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Likelihood of Hysterectomy after Endometrial Ablation
Abstract & Commentary
By Frank W. Ling, MD, Clinical Professor, Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, is Associate Editor for OB/GYN Clinical Alert.
Dr. Ling reports no financial relationship to this field of study.
Synopsis: The type of procedure or presence of fibroids is less important than age at the time of endometrial ablation in predicting subsequent hysterectomy.
Source: Longinotti MK, et al. Probability of hysterectomy after endometrial ablation. Obstet Gynecol 2008;112:1214-1220.
In a retrospective analysis of 3681 women who underwent endometrial ablation from 1999 to 2004, data analyzed in 2007 from Northern California Kaiser Permanente showed hysterectomy was performed in 21% (774 patients) while uterine-sparing surgery was performed in another 3.9% (n = 143). Women younger than age 45 at the time of ablation were twice as likely to undergo hysterectomy as compared to those older than age 45. In fact, for those younger than age 40, the hysterectomy rate was 40%. Various types of ablation technique were used (first generation, hydrothermal, radio frequency, thermal balloon), with the type of procedure not being a significant factor in predicting subsequent hysterectomy. Similarly, neither the presence of leiomyomas nor the location of the procedure (inpatient vs outpatient) was a significant predictor. The authors also found that the risk of hysterectomy continued to rise through 8 years of follow-up rather than plateauing at any specific duration after the procedure. The overall probability of hysterectomy was 26% at 8 years with the majority being done within 3 years.
Here it is! Something useful that you can use to counsel patients about the potential role of endometrial ablation. Admittedly, it is limited because it is retrospective and it was only from one large HMO setting. Also, there are "apples and oranges" being mixed in together, i.e., different types of techniques and patients with various anatomical findings (more than 20% had fibroids). Even beyond that, the subjects ranged in age from 25 to 60 years (the extreme ages are a bit mind-boggling to me). OK, so no study is perfect; however, doesn't this really reflect what you face in your practice everyday?
Sure, endometrial ablation is meant for patients with menorrhagia, but we all know that patients with other bleeding patterns are often treated with this surgical approach. How many times have you asked yourself or been asked by others which ablation technique is best? According to this study, it may well not make a difference. The rate of hysterectomy is eye-opening if you're trying to be objective with counseling patients. They often ask about future surgery, but that has to be balanced with recovery time and morbidity. Remember that a patient's likelihood of dissatisfaction with the outcome of the ablation is likely higher than just the hysterectomy since there will also be those who get uterus-sparing procedures and/or require further medical management.
Where does this leave you as a clinician trying to do right by your patient? It probably doesn't make you a non-ablationist (I think I just created a word) if you are performing them now. The numbers certainly won't convince you to start doing them if you've been waiting for more research on long-term outcome. These data do help put risk in perspective and may be more concretely helpful to your patients who are sitting on the fence. No matter what your opinions, our goal is still to do the best for our patients. This includes incorporating new technologies when appropriate, but applying them selectively and prudently. Endometrial ablation can no longer be considered new technology, but its role in any individual patient still rests within that unique doctor-patient role that you have. Informed consent … not a new idea, but one that is constantly being tweaked by new data. Here's some new data. Enjoy!