Ultrasound-guided reoperative hysteroscopy: managing endometrial ablation failures

Endometrial ablation and hysteroscopic myomectomy and polypectomy are having an increasing impact on the care of women with abnormal uterine bleeding (AUB). The complications of these procedures include the late onset of recurrent vaginal bleeding, cyclic lower abdominal pain, hematometra and the inability to adequately sample the endometrium in women with postmenopausal bleeding. According to the 2007 ACOG Practice Bulletin, approximately 24% of women treated with endometrial ablation will undergo hysterectomy within 4 years. By employing careful cervical dilation, a wide variety of gynecologic resectoscopes, and continuous sonographic guidance it is possible to explore the entire uterine cavity in order to locate areas of sequestered endometrium, adenomyosis, and occult hematometra. Sonographically guided reoperative hysteroscopy offers a minimally invasive technique to avoid hysterectomy in over 60% to 88% of women who experience endometrial ablation failures. The procedure is adaptable to an office-based setting and offers a very low incidence of operative complications and morbidity. In addition, the technique provides a histologic specimen, which is essential in adequately evaluating the endometrium in postmenopausal women or women at high risk for the development of adenocarcinoma of the endometrium.