New insight into effectiveness of procedure to stop heavy menstrual bleeding

Experts estimate that 20 percent of women experience excessive or prolonged menstrual bleeding at some time during their lives, particularly as they approach menopause. A new, less invasive procedure called global endometrial ablation (GEA) preserves the uterus, while decreasing menstrual bleeding and shortening patients' recovery time. In an article published in the January issue of Obstetrics and Gynecology, Mayo Clinic researchers attempt to determine the percentage of women who do not achieve permanent symptom relief from GEA and identify several factors that put women at greater risk for this outcome.

For decades, hormone pills or hysterectomy, surgical removal of the uterus, were the standard treatments for excessive or prolonged menstrual bleeding. Although numerous studies have established the safety of GEA, some women who undergo this procedure require additional treatment or hysterectomy later because significant menstrual pain or heavy bleeding symptoms resume.

During this procedure, surgeons use an energy source (heat, cold and microwave or radiofrequency energy) to destroy just the uterine lining (endometrium) and leave the uterus intact. Once the cells or the tissue that line the uterus are destroyed, scar tissue forms, and monthly menstrual flow and any accompanying pain typically decrease.

Compared to hysterectomy, the newest forms of GEA were initially thought to be equally effective with slightly lower complication rates and costs.

'We've known for the past five to six years that global endometrial ablation devices are very effective,' says Mayo Clinic gynaecologic surgeon Abimbola Famuyide, M.B.B.S., one of the study's authors. 'But some physicians have observed that up to 30 percent of patients may require additional treatment five years and beyond after undergoing ablation.'

Undergoing a hysterectomy or another treatment following ablation to achieve permanent symptom relief can be costly and inconvenient for patients. Mayo researchers note that much of the medical research citing failure rates associated with GEA had relatively small study populations and differing definitions of what constituted failure. To establish more precise, population-derived data measuring how many women do not experience permanent symptom relief following GEA, they studied the medical records of approximately 816 women who underwent ablation from Jan. 1, 1998, through Dec. 31, 2005.

'We found that only 16 percent of our subjects required hysterectomy to treat excessive bleeding five years after ablation. That is nearly half of what has generally been reported in the literature to date,' explains Dr Famuyide.

Mayo researchers hypothesised that the low failure rate they observed might mean that their study patients received counselling about realistic expectations for symptom relief. 'For example, patients who are seeking complete cessation of menstrual bleeding after GEA are more likely to undergo hysterectomy later to treat bleeding symptoms of any severity,' says Dr Famuyide.

Mayo Clinic research data also showed that patients under age 45, patients who have undergone tubal ligation (a procedure to prevent pregnancy), and patients who experienced debilitating menstrual pain before undergoing GEA were less likely to experience permanent symptom relief following ablation.

According to the Mayo researchers, identifying risk factors that affect treatment outcomes following GEA is an important advance in this field. This knowledge can help surgeons determine whether GEA is appropriate for a specific patient and help them provide patients with better guidance when choosing a treatment option, say researchers.

'Optimising preoperative patient counselling and patient selection could allow failure rates associated with GEA to decrease,' explains Dr Famuyide.