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CMECNE

Endometrial Ablation – When is This Procedure Appropriate?

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Identify the tests that should be done prior to ablation
2. Name the contraindications to endometrial ablation

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Dec 31 2021, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

CLINICAL ACTIONS:

Endometrial ablation is indicated for treatment of abnormal uterine bleeding or patient-perceived heavy menstrual bleeding in premenopausal women with normal endometrial cavities.

    • Evaluate for malignancy, hyperplasia, and to ensure the cavity configuration is appropriate for ablation
      • Prior to ablation: Endometrial biopsy, transvaginal ultrasound, saline infusion sonohysterography, hysteroscopy or a combination of these procedures
    • Contraindications include
      • Endometrial cavity too large for the device parameters | Mullerian duct disorders (bicornuate/septate uterus) | Recent pregnancy | Active infection | Malignancy or hyperplasia
    • Relative contraindications include
      • Surgeries that may distort or weaken the myometrium such as classic cesarean section and transmural myomectomy
    • Consider ablation when patients have failed or have been intolerant of medical therapies
  • Determine your patient’s fertility plans
      • Pregnancies that occur after ablation have a high rate of malpresentation, prematurity and placenta accreta
    • Patients should be counseled to use effective contraception

SYNOPSIS:

Endometrial ablation is a minimally invasive surgical procedure to reduce menstrual flow and is designed to treat abnormal uterine bleeding in women who do not desire future fertility. A number of options are available including resectoscopic, thermal balloon, cryotherapy, heated free fluid, microwave and radiofrequency electricity. Endometrial thinning, either mechanical or by suppression/inhibition of ovarian function, has been used as an adjuvant to ablation.

KEY POINTS:

  • Complications are rare, but include
    • Distention media fluid overload | Uterine trauma | Thermal injury | Postablation tubal ligation syndrome | Perforation Infection
  • Anesthesia
      • local anesthesia with parenteral conscious sedation
      • para and intracervical block
    • general anesthesia

Recent Cochrane Reviews

  • Comparing first-generation techniques (endometrial laser ablation, transcervical resection of the endometrium, rollerball endometrial ablation) vs second-generation approaches (thermal balloon endometrial ablation, microwave endometrial ablation, hydrothermal ablation, bipolar radiofrequency endometrial ablation, endometrial cryotherapy)
    • Equivalent efficacy for heavy menstrual bleeding
    • Comparable rates of amenorrhoea
    • Second-generation techniques are associated with shorter operating times and are performed more often under local rather than general anaesthesia
  • Comparing endometrial ablation vs hysterectomy
    • Both procedures are effective with high satisfaction rates
    • Hysterectomy offers permanent and immediate relief from heavy menstrual bleeding but is associated with higher complication rates
    • Endometrial ablation cost initially lower, but unlike hysterectomy, retreatment is often necessary and therefore cost difference significantly narrows over time
  • Comparing surgical approaches vs levonorgestrel-releasing intrauterine device (LNG-IUS)
    • Both LNG‐IUS and conservative surgery appear to be safe, acceptable and effective
    • Quality of life and satisfaction scores are similar and no differences were seen at 2 years

Learn More – Primary Sources:

ACOG Practice Bulletin 81: Endometrial Ablation 

Endometrial ablation for heavy menstrual bleeding

Endometrial resection and ablation techniques for heavy menstrual bleeding (Cochrane)

Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding (Cochrane)

Surgery versus medical therapy for heavy menstrual bleeding (Cochrane)

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Related ObG Topics:

Managing Abnormal Uterine Bleeding with Ovulatory Dysfunction
Practical info for your gynecology practice
Hormonal Contraception Benefits – Beyond Pregnancy Prevention
IUD, Hysterectomy or Ablation for Menorrhagia?
What are the Risk Factors Associated with Endometrial Ablation?
Pregnancy after Endometrial Ablation – What is the Risk for a Morbidly Adherent Placenta?
What are the Risk Factors for Endometrial Ablation Failure?

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Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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