Endometrial ablation as a treatment for heavy menstrual bleeding

Until the 1980s, the only available definitive treatment for heavy menstrual bleeding (HMB) was hysterectomy, usually performed abdominally, and sometimes vaginally. Historically, multiple attempts to effect ablation of the endometrium were developed, including using steam and toxic chemicals, such as chloriquine. The advent of Nd-YAG laser endometrial ablation in the mid-1980s offered the first minimally invasive alternative to hysterectomy for the treatment of HMB. Nd-YAG ablation, however, was expensive, cumbersome, and difficult to learn; rollerball resectoscopic ablation was initially described by DeCherney in 1987, and soon overtook laser as the main method of ablation, although adoption continued to be limited because of the hysteroscopic skills necessary to perform the technique were not widely available. In 1994, the first "global" endometrial ablation, the Thermachoice™ (Ethicon Women's Health and Urology, Somerville, NJ) balloon was introduced in the U.S. Soon thereafter, four other techniques were introduced, namely microwave (MEA™, Microsulis, Hampshire, UK), circulating hot water (HTA™, Boston Scientific, Boston, MA), cryo-ablation (HerOption™, CooperSurgical, Trumbull, CT), and bipolar radiofrequency (Novasure™, Hologic, Bedford, MA). All of these techniques are done in an outpatient setting, often office-based, with little or no anesthesia, and success rates ranging from 50% to 70% amenorrhea, and 80% to 95% patient satisfaction. Although there have been few head-to-head comparisons of various techniques, current data suggests that they are all relatively effective, quite safe, and well-tolerated. This article describes the history and development of various ablation technologies, and explores each technique in depth, including published data, indications, risks, and benefits.