Prediction of endometrial ablation success by preoperative findings

Objective: To determine the influence of preoperative findings on the outcome of hysteroscopic endometrial ablation.Design: We performed a retrospective chart review of 80 women between the ages of 25 and 50 years who underwent an endometrial ablation for menorrhagia or menometrorrhagia from 1992 to 1996, through a university reproductive endocrinology clinic.Materials and Methods: All eligible patients had a detailed subjective history obtained for duration of dysmenorrhea (Dys) and menorrhagia or menometrorrhagia (Men). Each had a preoperative transvaginal pelvic ultrasound with documentation of the uterine cavity contour and if an intramural myoma was present. A gynecological examination was ascertained from the patients clinical record with regard to uterine size. A benign Papanicolaou smear within 1 year of surgery and a normal endometrial biopsy was required for inclusion. Those with evidence of carcinoma or menopausal symptoms were excluded. Each patient had endometrial preparation with either danazol, GnRHa, or progestin. All ablations were performed by the same surgeon with "rollerball" electrocautery. Those patients who required medical management or additional surgery to control their vaginal bleeding during follow-up were designated as ablation failures. The use of stepwise logistic regression with ablation outcome as the dependent measure was used along with univariate analyses via chi(2) and t test to compare successes and failures on specific characteristics.Results: The sample was divided into two groups, success (group 1) or failure (group 2), and were matched for gravity, parity, and uterine size. Between the two groups there were no significant differences in the duration of menorrhagia/menometrorrhagia or dysmenorrhea. Additional therapy was required in 41% of the study group, designated as failures. The length of follow-up was 36 months for group 1 and 27.7 months for group 2. The results are summarized in the table below.The difference in age between the two groups strongly suggests a tendency toward failure with increasing age (P =.06). The diagnosis of a normal uterine cavity preoperatively shows a trend for a successful outcome (P =.07) when compared with the presence of an intracavity lesion, fibroid, or polyp. Those patients with an intramural fibroid had a tendency toward a higher failure rate (P =.10). Comparing the medications used to prepare the endometrium, patients treated with danazol had a trend toward a higher success rate (P =.09) than GnRHa or progestins.Conclusion: Preoperative findings can provide additional information with regard to endometrial ablation success. It appears that the trend toward failure is increased in patients with increased age, the diagnosis of an abnormal uterine cavity by ultrasound, and the presence of an intramural fibroid. Danazol administration, to prepare the endometrium, appears to offer a lower failure rate compared to GnRH agonists or progestins. Patients at greater risk of endometrial ablation failure based on age >/=41 years, abnormal intrauterine cavity, or the presence of intramural fibroids should be counseled about the higher failure rate and consider an alternative procedure such as hysterectomy.