Members of the guideline committee were selected on the basis of individual expertise to represent a range of practical and academic experience in terms of both location in Canada and type of practice, as well as subspecialty expertise and general background in gynaecology. The committee reviewed all available evidence in the English medical literature, including published guidelines, and evaluated surgical and patient outcomes for the various EA techniques. Recommendations were established by consensus.
EVIDENCE: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).
RESULTS: EA is a safe and effective minimally invasive option for the treatment of AUB of benign etiology. Summary Statements 1.
Endometrial ablation is a safe and effective
minimally invasive surgical procedure that has become a well-established alternative to medical treatment or
hysterectomy to treat abnormal
uterine bleeding in select cases. (I) 2. Endometrial preparation can be used to facilitate resectoscopic
endometrial ablation (EA) and can be considered for some non-resectoscopic techniques. For resectoscopic EA, preoperative endometrial thinning results in higher short-term
amenorrhea rates, decreased irrigant fluid absorption, and shorter
operative time than no treatment. (I) 3. Non-resectoscopic techniques are technically easier to perform than resectoscopic techniques, have shorter
operative times, and allow the use of local rather than general anaesthesia. However, both techniques have comparable patient satisfaction and reduction of
heavy menstrual bleeding. (I) 4. Both resectoscopic and non-resectoscopic
endometrial ablation (EA) have low complication rates.
Uterine perforation, fluid overload,
hematometra, and cervical
lacerations are more common with resectoscopic EA; perioperative
nausea/
vomiting, uterine cramping, and
pain are more common with non-resectoscopic EA. (I) 5. All non-resectoscopic
endometrial ablation devices available in Canada have demonstrated effectiveness in decreasing menstrual flow and result in high patient satisfaction. The choice of which device to use depends primarily on surgical judgement and the availability of resources. (I) 6. The use of local anaesthetic and blocks, oral
analgesia, and
conscious sedation allows for the provision of non-resectoscopic EA in lower resource-intense environments including regulated non-hospital settings. (II-2) 7. Low-risk patients with satisfactory
pain tolerance are good candidates to undergo
endometrial ablation in settings outside the operating room or in free-standing surgical centres. (II-2) 8. Both resectoscopic and non-resectoscopic
endometrial ablation are relatively safe procedures with low complication rates. The complications perforation with potential injury to contiguous structures,
hemorrhage, and
infection. (II-2) 9. Combined hysteroscopic sterilization and
endometrial ablation can be safe and efficacious while favouring a minimally invasive approach. (II-2) Recommendations 1. Preoperative assessment should be comprehensive to rule out any
contraindication to
endometrial ablation. (II-2A) 2. Patients should be counselled about the need for permanent
contraception following
endometrial ablation. (II-2B) 3. Recommended evaluations for abnormal
uterine bleeding, including but not limited to endometrial sampling and an assessment of the uterine cavity, are necessary components of the preoperative assessment. (II-2B) 4. Clinicians should be vigilant for complications unique to resectoscopic
endometrial ablation such as those related to fluid distention media and electrosurgical
injuries. (III-A) 5. For resectoscopic
endometrial ablation, a strict protocol should be followed for fluid monitoring and management to minimize the risk of complications of distension medium overload. (III-A) 6. If
uterine perforation is suspected to have occurred during cervical dilatation or with the resectoscope (without
electrosurgery), the procedure should be abandoned and the patient should be closely monitored for signs of intraperitoneal
hemorrhage or visceral injury. If the perforation occurs with
electrosurgery or if the mechanism of perforation is uncertain, abdominal exploration is warranted to obtain hemostasis and rule out visceral injury. (III-B) 7. With resectoscopic
endometrial ablation, if
uterine perforation has been ruled out acute
hemorrhage may be managed by using intrauterine Foley balloon tamponade, injecting intracervical vasopressors, or administering rectal
misoprostol. (III-B) 8. If repeat
endometrial ablation (EA) is considered following non-resectoscopic or resectoscopic EA, it should be performed by a hysteroscopic surgeon with direct visualization of the cavity. Patients should be counselled about the increased risk of complications with repeat EA. (II-2A) 9. If significant intracavitary pathology is present, resectoscopic
endometrial ablation combined with hysteroscopic
myomectomy or polypectomy should be considered in a non-fertility sparing setting. (II-3A).