Endometrial ablation

Endometrial ablation is a minimally invasive surgical procedure that involves the destruction of the uterine endometrium commonly performed for menorrhagia in premenopausal or perimenopausal women.

It has evolved as an alternative to hysterectomy and is associated with good outcomes and patient satisfaction ¹. Radiologists may encounter complications of ablation on pelvic imaging and so need to be aware of possible findings.

Indications

• benign uterine bleeding or menorrhagia

Contraindications

• active genitourinary infection

• malignant or premalignant uterine disease

• recent pregnancy or desired future pregnancies

• postmenopausal women

Procedure

Technique

Various procedures and devices are available for performing endometrial ablation, each with their own advantages and limitations. All are done transvaginally via various probes inserted into the uterine cavity, usually with ultrasound guidance.

• radiofrequency ablation

• microwave ablation

  • probe generating microwaves heats and destroys the uterine lining

• cryoablation

  • endometrium frozen using the tip of a probe inserted in the uterus

• balloon ablation

  • balloon passed into the uterus and filled with heated material to destroy the endometrium

• electrosurgery

  • a resectoscope is inserted into the uterus with a wire loop or roller ball to remove the uterine lining

  • usually under general anesthesia

Complications

• perioperative complications 

  • uterine perforation

  • cervical laceration

  • uterine hemorrhage

  • severe cramping pelvic pain

  • urogenital infection

• long-term complications

  • painful obstructed menses

  • post-ablation tubal sterilization syndrome

  • adenomyosis (up to 43% of patients on uterine histology) ⁴

  • post-ablation pregnancy (incidence 0.7%)

Normal post-ablation imaging findings

A range of findings can be considered normal on early postoperative imaging following ablation:

Ultrasound

• distorted endometrial cavity

• indistinct endometrial border

• intact or regenerating endometrium

• islands of endometrial tissue

• thickened endometrium >3 mm is more frequently associated with symptoms

MRI

• residual or regenerating endometrium may be seen, commonly towards the tubal ostia

• endometrium within the junctional zone or myometrium

• widening of the junctional zone (up to 3 months post-ablation)

• hematometra