Endometrial Ablation at Younger Age Linked to Higher Risk for Subsequent Hysterectomy


Test Questions


1. A 30-year-old woman undergoes endometrial ablation for vaginal bleeding. Which of the following percentages most accurately describes the risk for hysterectomy after endometrial ablation for women in her age group?



    • 10%
    • 20%
    • 30%
    • 40%
    • 50%

2. A woman had endometrial ablation for vaginal bleeding with pain. Which of the following factors would most likely be linked with an increased risk for hysterectomy?

    • Radiofrequency technique
    • Inpatient setting
    • Presence of leiomyomas
    • All of the above
    • None of the above


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Answers / Explanations:


1.A 30-year-old woman undergoes endometrial ablation for vaginal bleeding. Which of the following percentages most accurately describes the risk for hysterectomy after endometrial ablation for women in her age group?


[HIDE]
Answer: 40%


According to the study by Longinotti and colleagues, the risk for hysterectomy increases with decreasing age and is 40.6% in women up to age 40 years.

[/HIDE]
2. A woman had endometrial ablation for vaginal bleeding with pain. Which of the following factors would most likely be linked with an increased risk for hysterectomy?


[HIDE]Answer: None of the above


According to the study by Longinotti and colleagues, overall endometrial ablation technique, procedure setting, and presence of leiomyomas were not risk factors for hysterectomy after endometrial ablation.[/HIDE]

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For your Reference:

Endometrial Ablation at Younger Age Linked to Higher Risk for Subsequent Hysterectomy


December 23, 2008 Endometrial ablation in women younger than 40 years is linked to a higher risk for subsequent hysterectomy, according to the results of a retrospective cohort analysis reported in the December issue of Obstetrics & Gynecology.

"Destruction of the endometrium by endometrial ablation has emerged as a minimally invasive alternative to hysterectomy," write Mindyn K. Longinotti, MD, from Kaiser Permanente Northern California in San Francisco, and colleagues. "A recent Cochrane review concluded that success rates and complication profiles of newer techniques compared favorably with first-generation methods, although they included limited data on hysterectomy rates beyond 2 years. Without long-term follow-up it is difficult to accurately counsel patients on whether endometrial ablation techniques are more likely to replace, or merely delay, hysterectomy."

The goal of this study was to assess risk factors for hysterectomy after endometrial ablation.

Data were collected through 2007 from 3681 women, aged 25 to 60 years, who underwent endometrial ablation from 1999 to 2004 at 30 Kaiser Permanente Northern California facilities. The investigators evaluated risk factors including age, the presence of leiomyomas, inpatient vs outpatient setting for the procedure, and type of ablation procedure performed (first-generation, radiofrequency, hydrothermal, or thermal balloon). Risk factors were identified, and the probability of hysterectomy was estimated with use of univariable and survival analyses.

Of the 3681 women who underwent endometrial ablation, 774 (21%) had subsequent hysterectomy, and 143 (3.9%) had uterine-conserving procedures. Age significantly predicted subsequent hysterectomy (P < .001); compared with women older than 45 years, women aged 45 years or younger were 2.1 times more likely to have a hysterectomy (95% confidence interval, 1.8 - 2.4), according to Cox regression analysis. Hysterectomy risk was more than 40% in women aged 40 years or younger and increased with each decreasing stratum of age.

In contrast, the type and setting of endometrial ablation procedure and the presence of leiomyomas did not predict subsequent hysterectomy. However, the individual types of procedures did have some predictive value. For patients undergoing first-generation endometrial ablation, concomitant myomectomy was associated with a decreased risk for hysterectomy (P = .02). Outpatient location for hydrothermal endometrial ablation was associated with an increased risk for hysterectomy (P < .001).

"Age is more important than type of procedure or presence of leiomyomas in predicting subsequent hysterectomy after endometrial ablation," the study authors write. "Women undergoing endometrial ablation at younger than 40 years of age are at elevated risk of hysterectomy, and rather than plateauing within several years of endometrial ablation, hysterectomy risk continues to increase through 8 years of follow-up."

Limitations of this study include those related to coding accuracy and use of a definition of endometrial ablation failure that was likely to underestimate the true rate of dissatisfaction.

"Endometrial ablation for menorrhagia permits uterine conservation in more than 80% of women over age 45 years when followed up to 8 years," the study authors write. "For women aged younger than 40 years, probability of hysterectomy is 40%....Additional studies with longer follow-up are necessary to determine whether endometrial ablation is more likely to replace, or merely delay, hysterectomy in women aged younger than 40 years at the time of the procedure."

Study Highlights
  • 3681 women aged 25 to 60 years underwent endometrial ablation from 1999 to 2004 in 30 Kaiser Permanente Northern California centers.
  • Endometrial ablation techniques were categorized as first-generation procedures, hydrothermal, radiofrequency, thermal balloon, and unclassified.
  • Mean age of the women was 44.3 years (SD, 6.2 years).
  • Leiomyomas were present in 742 women (20.2%).
  • 2735 procedures (74.3%) occurred in the inpatient setting.
  • Inpatient setting was used for all first-generation techniques, 92 (14.8%) hydrothermal, 381 (95.5%) radiofrequency, all thermal balloon, and 1528 (79.3%) unclassified techniques.
  • 774 women (21%) had subsequent hysterectomy.
  • Indications for hysterectomy included vaginal bleeding in 51.6%, pain in 22%, vaginal bleeding with pain in 20.3%, possible cancer in 2.5%, prolapse or incontinence in 2.5%, suspected adnexal pathologic condition in 2.5%, and infection in 0.3%.
  • 728 hysterectomy cases (94.1%) had pathology reports showing leiomyomas in 33.4%, adenomyosis in 23.6%, leiomyomas and adenomyosis in 22.4%, no significant pathologic condition in 16.9%, endometriosis in 7%, and cancer or precancer in 1.6%.
  • 143 women (3.9%) had a second uterine-conserving procedure: repeated endometrial ablation in 106 (2.9%), uterine artery embolization in 23 (0.6%), and myomectomy in 14 (0.4%).
  • Continuous or categoric younger age at time of ablation was linked with greater hysterectomy probability, which continued to increase during 8-year follow-up: 12% for age older than 50 years, 19.8% for ages 45 to 49.9 years, 31% for ages 40 to 44.9 years, and 40.6% for age younger than 40 years.
  • Cox regression analysis showed that women 45 years or younger vs older than 45 years were more likely to have a hysterectomy (hazard ratio, 2.1; 95% confidence interval, 1.8 - 2.4).
  • Survival analysis showed that hysterectomy probability was 9.3% at 1 year, 14.4% at 2 years, 22.2% at 5 years, and 26.2% at 8 years.
  • Overall type of endometrial ablation procedure, outpatient vs inpatient setting of procedure, and presence of leiomyomas were not linked with hysterectomy risk.
  • Hysterectomy was more common in patients who had hydrothermal endometrial ablation in outpatient setting vs inpatient setting (21% vs 4.3%; P < .001).
  • Hysterectomy was less common in patients who had first-generation endometrial ablation plus myomectomy vs without myomectomy (14.2% vs 24.2%; P = .02).
  • Unclassified technique with or without myomectomy was not significantly linked with hysterectomy risk.
  • Myomectomy rate was too low to analyze in the hydrothermal group, the radiofrequency group, and the thermal balloon group.
  • Limitations of the study included miscoding, no differentiation between resection and ablative first-generation techniques, lack of assessment of size or location of leiomyomas, and lack of comparison among the facilities.