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ORIGINAL RESEARCH |
From the Sydney Centre for Reproductive Health Research, Family Planning NSW, Ashfield, New South Wales, Australia; the Department of Obstetrics and Gynaecology, University of Sydney, New South Wales, Australia; and the Department of Obstetrics and Gynaecology, King George V and Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.
Address reprint requests to: Raewyn Teirney, MBChB, MRACOG Royal Hospital for Women Department of Reproductive Medicine Barker Street Randwick, NSW 2031 Australia
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Abstract |
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Methods: Thirty-nine women with menorrhagia due to ovulatory dysfunctional bleeding treated previously by rollerball ablation were followed up 5–6 years later. Menstrual blood in sanitary towels was measured with the alkaline hematin technique in 26 women who were still premenopausal and in whom menstrual blood loss had been measured before and immediately after the original ablation.
Results: Mean (± standard deviation [SD]) menstrual blood loss (per menstrual period) was reduced from 90 mL ± 14.4 before ablation to 3.8 mL ± 2.1 at 3 months, 1.8 mL ± 1.0 at 6 months, and 3.3 mL ± 1.3 at 5–6 years after ablation. In women who were still menstruating, the mean hemoglobin concentration rose significantly from 126 to 135 g/L (P = .022).
Conclusion: Rollerball endometrial ablation is a highly effective long-term therapy for carefully selected women with menorrhagia due to ovulatory dysfunctional uterine bleeding.
Endometrial ablation has been used increasingly since the mid–1980s and is now well established as an effective treatment for some women with menorrhagia. Advantages that make it a popular alternative to hysterectomy include minimally invasive transcervical approach, low morbidity, rapid recovery, and lower costs.1 Three approaches are used commonly: Nd:YAG laser, loop resection with resectoscope, and rollerball. The rollerball is the easiest to master and is safe in trained hands.2
The literature reports success rates from 60–90% for hypomenorrhea and amenorrhea combined.3,4 Most studies reported short-term outcomes, with few data on long-term outcomes after endometrial ablation.5,6 In assessment of outcomes such as menstrual pattern and volume of menstrual blood loss, few studies used objective techniques.7 Most results were through subjective approaches, such as patient recall in postal, phone, or face-to-face interviews, or semiobjective techniques, such as pictorial blood loss assessment charts.8,9
We studied women pretreated with goserelin implants or danazol in a randomized trial before rollerball endometrial ablation with the use of objective measurements of menstrual blood loss before and at 6 months after operations.10 There was a dramatic decrease in menstrual blood loss, with amenorrhea in 62% and 74% in the danazol and goserelin groups, respectively. Those women have now been reassessed objectively with menstrual blood loss measurements at 5–6 years after the original endometrial ablation study.
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Materials and Methods |
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The 39 women who completed the original study in the Sydney center were followed up between 5 and 6 years after their endometrial ablations. Full menstrual and gynecologic histories were taken, and those who were still menstruating were investigated further with a full blood count and measurement of menstrual blood loss over two cycles. Those who were amenorrheic were assessed to determine whether they were menopausal.
Menstrual blood loss was measured with the alkaline hematin method of Hallberg and Nilsson with a semi-automatic extractor.11,12 Blood loss measurements were taken in two menstrual cycles from each woman with the mean of the two measurements in the analysis. Blood loss measurements were categorized as hypomenorrhea (spotting or staining, 0.1–7 mL), light bleeding (7.1–25 mL), moderate bleeding (25.1–60 mL), and heavy bleeding (greater than 60 mL). Those categories were based on perceptions and objective menstrual blood loss measurements of women with menorrhagia reported previously.13
The protocol for the follow-up study was approved by the Ethics Committee of Family Planning New South Wales, and informed consent was obtained from each participant. Menstrual blood loss over time in the same women was compared with the Wilcoxon sign-rank test. Comparisons between treatment groups used Wilcoxon rank-sum test. Paired t test was used to compare hemoglobin levels in the same woman pretreatment and at 5–6 years after treatment. P 
.05 was considered statistically significant.
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Results |
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One of two women who had hysterectomies at age 52 had unacceptable irregular and prolonged bleeding with postmenopausal hormone replacement therapy (HRT) and had focal adenomyosis and multiple small fibroids. She had hypomenorrhea until menopause. The second had a hysterectomy 5 years after ablation at age 46 for increasing pain due to endometriosis involving the utero-sacral ligaments, broad ligaments, and pouch of Douglas. She has been amenorrheic since ablation. There were no repeat endometrial ablations.
Twelve of 26 women (46%) were amenorrheic, nine (35%) had less than 7 mL measured menstrual blood loss per menstrual period, and the remaining five (19%) had mean measured blood loss between 7.1 and 25 mL, defined as light bleeding (Table 1
). There was no heavy bleeding. Two of three women with blood losses greater than 15 mL perceived the first day of those periods as "heavy," although the measured blood loss on those days was less than 30% of the measured volume on day 1 of their pretreatment periods.
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Menstrual blood loss measurements by pretreatment group and assessment time after endometrial ablation are summarized in Table 2. There was a significant reduction in mean measured menstrual loss between the pretreatment cycle and 3 months, 6 months, and 5–6 years, respectively, after the procedure in those 26 women. That reduction also was significant within the pretreatment groups at each time point. When comparing pretreatment groups, women with depot goserelin had significantly lower menstrual blood losses in assessments at 3 and 6 months after ablation (P < .012; P < .034). When those 26 women were compared 5–6 years later, there was no difference in measured blood loss between pretreatment groups (depot goserelin 3.7 ± 7.1, danazol 3.2 ± 5.4; mean ± SD; P > .05). The lack of significance between goserelin and danazol in menstrual blood loss and amenorrhea at 5–6 years might be a result of the small sample giving inadequate power to detect a difference.
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Discussion |
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In the original study, those women all had dramatic decreases in menstrual blood loss, with complete amenorrhea in 74% of goserelin- and 62% of danazol-users 6 months after ablation. Among women who did not achieve complete amenorrhea, those in the danazol group were more likely to have occasional episodes of moderate bleeding. The mean menstrual blood loss decreased from 90 mL before ablation to 3.3 mL 5–6 years after the procedure.
Women with diagnoses of ovulatory dysfunctional bleeding can expect an excellent long-term prognosis after rollerball endometrial ablation, although a small proportion might turn out to have other uterine or pelvic diseases that require hysterectomies. No cancers were found in the small sample, but endometrial cancers have been reported rarely in women who have had endometrial ablation.14 Effective removal of most of the basal layer of endometrium during ablation should result in a substantial reduction in the long-term incidence of endometrial carcinoma in those women, although the risk cannot be eliminated as with hysterectomy. Endometrium and adenomyotic tissue cannot be removed completely with certainty, so women who are in high-risk groups for endometrial adenocarcinoma are not suitable for endometrial ablation.
Relatively few long-term follow-up data are available for women treated with endometrial ablation,5,6 and most were assessed subjectively by history rather than objective menstrual blood loss measurements. Evidence is growing that carefully selected women with menorrhagia due to ovulatory dysfunctional bleeding, "superficial adenomyosis," and small intramural myomata usually have excellent long-term outcomes with careful rollerball, loop resection, or Nd-YAG laser ablation. Most of those women should be able to avoid hysterectomy, a treatment that most women in this study were offered before ablation. There is evidence that women who need hysterectomies after endometrial ablation will need them within the first 3 years after ablation.4
One Australian study found a high incidence of further gynecologic surgery after endometrial ablation.15 The present study and other experience suggest that poor outcomes might be due to combined unwise patient selection, incorrect or hurried ablation, or incomplete pretreatment counseling of women, leading to poor tolerance of persistent light bleeding.
Presurgical thinning of endometrium with depot goserelin or danazol eases surgery and aids in more effective short-term outcomes after ablation,9,10 although there are no data on its effects on longer-term outcomes.
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Footnotes |
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Received January 19, 1999. Received in revised form July 27, 1999. Accepted August 12, 1999.
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References |
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2. Fraser IS, Aungsuwathana S, Mahmoud F, Yezerski S. Short and medium-term outcomes after rollerball endometrial ablation for menorrhagia. Med J Aust 1993;158:454–7.[Medline]
3. Garry R, Shelley-Jones D, Mooney P, Phillips G. Six hundred laser ablations. Obstet Gynecol 1995;85:24–9.[Abstract]
4. Chullapram T, Song JY, Fraser IS. Medium term follow-up of women with menorrhagia treated by rollerball endometrial ablation. Obstet Gynecol 1996;88:71–6.[Abstract]
5. O’Connor H, Magos A. Endometrial resection for the treatment of menorrhagia. N Engl J Med 1996;335:151–6.
6. Baggish MS, Sze EHM. Endometrial ablation. A series of 568 patients treated over an 11 year period. Am J Obstet Gynecol 1996;174:908–13.[Medline]
7. Magos AL, Baumann R, Lockwood GM, Turnbull AC. Experience with the first 250 endometrial resections for menorrhagia. Lancet 1991;337:1074–8.[Medline]
8. Bhattacharya S, Cameron IM, Parkin DE, Abramovich DR, Mollison J, Pinion SB, et al. A pragmatic randomised comparison of transcervical resection of the endometrium with endometrial laser ablation for the treatment of menorrhagia. Br J Obstet Gynaecol 1997;104:601–7.[Medline]
9. Donnez J, Vilos G, Gannon MJ, Stampe-Sorensen S, Klinte I. Goserelin acetate (Zoladex) plus endometrial ablation for dysfunctional uterine bleeding. Aztec: 12-month follow-up results. Acta Obstet Gynecol Scand 1997;76 Suppl 167:4:23–32.
10. Fraser IS, Healy DI, Torode H, Song JY, Mamers P, Wilde F. Depot Goserelin and danazol pretreatment before rollerball endometrial ablation for menorrhagia. Obstet Gynecol 1996;87:544–50.[Abstract]
11. Hallberg L, Nilsson L. Determination of menstrual blood loss. Scand J Clin Lab Invest 1964;16:244–8.
12. Newton JR, Barnard G, Collins W. A rapid method for measuring menstrual blood loss using automatic extraction. Contraception 1977;16:269–82.
13. Fraser IS, McCarron G, Markham R. A preliminary study of factors influencing perception of menstrual blood loss volume. Am J Obstet Gynecol 1984;149:788–93.[Medline]
14. Iqbal PK, Paterson MEL. Endometrial carcinoma after endometrial resection for menorrhagia. Br J Obstet Gynaecol 1997;104:1097–8.[Medline]
15. Molloy D, Taylor PT. Gynaecological surgery after endometrial ablation. Med J Aust 1994;161:604–6.[Medline]
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