Tissue effects differ with ablation technique
The study authors suggested that different tissue effects occur with freezing compared with heating ablation techniques. With freezing, over weeks to months the chronic inflammatory tissue is eventually replaced by a fibrous scar of collagen, with some preservation of the collagen matrix during tissue repair. This may be different from the charring and boiling of heated tissue that results in architectural tissue loss and may interfere with wound repair and tissue remodeling. Although the incidence of postoperative adhesions after endometrial ablation is not well studied, it is encouraging that most patients who received cryoablation with the Cerene device were able to undergo an evaluation of the endometrium without general anesthesia.
Key takeaway
The main idea from this study is that the endometrium can be assessed by office hysteroscopy in most patients who undergo cryoablation with the Cerene device. This may have advantages in terms of reducing the risk of PATSS and hematometra, and it may allow easier evaluation of the endometrium for patients who have postablation abnormal uterine bleeding. This begs the question, does intrauterine scarring influence the detection of endometrial cancer? For answers, keep reading.
Does endometrial ablation place a patient at higher risk for a delay in the diagnosis of endometrial cancer?
Radestad AF, Dahm-Kahler P, Holmberg E, et al. Long-term incidence of endometrial cancer after endometrial resection and ablation: a population based Swedish gynecologic cancer group (SweGCG) study. Acta Obstet Gynecol Scand. 2022;101:923-930.
Oderkerk TJ, van de Kar MRD, Cornel KMC, et al. Endometrial cancer after endometrial ablation: a systematic review. Int J Gynecol Cancer. 2022;32:1555-1560.
The answer to this question appears to be no, based on 2 different types of studies. One study was a 20-year population database review from Sweden,4 and the other was a systematic review of 11 cohort studies.5
Population-based study findings
The data from the Swedish population database is interesting because since 1994 all Swedish citizens have been allocated a unique personal identification number at birth or immigration that enables official registries and research. In reviewing their data from 1997 through 2017, Radestad and colleagues compared transcervical resection of the endometrium (TCRE) and other forms of endometrial ablation against the Swedish National Patient Register data for endometrial cancer.4 They found no increase in the incidence of endometrial cancer after TCRE (0.3%) or after endometrial ablation (0.02%) and suggested a significantly lower incidence of endometrial cancer after endometrial ablation.
This study is beneficial because it is the largest study to explore the long-term incidence of endometrial cancer after TCRE and endometrial ablation. The investigators hypothesized that, as an explanation for the difference between rates, ablation may burn deeper into the myometrium and treat adenomyosis compared with TCRE. However, they also were cautious to note that although this was a 20-year study, the incidence of endometrial carcinoma likely will reach a peak in the next few years.
Systematic review conclusions
In the systematic review, out of 890 publications from the authors’ database search, 11 articles were eventually included for review.5 A total of 29,102 patients with endometrial ablation were followed for a period of up to 25 years, and the incidence of endometrial cancer after endometrial ablation varied from 0.0% to 1.6%. A total of 38 cases of endometrial cancer after endometrial ablation have been described in the literature. Of those cases, bleeding was the most common presenting symptom of the disease. Endometrial sampling was successful in 89% of cases, and in 90% of cases, histological exam showed an early-stage endometrial adenocarcinoma.
Based on their review, the authors concluded that the incidence of endometrial cancer was not increased in patients who received endometrial ablation, and more importantly, there was no apparent delay in the diagnosis of endometrial cancer after endometrial ablation. They further suggested that diagnostic management with endometrial sampling did not appear to be a barrier.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
The main findings from these 2 studies by Radestad and colleagues and Oderkerk and associates are that endometrial cancer does not appear to be more common after endometrial ablation, and it appears to be diagnosed with endometrial sampling in most cases.4,5 There may be some protection against endometrial cancer with nonresectoscopic endometrial ablation, although this needs to be verified by additional studies. To juxtapose this information with the prior information about cryotherapy, it emphasizes that the scarring within the endometrium will likely reduce the incidence of PATSS and hematometra, which are relatively low-incidence occurrences at 5% to 7%, but it likely does not affect the detection of endometrial cancer.
The main findings from these 2 studies by Radestad and colleagues and Oderkerk and associates are that endometrial cancer does not appear to be more common after endometrial ablation, and it appears to be diagnosed with endometrial sampling in most cases.4,5 There may be some protection against endometrial cancer with nonresectoscopic endometrial ablation, although this needs to be verified by additional studies. To juxtapose this information with the prior information about cryotherapy, it emphasizes that the scarring within the endometrium will likely reduce the incidence of PATSS and hematometra, which are relatively low-incidence occurrences at 5% to 7%, but it likely does not affect the detection of endometrial cancer.
Longer-term data for relugolix combination treatment of symptomatic uterine bleeding from fibroids shows sustained efficacy
Al-Hendy A, Lukes AS, Poindexter AN, et al. Long-term relugolix combination therapy for symptomatic uterine leiomyomas. Obstet Gynecol. 2022;140:920-930.
Relugolix combination therapy was previously reported to be effective for the treatment of fibroids based on the 24-week trials LIBERTY 1 and LIBERTY 2. We now have information about longer-term therapy for up to 52 weeks of treatment.6
Relugolix combination therapy is a once-daily single tablet for the treatment of heavy menstrual bleeding thought to be due to uterine fibroids in premenopausal women. It is comprised of relugolix 40 mg (a GnRH antagonist), estradiol 1.0 mg, and norethindrone acetate 0.5 mg.
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