Endometrial ablation in Women with MENSTRUAL DISORDERS: A systematic review Y W Liao1, S Shaman1, C S Chean1, S S Poon1, A Soltan1 Liverpool Women’s Hospital, Liverpool1 Endometrial ablation offers a reasonable surgical option for women with heavy menstrual bleeding where medical treatment has failed and hysterectomy is not desired. Y W Liao, 3rd year medical student, Liverpool Mr A Soltan, consultant gynaecologist and lead ambulatory services, Liverpool Women Hospital

Objectives To measure the efficacy of endometrial ablation using first and second generation technology. Primary outcomes: Short and long term rates of amenorrhoea and patients’ satisfaction in women treated with 1st and 2nd generation endometrial ablation procedures. Secondary outcomes: Complication rates and rates of repeat intervention in women treated with 1st and 2nd generation of endometrial ablation.

Methodology Literature search using PubMED and Scopus databases to identify relevant studies. Inclusion criteria : only prospective/RCT studies of women with European or North American ethnicity and with outcome data on ablation and median age of under 46.3 years, which is less than 5 years of median age menopause of 51.3 years [Kato et al., 1998]1 at the time of ablation were included. Exclusion criteria : Case reports, editorial comments, cohort studies, abstracts, studies with median age of more than 46.3 years and studies including women who never conceived before. 1- Prospective study of factors influencing the onset of natural menopause". J Clin Epidemiol51 (12): 1271– 1276. doi:10.1016/S0895-4356(98)00119-X.PMID 10086819. Exclusion criteria – mean age of women within 5 years of menopause

Figure 1. Flow diagram of included studies Papers identified through database searching (n = 1056) Identification Papers screened for duplicates and full text assessed for eligibility (n = 350) Papers excluded (n = 706) Screening Only RCT selected for and screened for duplicates (n = 42) Papers excluded (n = 308) Eligibility Full text RCTs assessed for eligibility and included in quantitative and qualitative synthesis (n = 26) Included

Results 26 papers (n = 4424) fulfilled the search and inclusion criteria and were included in the final analyses. They were all premenopausal women of European or North American ethnicity and with average age of <46.3 years at time of ablation. The median age of the women is 41.9 (40.2 – 46.1 ) years with a median BMI of 28.0 (22.9 – 30.2) kg/m2 and have a median parity of 2.4 (1.8 – 3.0). All women were treated with endometrial destructive techniques that belonged to either Generation 1 or Generation 2.

Table 1: Overall outcomes of Endometrial Ablation Outcome measures Short term follow up (4-12 months) Long term follow up (>5 years) Rates of amenorrhea 40% (8.0% - 61.3%) 61% (23% - 88%) Patient satisfaction rate 87.4% (27% - 99%) 79% (52% - 96%)  Rate of re-intervention 9.7% (0 - 11%)  16.5% (1% - 28%) Repeat ablation 2.2% (0 - 11%) 1.8% (1% - 2.3%) Hysterectomy rate 7.5% (0.5% - 14.7%) 14.7% (7% - 28%) Complication rate (1.8% - 35.7%) - Definition of re-intervention – any pro *Median (Range) *0 – Unreported

Table 2: Short term endometrial ablation outcomes: Generation 1 vs Table 2: Short term endometrial ablation outcomes: Generation 1 vs. Generation 2 (up to 12 months follow up) Generation 1 [n=1289] Generation 2 [n=2004] Rates of amenorrhea 42.5% (24% - 55.7%) 39% (8% - 61.3%) Rates patient satisfaction rate 88% (60.5% - 99%) 86.1% (27% - 98.5%) Rates of re-intervention 12% (0 - 14.7%) 7.3% (0 -10.4%) Repeat ablation 3% (0 - 11%) 1.7% (0 - 2.7%) Hysterectomy rate 9% (0.9% - 14.7%) 5.6% (0.5% - 10.4%) Complication rate 9.5% (2.9% - 35.7%) 9.8% (1.8% - 22.6%) *Median (Range) *0 – Unreported

Table 3: Long term endometrial ablation outcomes: Generation 1 vs Table 3: Long term endometrial ablation outcomes: Generation 1 vs. Generation 2 (5-10 years follow up) Outcome measures Generation 1 [n=156] Generation 2 [n=651] Rate of amenorrhea 69% (33% - 88%) 60% (23% - 83%) Patient satisfaction rate 79% (52% - 96%) 81% (53% - 96%) Rate of re-intervention 26.8% (1.6% - 28%) 15% (1% - 26%) Repeat ablation 1.8% (1.6% - 2%) 1.7% (1% - 2.3%) Hysterectomy rate 25% (16.9% - 28%) 12.9% (7% - 17%) *Median (Range) *0 – Unreported

Conclusions Endometrial ablation is a lesser invasive option of treatment for women with menstrual disorders than hysterectomy with approximately 80% of women remain satisfied at 5 years follow up irrespective of technique whether 1st or 2nd generation.. Longer term (>5 years), there is about 60% increase in overall rates of re- intervention in premenopausal women (compared to <12months follow up) with almost doubling of the hysterectomy rates. 1st and 2nd generation ablation appear to yield comparable rates of amenorrhoea and patient satisfaction. However rates of re-intervention and particularly hysterectomy appear to be about 50% higher in 1st compared to 2nd generation ablative techniques. The flexibility of 2nd generation ablation techniques in offering shorter duration treatment with flexibility to outpatient/ambulatory and closer to home treatment would require further evaluation.

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