1. 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

2. 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.

3. 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: /S (98)00119-X.PMID 
Exclusion criteria – mean age of women within 5 years of menopause

4. 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

5. 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.

6. 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%
(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%
(7% - 28%)
Complication rate
(1.8% %) -
Definition of re-intervention – any pro
*Median (Range) *0 – Unreported

7. 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% %)
39%
(8% %)
Rates patient satisfaction rate
88%
(60.5% - 99%)
86.1%
(27% %)
Rates of re-intervention
12%
( %)
7.3%
( %)
Repeat ablation 3%
(0 - 11%)
1.7%
( %)
Hysterectomy rate 9%
(0.9% %)
5.6%
(0.5% %)
Complication rate
9.5%
(2.9% %)
9.8%
(1.8% %)
*Median (Range) *0 – Unreported

8. 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

9. 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.

10. Thank you for listening!