Expert Commentary

What are the risk factors for pain after endometrial ablation?

OBG Manag. 2015 February;27(2):15,24

A history of dysmenorrhea or tubal sterilization increases the likelihood of new or worsening postablation pain by 74% (adjusted odds ratio [OR], 1.74; 95% confidence interval [CI], 1.06–2.87) and more than 100% (adjusted OR, 2.06; 95% CI, 1.14–3.70), respectively, according to this retrospective cohort study.

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References

1. National Institute for Health and Care Excellence. NICE Clinical Guideline CG44: Heavy Menstrual Bleeding. http://www.nice.org.uk/guidance/cg44. Published January 2007. Accessed January 18, 2015.

2. Lethaby A, Penninx J, Hickey M, Garry R, Marjoribanks J. Endometrial resection and ablation techniques for heavy menstrual bleeding. Cochrane Database Syst Rev. 2013;(8):CD001501.

3. El-Nashar SA, Hopkins MR, Creedon DJ, et al. Prediction of treatment outcomes after global endometrial ablation. Obstet Gynecol. 2009;113(1):97–106.

4. Longinotti MK, Jacobson GF, Hung YY, Learman LA. Probability of hysterectomy after endometrial ablation. Obstet Gynecol. 2008;112(6):1214–1220.

5. Wortman M, Cholkeri A, McCausland AM, McCausland VM. Late-onset endometrial ablation failure (Loeaf)—etiology, treatment, and prevention [published online ahead of print October 31, 2014]. J Minim Invasive Gynecol. pii: S1553-4650(14)01484-8. doi: 10.1016/j.jmig.2014.10.020.

6. Thomassee MS, Curlin H, Yunker A, Anderson TL. Predicting pelvic pain after endometrial ablation: which preoperative patient characteristics are associated? J Minim Invasive Gynecol. 2013;20(5):642–647.

7. Carey ET, El-Nashar SA, Hopkins MR, Creedon DJ, Cliby WA, Famuyide AO. Pathologic characteristics of hysterectomy specimens in women undergoing hysterectomy after global endometrial ablation. J Minim Invasive Gynecol. 2011;18(1):96–99.

Heavy menstrual bleeding is a common gynecologic problem and can negatively affect a woman’s quality of life.¹ Endometrial ablation is an effective treatment option.² Despite its efficacy, however, endometrial ablation has failure rates ranging from 15% to 30%.^3,4 Two consistent reasons for failure are persistent bleeding and new or worsening pain. Endometrial regrowth and intrauterine scarring are thought to be key factors in this pain process.⁵

Details of the trial
Wishall and colleagues conducted their retrospective cohort study using patient data from two large academic medical centers. The primary outcome was the development of new or worsening pain following endometrial ablation. The two most commonly used endometrial ablation devices in this study were thermal balloon ablation and bipolar radiofrequency ablation.

Twenty-three percent of patients developed new or worsening pain following the ablation, a finding in accordance with earlier studies looking specifically at pain after endometrial ablation.⁶ In addition, 19% of patients underwent hysterectomy after ablation—again, within the range commonly reported in the literature.^3,4

Risk factors for new or worsening pain after ablation included a preprocedure history of dysmenorrhea or tubal sterilization. White race was protective of postprocedure new or worsening pain (adjusted OR, 0.55; 95% CI, 0.34–0.89).

Risk factors for hysterectomy after ablation included a history of cesarean delivery (adjusted OR, 2.33; 95% CI, 1.05–5.16) and uterine abnormalities on imaging, including leiomyoma, adenomyosis, a thickened endometrial lining, and polyps (adjusted OR, 3.96; 95% CI, 1.25–12.56). When the ablation procedure was performed in an operating room, the risk of postprocedure hysterectomy decreased (adjusted OR, 0.24; 95% CI, 0.07–0.77). In histopathologic analysis of the hysterectomy specimens, leiomyomas or adenomyosis, or both, were the most common findings, consistent with other reports on pathologic findings in this setting.⁷

Placing these findings in context
Overall, the findings of Wishall and colleagues support those of other studies exploring endometrial ablation, an effective uterine-conserving procedure for the treatment of heavy menstrual bleeding. All conservative procedures have inherent failure rates and can lead to unintended adverse effects. Common reasons for failure after endometrial ablation include bleeding or pain, or both.

Although there are discrepancies between studies in regard to some of the individual predictors of failure or development of pain, the collection of retrospective studies on this subject to date have made it clear: There are predictors of treatment failure. Future efforts should focus on model development and prospective validation of these models to improve patient selection.

What this evidence means for practice
This study reinforces the idea that patient selection for conservative procedures such as endometrial ablation is one of the most important steps in the process. In light of these findings, I recommend that women with a history of dysmenorrhea or tubal sterilization be counseled about the potential for postprocedure pain and subsequent treatment failure.
— Matthew R. Hopkins, MD

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