Background: A significant proportion of women who have endometrial ablation require hysterectomy. The aim of the current study was to identify indications for hysterectomy following endometrial ablation, describe the surgical outcome of minimally invasive hysterectomy (MIH), and report on the ultrasound and pathologic findings among these patients.

Material and Methods: We conducted a retrospective chart review study of all patients who had hysterectomy following endometrial ablation between January 2010 and October 2022. The medical records were reviewed and patients characteristics, indications for the hysterectomy, method of hysterectomy, surgical outcome, ultrasound findings before and pathologic findings after the hysterectomy were recorded.

Results: 130 patients were included. The median age of these patients was 45 (range 26-74), and the median duration between the ablation and the hysterectomy was 2 years (range <1-25). The most common indications for hysterectomy were abnormal bleeding (36.1%), pelvic pain (32.3%), and both pelvic pain and abnormal bleeding (33.8%). The hysterectomy was performed using MIH techniques in 115 (88.5%) with a median estimated blood loss of 75 mL, and conversion rate of 2.6%. Operative and postoperative complications were 1.4% and 3.9%, respectively, and the median hospital stay was one day (range 0-5). The most common ultrasound findings were uterine fibroids (38.5%), indistinct endometrial lining (30%), myometrial cysts 30 (23%), and adenomyosis (15.4%). The most common pathologic findings were uterine fibroids (50.1%), adenomyosis (35.3%) and endometriosis (17.6%).

Conclusions: Half the patients who undergo hysterectomy following ablation do so in the first two years following the ablation. MIH is a safe technique for these patients with excellent surgical outcome. Uterine fibroids are the most common ultrasound and pathologic findings among these patients.

• Hysterectomy

• Endometrial ablation

• Laparoscopic hysterectomy

• Robotic hysterectomy

Eltabbakh GH, Gregoire S, Miranda Gordon RN, Eltabbakh GD (2024) Postablation Hysterectomy: Indications, Surgical Outcome, Ultrasound and Pathologic Findings. Med J Obstet Gynecol 12(1): 1185

Abnormal uterine bleeding is one of the most common reasons for visits to a gynecologist and subsequent surgery. Women who fail medical treatment are usually offered surgery, usually endometrial ablation, or hysterectomy. Because of the increased prevalence of obesity among women, the incidence of abnormal uterine bleeding has been increasing.

First generation endometrial ablation involved endometrial destructive techniques under direct hysteroscopic vision using the rollerball, resectoscope or laser. These procedures required anesthesia and the use of distending media for the hysteroscopy and subsequently were sometimes associated with significant complications. Second generation endometrial ablation devices do not require hysteroscopic vision, can be performed under local anesthesia in an office setting and are quicker. The second generation endometrial ablation devices provide global ablation of the endometrial cavity and include five techniques for destruction of the endometrial lining: high-temperature fluid within a balloon (Thermachoice and Cavaterm), microwave (Microsulis), bipolar radiofrequency electrical energy (Novasure), free fluid at elevated temperature (Hydrothermablator) or cryoablation (HerOption) [1].These techniques became more popular because they are easier to perform, involve shorter hospital stay and are safer [1].

Late complications of endometrial ablation include failure to control the heavy periods, pain, pregnancy and masking the diagnosis of endometrial cancer [1]. Patients who continue to have problems with heavy bleeding following ablation are offered repeat ablation or hysterectomy. Those who have pain resulting from obstructed menses are offered dilation and curettage, hysteroscopic lysis of intra-uterine adhesions or hysterectomy. Hysterectomy is needed in a considerable number of patients who fail endometrial ablation or have complications from it.

Postablation hysterectomy was reported in 13-20% of women who had endometrial ablation and were followed up for several years [2-5]. The need for hysterectomy usually emerges in the first years following ablation, and in a study from Finland, 75% of hysterectomies were performed in the first 4 years following ablation [6]. Pre-operative predictors of ablation failure included: age younger than 45, parity >5, prior tubal sterilization, preoperative dysmenorrhea and adenomyosis. The incidence of postablation tubal sterilization syndrome (PATSS) is 6-8% and usually develops 2-3 years after endometrial ablation [7]. The definitive treatment of PATSS is hysterectomy.

The aim of the current study was to identify indications for hysterectomy following endometrial ablation, describe the surgical outcome of minimally invasive hysterectomy (MIH), and report on the ultrasound and pathologic findings among women who had hysterectomy following endometrial ablation. 

We conducted a retrospective chart review study of all patients who had hysterectomy and had history of endometrial ablation in our practice between January 2010 and October 2022. Patients were identified through our practice electronic medical records and operative records. Because of the retrospective nature of the study internal board review was not needed. The medical records of these patients were reviewed and the following data abstracted by two of the co-authors (SG and MG): age at hysterectomy, age at endometrial ablation, time between hysterectomy and endometrial ablation, history of previous laparotomy, history of previous cesarean section, body mass index (BMI), indications for the hysterectomy, ultrasound findings prior to the hysterectomy, result of endometrial biopsy prior to hysterectomy if performed, type of hysterectomy, estimated blood loss, operative and postoperative complications, uterine weight, presence of adhesions at time of hysterectomy, hospital stay following the hysterectomy and pathologic findings of the hysterectomy. All hysterectomies were performed by the senior author (GHE).

Our search identified 130 patients who had hysterectomy following endometrial ablation. Table 1 lists the patients’ characteristics,

Table 1: characteristics of patients who had hysterectomy following endometrial ablation, method of hysterectomy, surgical outcome, age of endometrial ablation and duration between hysterectomy and endometrial ablation

indications for hysterectomy, method of hysterectomy, surgical outcome, ultrasound features prior to the hysterectomy, pathology report of the hysterectomy specimens, age at endometrial ablation and time between endometrial ablation and the hysterectomy. The median age of patients at hysterectomy was 45 (range 26-74), the median age for endometrial ablation was 42 (23-56), and the median duration between the ablation and the hysterectomy was 2 years (range <1 -25). Most of the patients (75.4%) had hysterectomy in the first 5 years following the ablation. Forty-eight percent of the patients were obese and 16% of them were morbidly obese. About 35% of the patients who had hysterectomy had a history of one or more C sections. At time of the hysterectomy, adhesions were found in about 57% of the patients.

The most common technique for the hysterectomy were conventional laparoscopy (57.7%), followed by robotic hysterectomy (30%), abdominal hysterectomy (11.5%) and vaginal hysterectomy (3.1%). Thus, MIH (laparoscopic, robotic and vaginal) was adopted in 115 patients (88.5%). In 3 (2.6%) patients the procedure was converted to laparotomy because of adhesions. Operative and postoperative complications were 1.4% and 3.9%, respectively. The median hospital stays following the hysterectomy was one day (range 0-5). None of the patients required blood transfusion. The most common indications for the hysterectomy were: abnormal uterine bleeding (36.1%), pelvic pain (32.3%) and both pelvic pain and abnormal bleeding (33.8%).

Ultrasound findings before the hysterectomy included the following: indistinct endometrial lining : 39 (30%), endometrial thickness equal to or less than 3 mm: 17 (13%), endometrial thickness between 4 and 10 mm: 34 (26.1%), endometrial thickness more than 10 mm: 9 (6.9%), heterogeneous endometrial lining: 15 (11.5%), endometrial cysts: 2 (1.5%), hydrometra: 2 (1.5%), myometrial cysts: 30 (23%), hematometra: 1 (0.7%), fibroids: 50 (38.5%), adenomyosis: 20 (15.4%), endometrial polyp: 1 (0.7%), ovarian masses: 26 (20.3%), endometrial mass: 1 (0.7%), and myometrial mass: 1 (0.7%).

Twenty-three (17.7%) patients had uteri weighing 250 gm or more and 7 (5.4%) patients had uteri weighing 500 gm or more. The pathologic findings of the hysterectomy specimens showed: no abnormalities: 24 (18.4%), uterine fibroids: 66 (50.1%), adenomyosis: 46 (35.3%), endometriosis: 23 (17.6%), salpingitis: 6 (4.6%), benign tumors of the ovary: 7 (5.3%), functional ovarian cysts: 8 (6.1%), adenomatoid tumor of the uterus: 2 (1.5%), endosalpingiosis : 1 ((0.7%) and leiomyosarcoma of the uterus: 1 patient (0.7%). None of our patients had endometrial cancer and one patient had leiomyosarcoma.

A significant proportion of women who have endometrial ablation eventually require hysterectomy. Shavell et al., reported that 13.4% of women who had endometrial ablation had subsequent hysterectomy. These authors found that women who underwent hysterectomy were significantly younger at ablation and were more likely to have delivered via cesarean section. Soini et al., found that leiomyomata, young age and history of prior cesarean section or sterilization to be associated with an increased risk of post ablation hysterectomy. Leiomyomata were a significant risk factor for hysterectomy (3 studies). Smithling et al. identified preoperative dysmenorrhea, prior tubal ligation and obesity as risk factors for ablation failure. These authors found that preoperative bleeding pattern did not appear to affect failure rates or the need for gynecological procedures after endometrial ablation. Our study found a relatively high history of previous cesarean sections (35%), pelvic adhesions (57%) and uterine fibroids (50%) among the women who had hysterectomy following ablation.

In our study the most common indications for hysterectomy were abnormal bleeding, pelvic pain and a combination of abnormal bleeding and pelvic pain. This is similar to the findings of other studies [6,8]. In the largest report of hysterectomies following endometrial ablatio, Soini et al., reported that the indications for hysterectomy were abnormal uterine bleeding (47.8%), leiomyomata (19.8%), dysmenorrhea (9.1%), endometriosis or adenomyosis (8%), and endometrial hyperplasia (1.8%).

Half the patients in our study had the hysterectomy in the first two years and 75% of them had the hysterectomy in the first 5 years following the ablation. This agrees with the findings of Soini et al. [6], who reported that 75% of hysterectomies were performed in the first 4 years following ablation.

Our study found that the most common ultrasound findings were uterine fibroids (38.5%), indistinct endometrial lining (30%), myometrial cysts (23%) and adenomyosis (15.4%). Alhilli et al. [7], found that an indistinct endometrial border to be the most common ultrasound finding following endometrial ablation. The same authors showed that symptomatic patients tend to have a greater mean endometrial thickness than asymptomatic patients. A cut-off endometrial thickness of greater than 3 mm was reported to be significantly associated with post ablation symptoms [7-13].There are different radiologic findings detected on ultrasound and magnetic imaging following endometrial ablation [14].

The histologic features in post ablation hysterectomy depend on the time elapsed between the ablation and the hysterectomy. Pathologic changes found in hysterectomies performed less than one year following the ablation, show high incidence of necrosis, granulomatous inflammation, and pigment-laden macrophages. Over time, the necrosis is replaced by granulation tissue and endometrial reparative processes [9]. Karpathiou et al. [9], reported that necrosis, fibrosis, and vascular changes were found during the first year of post-thermal uterine effects and that hysterectomies performed later showed less prominent changes and almost normal endometrial lining. Shavell et al. [5], found adenomyosis to be present in 44.4% of post ablation hysterectomy specimens. Carey et al. [15], found leiomyomata to be the most frequent pathologic findings in women who had hysterectomy following ablation (49%) and they found hematometra in 26% of patients who had hysterectomy following endometrial ablation because of pain. Nakayama et al. [16], found increased tubal metaplasia and negative expression of estrogen and progesterone receptors in the endometrium following microwave endometrial ablation. The authors suggested that the low estrogen and progesterone receptors was the cause of ineffective hormonal treatment following endometrial ablation. Riley et al. [8], reported that the most common pathologic findings in hysterectomy following endometrial ablation was endometriosis (69%), followed by leiomyomata (62%) and adenomyosis (43%). In the report by Soini et al. [6], only 0.05% of women who had hysterectomy following endometrial ablation had endometrial cancer.

In our study, 115 patients (88.5%) had MIH with a median estimated blood loss of 75 mL, low conversion rate (2.6%), low operative (1.4%) and postoperative (3.9%) complications. To our knowledge this is the largest number of MIH reported following endometrial ablation. Our findings support the use of MIH as a first choice for women requiring hysterectomy following endometrial ablation. Riley et al. [8], reported on 47 patients who had laparoscopic hysterectomy and 4 patients who had vaginal hysterectomy following endometrial ablation. The proportion of patients having MIH in our study could have been higher if it weren’t for the relatively high incidence of patients with uteri larger than 250 gm (17.7%), pelvic adhesions (56.9%) and ovarian masses (12.3%), all of which increase the chance of abdominal hysterectomy.

Half the patients who undergo hysterectomy following ablation do so in the first two years following the ablation. MIH is a safe technique for these patients with excellent surgical outcome. Uterine fibroids are the most common ultrasound and pathologic findings among these patients.

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