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Endometrial Ablation vs. Radiofrequency Ablation: What’s The Difference?

 

The term “ablation” refers to a process by which tissue is destroyed, typically using either heat (thermal ablation) or cold (cryoablation). Ablative technologies are used to treat numerous medical conditions, including gynecological issues. We often hear of two procedures in particular, endometrial ablation, and radiofrequency ablation, and many people confuse the two treatments. Don’t let the similar names deceive you though: while both procedures leverage ablative technology, they are very different in their applications. To clear up the confusion, here’s a rundown on the defining characteristics of the two ablation therapies.

Endometrial Ablation (EA)

How EA Works
Endometrial ablation is typically used to treat prolonged, abnormal uterine bleeding. It does so by ablating the lining of the uterus, known as the endometrium, permanently destroying the tissue. There are several different methods of endometrial ablation: these include freezing (cryoablation techniques), directly applying heat from fixed-frequency microwaves or radiofrequency energy; and using hot fluid through techniques like balloon endometrial ablation.

In EA, treatment is limited to the endometrial layer, the surface tissue that lines the uterine cavity, and the basalis layer, where the endometrial tissue originates. Destroying the basalis layer prevents new tissue from growing, thereby reducing or eliminating menstrual bleeding.

EA procedures are performed in an office or hospital setting, usually with the patient under conscious sedation. Patients typically go home the same day, and full recovery takes about 1-2 weeks, depending on the specific procedure.

Outcomes
Endometrial ablation is used to control prolonged, abnormal vaginal bleeding. EA is most appropriate for patients that have completed childbearing, who have not seen results from other treatment approaches, and who are seeking an alternative to hysterectomy.

In most cases, EA meets its objective: an estimated 9 out of 10 women have lighter periods or no periods after undergoing the procedure. However, it’s difficult to predict whether a woman’s bleeding will stop completely. Estimates regarding the incidence of amenorrhea (the absence of menstrual bleeding) after EA vary widely from one study to the next, but it’s typically estimated to fall between 20% and 50%. A study by El-Nashar et al. asserted that the likelihood of amenorrhea occurring after EA depends on the type of ablative technology used, as well as patient characteristics like age and uterus size. Regardless, amenorrhea is not a guaranteed outcome. “If… a woman’s goal is amenorrhea, hysterectomy is the only reliable op¬tion,” reports Dr. Joseph Sanfilippo in an update to the medical community on EA-related developments.

It is important to note that endometrial ablation is not indicated for the treatment of uterine fibroids; any destruction of fibroids in the process of ablating the endometrium is incidental. Fibroids that grow partially or entirely within the walls of the uterus (known as intramural fibroids), as well as those growing outside the uterus (subserosal fibroids), are not reached during ablation. Those that protrude into the uterine cavity (submucosal) are sometimes shaved down hysteroscopically before ablation; however, if the fibroid originates below the basalis layer of tissue, it cannot be completely eradicated during ablation and may grow back, following the procedure.

Radiofrequency Ablation (Acessa Procedure)

How RFVTA Works
Radiofrequency ablation (short for “radiofrequency volumetric thermal ablation”, or RFVTA) is a specific ablation technique that is used to treat uterine fibroids in a procedure known as Acessa. In the Acessa procedure, a controlled volume of heat is applied directly to the fibroid, killing the tissue of the fibroid while leaving healthy surrounding tissue unharmed. Once the fibroid is destroyed, the dead tissue is simply reabsorbed by the body.
In performing RFVTA, a scope and a laparoscopic ultrasound probe are inserted through the abdominal incisions. Using the scope in conjunction with the ultrasound probe allows the operating physician to precisely pinpoint the fibroids’ location. Once the fibroids have been located, the surgeon uses a special tool with a retractable electrode array (the Acessa handpiece) to ablate the fibroid with radiofrequency energy.
RFVTA is performed in an outpatient setting. The surgery is minimally invasive: with the exception of two tiny incisions (no wider than 1/4 inch) on the abdomen, there is no cutting or suturing of uterine tissue. Patients go home the same day and return to normal activities within 2-3 days.

Outcomes
Clinical research has shown radiofrequency ablation to be very effective in shrinking or completely eliminating fibroids. The use of laparoscopic ultrasound reduces the risk of symptom recurrence by allowing the physician to find and treat all fibroids present in the uterus, not just the ones that were identified through previous diagnostic imaging. At 36 months post-treatment, 90% of patients needed no additional fibroid treatment. Though objectively measured bleeding at 12 months of follow up decreased in 82% of the women treated with RFVTA, the goal of treatment was not to destroy the endometrium or induce amenorrhea but merely to treat the fibroids.
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In the field of gynecology, ablation techniques can be used in addressing multiple conditions but it’s important to understand the difference between the technologies. Radiofrequency ablation with Acessa is an effective method for treating only the uterine fibroids without harming the rest of the uterus, whereas endometrial ablation effectively controls abnormal vaginal bleeding by directly ablating the lining of the uterus. Their usefulness is entirely related to their objective, and despite the commonality of a name, these procedures are very different in the objectives they serve.

SOURCES:

  1. American Society for Reproductive Medicine, “Endometrial Ablation”, ReproductiveFacts.org: 2011. Retrieved May 28, 2015, from http://www.reproductivefacts.org/uploadedFiles/ASRM_Content/Resources/Patient_Resources/Fact_Sheets_and_Info_Booklets/endoablation.pdf
  2. El-Nashar, S.A. et al. ” Prediction of Treatment Outcomes After Global Endometrial Ablation”, Obstetrics & Gynecology, Jan. 2009; 113(1): 97–106. doi:10.1097/AOG.0b013e31818f5a8d.
  3. Sanfilippo, J. “Update: Options in Endometrial Ablation”, Supplement to OBG Management, Dec. 2009
  4. Berman, J.M. et al. “Three Years’ Outcome from the Halt Trial: A Prospective Analysis of Radiofrequency Volumetric Thermal Ablation of Myomas”, The Journal of Minimally Invasive Gynecology, 2014.

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Fibroid Treatments Demystified, Part I: Uterine Artery Embolization

Many women of reproductive age seek uterine-sparing methods of fibroid treatment: uterine artery embolization (UAE), sometimes called uterine fibroid embolization (UFE), is one of the hysterectomy alternatives available to women with fibroids.

How UAE Works

Uterine artery embolization (UAE) is a minimally-invasive procedure that is performed by an interventional radiologist. UAE treats fibroids “in situ”, meaning ‘in place’, by cutting off their blood supply and causing them to die from what is known as “ischemic necrosis”. To do so, an interventional radiologist inserts a catheter through the femoral artery (located in the upper thigh) and into the uterine artery, which supplies blood to the uterus. A type of material known as an “embolic agent” is then injected through the catheter, into the blood vessels that supply blood to the fibroids. Typical embolic agents include polyvinyl alcohol (PVA), gelatin sponge plegets, or gelatin microspheres. Once injected, particles of the agent block the blood supply to the tiny arteries that carry blood to the fibroids. Without adequate blood flow, the fibroids shrink and, ultimately, die.

Treatment Outcomes

UAE is successful in diminishing fibroids and associated symptoms in an estimated 85% of cases. For patients who are looking for a minimally invasive fibroid treatment, embolization’s non-surgical approach is appealing. The recovery period is generally short, though it is notoriously painful. Fred Burbank, author of Fibroids, Menstruation, Childbirth, and Evolution, states “nearly all women who undergo [UAE] have severe pelvic pain generally lasting 4 to 6 hours, but others, lasting up to a day” (p.124). The American Society For Reproductive Medicine also notes, “patients typically experience several days of pain after the procedure”. Many women are hospitalized overnight for pain control.

The incidence of fertility-compromising outcomes has called into question the appropriateness of the procedure for women seeking to get pregnant, though additional research is needed to assess the risk. Here’s what researchers do know: once the embolic agent has been injected, the particles stay in the body. In some cases, those particles can migrate to the ovarian blood supply, compromising fertility and triggering the onset of menopause. Burbank describes the physiological process after injection of the embolic agent:

Anatomically, connections exist that allow particles injected into the uterine artery to reach any structure supplied by branches of the uterine artery. The physiology of blood flow from the uterine artery to its branches determines the relative number of particles that reach the myometrium, fibroids, and the ovaries. Injected particles are indifferent to where they go.(p.111) A significant number of women who undergo UAE become amenorrheic (cease to have periods)as a result of the procedure; however, research has indicated that younger patients see fewer complications of this nature. A longitudinal study by Goodwin et. al found that, at 36 months post-procedure, approximately 85% of patients had no intervention but 28.6% of UAE patients were amenorrheic with the largest proportion(78.9%) of patients over the age of 45.

UAE isn’t right for everyone: women with fibroids should talk to a gynecologist about the risks and benefits of UAE and other available fibroid treatment options, before seeking treatment. However, as one of the less invasive methods for treating fibroids, UAE helps meet the growing demand for alternatives to hysterectomy.

SOURCES:

  1. American Society for Reproductive Medicine, “Treatment of Uterine Fibroids”, ReproductiveFacts.org: 2011. Retrieved May 25, 2015, from http://www.reproductivefacts.org/FACTSHEET_Treatment_of_Uterine_Fibroids/
  2. Goodwin, S. et al./Fibroid Registry for Outcomes Data (FIBROID) Registry Steering Committee and Core Site Investigators.”Uterine Artery Embolization for the Treatment of Leiomyomata: long term outcomes from the FIBROID Registry”, Obstetrics & Gynecology, Jan 2008; Vol 11(1):22-33
  3. Burbank, F. Fibroids, Menstruation, Childbirth, and Evolution, p. 110. Wheatmark, 2009. Tucson, AZ.

 

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