Common gynecological surgery for abnormal bleeding associated with a high risk of hysterectomy

A recent study has found that 29% of people in Ontario who undergo endometrial ablation will have a subsequent hysterectomy to remove the entire uterus within 15 years.

Researchers from ICES, the Schulich School of Medicine & Dentistry at Western University, and Lawson Health Research Institute examined 76,446 patients who were followed for 15 years, addressing the question of surgical interventions after a first endometrial ablation (EA).

EA is a minimally invasive surgery that treats abnormal uterine bleeding (AUB) and is often offered as an alternative to hysterectomy. EA has been established as a safe procedure with low complication rates, but less is known about whether people undergoing EA will need further surgical intervention down the road.

Published in the journal Facts, Views and Vision in ObGyn, the study included patients who had undergone their first EA in Ontario between 2002 and 2017.

“These results provide valuable information to care providers, who can counsel their patients about more realistic outcomes of endometrial ablation, and the potential need for a future hysterectomy,” says lead author Dr. Jacob McGee, an adjunct scientist at ICES Western, assistant professor in the department of obstetrics & gynecology at Schulich Medicine & Dentistry, and associate scientist at Lawson.

Risk of hysterectomy shows no signs of plateauing

The study found 22% of patients received a subsequent surgical intervention after their primary EA.

Within one year of EA, 5% of women went on to have a hysterectomy. This increased to 17% at five years, 23% at 10 years and 29% at 15 years. This increase showed no evidence of plateauing by the 15-year follow-up.

People who were younger, had a complex diagnosis, or previous abdominal surgery (such as tubal ligation) were more likely to have a subsequent hysterectomy.

“The large number of women progressing to hysterectomy following a primary EA is concerning and suggests that EA is best considered as an intervention that will improve symptoms in the short-term and will ultimately delay the need for a hysterectomy, rather than prevent it,” says McGee.

Another finding showed a link between surgeon experience and future surgical risk following EA. As the experience of the surgeon increased (using their age as a surrogate measure), the likelihood of a person requiring a hysterectomy decreased by 3% for each increase in year of experience.

“We suggest that if endometrial ablation is to be performed, that clinicians consider how they communicate longer-term outcomes to patients,” says Dr. George Vilos, a professor in the department of obstetrics & gynecology at Schulich Medicine & Dentistry.

The researchers call attention to the potential use of combination treatments, including IUDs or hormone replacement therapies, which may extend the effectiveness of EA, and could eliminate the need for additional surgeries if patients were to enter menopause. They note that further research is needed to explore these options.