablation resulted in similar rates of amenorrhea at 1 year (37% vs 38%) 

Preoperative Evaluation

• Evaluate the structure and histology of the endometrial cavity 

• Reasons:

  • Rule out cancer - either via hysteroscopy or endometrial biopsy in the office

    • Don’t want the reason for heavy bleeding to be cancer and complete endometrial ablation which can scar the endometrium and make later evaluation very difficult  

    • Those with hyperplasia (EIN) or cancer should not undergo ablation 

  •  Evaluate the shape of the uterine cavity 

    • Can be done either via sounding + transvaginal ultrasound, sonohysterogram, hysteroscopy, or combination 

    • Evaluate internal architecture (ie. is there a bicornuate uterus? Are there fibroids?)

    • Reason is that many of the devices have uterine cavity requirements.

      • For example, for Novasure, the cavity must sound between 6-10cm and have a cornua to cornua distance of at least 2.5cm. Also, those with polyps or fibroids > 2cm were excluded from the FDA approval studies 

• Pretreatment 

  • Not required, but most surgeons will usually use hormonal agents to pre-treat to thin the endometrium 

  • GnRH agonist can be used 30-60 days prior to procedure 

• Risk counseling

  • There are many adverse events that have been reported from ablation and can depend on the device used:

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• Some rare but possible complications: 

  • Distention media overload - just like in hysteroscopy.

    • Especially if you are doing resectoscope and you are using monopolar instruments, you have to use electrolyte-free fluid like 3% sorbitol or 5% mannitol - review our hysteroscopy episode with Dr. Dolinko to learn more! 

  • Uterine trauma - as with any procedure in the uterus, there is possibility of injury. Specifically, with ablation, injury is usually caused when there is hemorrhage or perforation.

    • Cervical lacerations and vaginal burns can also occur if hot fluid comes out through the cervix  

  • Postablation tubal ligation syndrome

    • Can occur in patients with history of tubal ligation 

    • Described as cyclic pelvic pain, likely due to residual and trapped endometrium in one or both cornua - tissue cannot exit through the cervix or through the cornua due to ablation causing scar tissue + tubal ligation causes scar tissue 

    • Incidence has been reported as high as 10%  

• Complications that are more significant 

  • Pregnancy 

    • Ablation is not designed to be a form of birth control. Patients should be counseled extensively that they should not get pregnant and use a form of reliable birth control afterward 

    • Pregnancy can still occur after ablation 

      • Those that continue pregnancy have higher rates of malpresentation, prematurity, placenta accreta, and perinatal mortality 

  • Endometrial malignancy 

    • Endometrial ablation does not seem to delay the diagnosis of malignancy 

    • However, due to scarring of the endometrium, it can make it more difficult for usual assessment of the endometrial tissue such as biopsy or hysteroscopy 

    • In one study of 303 patients who needed endometrial sampling after ablation, the failure rate for obtaining bleeding assessment was 40% 

Contraindications to Endometrial Ablation

• Uterine size/shape - as discussed before; all available non-resectoscopic endometrial ablation devices have limitations with respect to size of cavity and extent of anatomic distortion 

• Do not perform if:

  • Pregnant or recently pregnant or desires future pregnancy 

  • Presence of active or recent uterine infection 

  • Endometrial malignancy or EIN 

• Consider not performing if: 

  • Uterine anomalies - ie septum or unicornuate uterus 

  • Myometrial thinning after uterine surgery 

  • Postmenopausal women - very few studies on postmenopausal women, and those are usually small; the studies were done in those with persistent bleeding after using HRT 

Outcomes from endometrial ablation

• Overall outcomes 

  • Non-resectoscopic and resectoscopic ablation result in comparable rates of amenorrhea and patient satisfaction 

  • However, resectoscopic ablation is associated with more OR time, more frequent use of GA, increased risk of surgical complication (ie. fluid overload) 

  • Resectoscopic procedures are less costly

    • Resectoscopic procedures: $125-$150 

    • Non-resectoscopic: $850-$1300  

• Improvement in bleeding 

  • Patients may have irregular bleeding immediately following procedure 

  • Success rates should not be determined until 8-12 weeks after surgery 

  • Randomized trial of Her Option cryo vs. resectoscope (279 patients): comparable rates of menstrual reduction at 1 year (85 vs. 89%) 

  • Patient satisfaction overall is high for both types of ablation (91 vs 88%) at one year, and similarly at 2-5 years (93 vs 87%) 

• Surgical outcomes 

  • Subsequent surgery rates range from 17-25% for both types 

  • Hysterectomy rates are 14 vs 19% 

  • Higher risk of treatment failure in younger patients (<45 years old): 

    • Risk of subsequent hysterectomy or repeat ablation was 2x in patients <45 years old compared to patients >45 years old 

von Willebrand's Disease, feat. Dr. David Abel

Today we welcome Dr. David Abel, Assistant Professor in obstetrics and gynecology at the Oregon Health and Sciences University. Dr. Abel’s expertise and interest is in the most commonly encountered bleeding disorder for OB/GYNs: von Willebrand disease.

You can join the Foundation for Women and Girls' with Blood Disorders as a student, resident, or fellow for FREE and get access to their educational content by visiting this link.

Some light reading to accompany today’s podcast:

• ACOG CO 580

• American Society of Hematology (ASH) guidelines on VWD

• VWD Review written by Andra James, MD, an MFM at Duke and Dr. Abel’s mentor

What is von Willebrand’s disease?

• First described in 1926 by Erik von Willebrand, a Finnish pediatrician.

• Most common inherited bleeding disorder, accounting for about 80 to 85% of all bleeding disorders.

• Prevalence about 1 in 10,000, though possibly as high as 1 to 2% of the general population.

  • With respect to women with heavy menstrual bleeding, the prevalence appears be greater, ranging from 5 to 24%. 

• Von Willebrand Factor is a large glycoprotein encoded by a gene on chromosome 12 that is synthesized in endothelial cells and megakaryocytes, the hematopoietic cells that produces platelets.

  • It is assembled from identical subunits into strings of subunits that vary in size and are referred to as multimers.

  • Two main functions:

    • Needed for normal adhesion of platelets to sites of injured endothelium

    • Serves as a carrier for Factor VIII, which also protects vWF from proteolysis

      • When vascular injury occurs, this multimeric protein uncoils which results in platelet adhesion, activation and aggregation.

• Three main types of disease:

  • Type I: A partial quantitative deficiency of both von Willebrand factor and Factor VIII. This reduction is usually mild to moderate. 

    • Most common, accounting for 70-80% of cases of vWD

  • Type II: Quantitative reduction in von Willebrand Factor, with subtypes noted as A, B, M and N.

    • Accounts for 10 to 30 percent of cases of vWD

    • Patients with Type 2B vWD may have a moderate to severe bleeding phenotype that may present with thrombocytopenia during pregnancy.

      • Though uncommon, when you go through your differential for thrombocytopenia during pregnancy, you can keep type 2B von Willebrand disease on your radar!

  • Type 3 Most severe, characterized by the virtual absence of von Willebrand factor. 

    • Least common type, accounting for only 1-5% of cases.

• VWD is usually inherited in an autosomal dominant fashion

  • Baby generally has a 50% chance of inheriting this condition — obstetric/neonatal implications.

  • Rarely vWDz is inherited as an autosomal recessive condition, namely in type 3,  and some cases of type 2. 

 How do we establish a diagnosis of von Willebrand’s disease?

• Most common bleeding symptoms: bruising, epistaxis, bleeding after injury, surgery or tooth extraction, postpartum bleeding, and menorrhagia (most commonly reported symptom).

  • In addition to mucocutaneous and soft tissue bleeding, joint and muscle bleeding can also occur.

  • Severity of bleeding is usually related to the degree of von Willebrand factor and Factor VIII deficiency. 

• Initial work up typically consists of nonspecific tests such as a CBC, PT, PTT and fibrinogen which are helpful in excluding a clotting factor deficiency.

  • PTT may be normal in patients with von Willebrand’s.

  • If thrombocytopenia is detected, type 2B vWDz is in the differential.

• Next step are tests that are specific for von Willebrand Disease, three:

  • von Willebrand factor antigen (vWF:Ag) measures the quantity of von Willebrand Factor protein in the plasma.

  • Factor VIII assay measures Factor VIII activity which is essentially a surrogate marker for the activity of von Willebrand factor.

  • von Willebrand factor activity a functional assay that measures the interaction between VWF and platelets.

    • Historically this was measured by the von Willebrand Factor ristocetin cofactor activity assay (VWF:RCo).

    • Consultation with hematology will be helpful with diagnostic testing and interpretation of results. 

Why does von Willebrand’s disease matter for us in OB/GYN?

• Strong association between von Willebrand Disease and heavy menstrual bleeding.

  • Among women with heavy menstrual bleeding, von Willebrand Dz is found to be the etiology frequently, with a reported prevalence ranging from 5 to 20%. 

• Many treatment options are available for women with von Willebrand disease and heavy menstrual bleeding, including hormonal and nonhormonal therapies.

  • Association of VWD with other gynecologic problems, including ovarian cysts, endometriosis, and leiomyomas is unclear. 

• Prior to procedures as egg retrieval if IVF is planned, or invasive procedure during pregnancy such as CVS and amniocentesis, DDAVP or VWF concentrates can be administered immediately prior to these procedures (more on treatment later).

Antepartum and Intrapartum Management of vWD

• Both von Willebrand Factor and Factor VIII levels increase during pregnancy, an increase that usually starts in the second trimester and peaks in the third trimester.

  • The increase in VWF and FVIII levels usually reduces the likelihood that our patients warrant treatment during the antepartum, intrapartum or even postpartum period.

  • If a patient was previously undiagnosed, the increase in levels during pregnancy may obscure the diagnosis.

    • In general, women with baseline levels of VWF and FVIII of >30 U/dL, suggesting type 1 VWD, usually have a high likelihood to achieve normal levels by the end of pregnancy.

  • In the case of the severe and uncommon type III vWDz, both VWF and FVIII levels do not increase during pregnancy.

• Levels of vWF and FVIII fall rapidly after delivery.

  • Levels start to approach patient’s baseline by one week postpartum and fully reach baseline by three weeks postpartum. 

• Potential complications of vwD during pregnancy include antepartum bleeding, postpartum hemorrhage and perineal hematoma which are all increased by 2–10-fold.

• Importantly the risk of delayed postpartum hemorrhage (bleeding occurring after 24 hours post-delivery) is also increased.

  • 16-29% of women with VWD will have postpartum hemorrhage within the first 24 hours of delivery,

  • 20-29% of women will experience delayed postpartum bleeding.

  • Bleeding is frequently reported to occur more than 2 to 3 weeks postpartum.

• Factor VIII and von Willebrand Factor ristocetin cofactor activity assay are checked early in pregnancy and again in the third trimester.

  • Consult hematology to decide if any additional testing is needed

• Women with type I vwDz with Factor VIII and ristocetin cofactor activity levels less than 50 IU/dL, and no history of severe bleeding, do not require special treatment at the time of delivery.

  • They can often be cared for by the general obstetrician in a community setting if the provider is comfortable and hematology available if needed. 

• If levels are less than 50 IU/dl, the patient is at risk of hemorrhagic complications including delayed postpartum hemorrhage. These patients require treatment usually close to delivery or after cord clamping.

  • The classic teaching is to administer DDAVP.

    • DDAVP causes release of VWF that has been stored in secretory granules within the endothelium, resulting in FVIII and VWF levels three to five times above basal levels within 30‐60 minutes.

    • Effective in patients with type 1 VWD with baseline VWF and FVIII levels higher than 10 IU/dL.

    • The recommended dose of DDAVP is 0.3 μg/kg IV given over 30 minutes or 300 μg given intranasally. 

      • Onset of action of DDAVP is approximately 15-30 minutes.

      • Usually given at the time of cord clamping, but because the peak effect is 1.5 to two hours after administration, it may be more beneficial if administered during the second stage of labor or immediately before cesarean delivery. 

    • Risks: water retention that can lead to hyponatremia and seizures.

      • Need fluid restriction to less than 1L in the 24 hours following DDAVP administration.  

      • However, fluid restriction after delivery can be very difficult, and is the reason why many experts do not use DDAVP as a first line treatment.

  • Alternative: plasma derived VWF concentrates.

    • Options:

      • Plasma derived VWF concentration that contains VWF alone without Factor VIII.

      • Recombinant VWF concentrate that contains only VWF without Factor VIII.

      • Plasma derived concentrate that contains both VWF and Factor VIII.

        • The decision regarding which one of these to use will depend upon levels of both VWF and Factor VIII, what is available in your hospital and input from hematology.

Regional anesthesia

• No consensus on levels that are safe for regional anesthesia, but if levels are greater than 50 IU/dL and assuming a normal platelet count, regional anesthesia is usually considered reasonable.

• Recent ASH guidelines recommend VWF activity levels should be maintained at 50 IU/dL while the epidural is in place and for at least 6 hours after removal. 

Mode of Delivery

• Fetal status unknown in most cases —> given AD inheritance and 50% risk, best to avoid procedures such as a fetal scalp electrode.

• Operative delivery is discouraged due to the potential risk of intracranial hemorrhage - cesarean delivery preferred to operative vaginal delivery. 

• The pediatrician should be made aware of the mother’s status and male circumcision should be postponed until the baby’s VWDz status can be determined.  

  • Sending cord blood at the time of delivery for a VonWill panel is recommended to determine the status of the newborn.

Postpartum Care

• High risk of both primary and delayed postpartum hemorrhage. Perineal hematomas can be seen.

• VWF and Factor VIII levels can significantly decrease postpartum, with a return to baseline within 7-21 days postpartum.

  • These levels are typically checked in the immediate postpartum period and then periodically.

  • Hematology consultation will be valuable to help work out these details.

  • NSAIDS should be avoided in the postpartum period. 

• ASH guidelines recommend the use of oral tranexamic acid in the postpartum period.

  • Administration of one mg intravenously can be administered prophylactically immediately after delivery and continued PO for 10-14 days postpartum.

Abnormal Uterine Bleeding: The Basics

Today we talk through the varied etiologies and a basic workup for a common GYN complaint: abnormal uterine bleeding. ACOG PB 128 makes for good companion reading for women of reproductive age.

The terminology of AUB has changed quite a bit, and you may still hear older terms being used. “Dysfunctional uterine bleeding” or DUB has fallen out of favor, as have terms such as metrorrhagia or menorrhagia, yielding instead to simpler terminology such as prolonged menstrual bleeding and heavy menstrual bleeding, respectively. The terms such as oligomenorrhea (bleeding cycles > 35 days apart) and polymenorrhea (cycles < 21 days apart) are also in use to some degree.

Heavy bleeding is difficult to discern, but for research purposes has been described as >80cc blood loss per cycle. In clinical practice, this is obviously impractical, so we rely on subjective descriptions of heavy bleeding to guide care.

The biggest takeaways from this episode include the PALM-COIEN classification of bleeding by FIGO, as well as the common culprits of bleeding by age group. Remember also the criteria for working up for disorders of coagulation, which we’ve put here (though contained in the practice bulletin).

Stay tuned for future episodes about the treatments of these various etiologies, or check out our friends at The OBG Project for excellent summaries of guidelines and new literature!

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ACOG PB 128

ACOG PB 128