Original Research

Postablation Risk Factors for Pain andSubsequent Hysterectomy

Kayla M. Wishall, MD, Joan Price, MD, MPH, Nigel Pereira, MD, Samantha M. Butts, MD, MSCE,and Carl R. Della Badia, DO

OBJECTIVE: To assess patient characteristics associated

with pain and hysterectomy after endometrial ablation.

METHODS: A retrospective cohort study was performed

using data from two large academic medical centers.

Three hundred patients who underwent endometrial

ablation between January 2006 and May 2013 were

identified for study. Data collected included baseline

characteristics at the time of ablation, relevant medical

history, and ablation technique. Univariate tests of

association and logistic regression were used to evaluate

risk factors for postablation pain or hysterectomy.

RESULTS: Of the 300 women who had endometrial

ablation performed during the study period, 270 had

follow-up data for analysis. Twenty-three percent devel-

oped new or worsening pain after ablation and 19%

underwent a hysterectomy. A history of dysmenorrhea

gave a 74% higher risk of developing pain (adjusted odds

ratio [OR] 1.74, 95% confidence interval [CI] 1.062.87)

and tubal sterilization conferred more than double the

risk (adjusted OR 2.06, 95% CI 1.143.70). Women of

white race were 45% less likely to develop pain (adjusted

OR 0.55, 95% CI 0.340.89). For hysterectomy, a history

of cesarean delivery more than doubled the risk

(adjusted OR 2.33, 95% CI 1.055.16), whereas uterine

abnormalities on imaging, including leiomyoma, adeno-

myosis, thickened endometrial strip, and polyps, quadru-

pled the risk (adjusted OR 3.96, 95% CI 1.2512.56). A

procedure performed in the operating room decreased

the risk of hysterectomy by 76% (adjusted OR 0.24, 95%

CI 0.070.77). Hysterectomies for the indication of pain

occurred more than 3 years sooner than for other indi-

cations (P,.001).

CONCLUSION: Patient characteristics should be con-

sidered when counseling patients about the possible

outcomes of endometrial ablation. A significant portion

of ablations are complicated by postablation pain.

(Obstet Gynecol 2014;124:90410)

DOI: 10.1097/AOG.0000000000000459

LEVEL OF EVIDENCE: II

Endometrial ablation is one of the less invasive sur-gical options for women with menorrhagia. Thefirst-generation techniques included roller ball abla-tion, bipolar endometrial resection, and laser ablation,all of which required visualization of the cavity for theentirety of the procedure.1 Second generation, non-hysteroscopic techniques have since been developedthat require less skill and can be performed in theoffice.2,3 These are devices that destroy the endome-trium blindly by various methods, including heatedwater in a balloon, bipolar radiofrequency, cryoabla-tion, microwave energy, and circulating hot fluid.These techniques offer an alternative to hysterectomyfor women who are poor surgical candidates or whowish to avoid major surgery. Head-to-head compari-sons of first- and second-generation ablation techni-ques with hysterectomy have found higher numbersof repeat operations with ablation, less patient satis-faction, and lower rates of amenorrhea. Although hys-terectomy guarantees amenorrhea, it has a longerrecovery time, greater cost, and much higher compli-cation rate.46

Postablation pain has been described after endome-trial ablation and variously attributed to hematometra

From the Department of Obstetrics and Gynecology and the Division ofMinimally Invasive Gynecologic Surgery, Drexel University College of Medicine,and the Department of Obstetrics and Gynecology, Perelman School of Medicine,University of Pennsylvania, Philadelphia, Pennsylvania.

Presented at the 42nd AAGL Global Congress of Minimally Invasive Gynecol-ogy, November 1014, 2013, Washington, DC.

The authors thank Irene Grias, DO, for development of the study design andeditorial assistance.

Corresponding author: Kayla M. Wishall, MD, Department of Obstetrics andGynecology, 245 N 15th Street, MS 495, 16th Floor, New College Building,Philadelphia, PA 19102; e-mail: Kayla.Wishall@drexelmed.edu.

Financial DisclosureDr. Della Badia is a research investigator for AbbVie. The other authors did notreport any potential conflicts of interest.

2014 by The American College of Obstetricians and Gynecologists. Publishedby Lippincott Williams & Wilkins.ISSN: 0029-7844/14

904 VOL. 124, NO. 5, NOVEMBER 2014 OBSTETRICS & GYNECOLOGY

and hematosalpinx.79 Postablation tubal sterilizationsyndrome has been described in patients with a historyof tubal ligation in which pain develops as a result ofremnant endometrium at the cornua.8,9 It has tradition-ally been thought that adenomyosis is responsible forpain after ablation, although several studies have notfound an association between adenomyosis on preoper-ative imaging and hysterectomy.1013 However, the sen-sitivity for identifying adenomyosis on ultrasound hasbeen found to range from 53% to 85%.14

Although continued bleeding is a common causefor ablation failure, postablation pain is experienced bya substantial number of patients, and many of thesepatients request a hysterectomy.13 One prior study spe-cifically looked at risk factors for pain after endometrialablation and found that a history of dysmenorrhea,smoking, tubal ligation, and younger age were all asso-ciated with developing pain.13 The aim of this studywas to identify prognostic factors that put women atrisk of dissatisfaction as a result of pain and subsequentrates that these women request a hysterectomy.

MATERIALS AND METHODS

The institutional review boards of Drexel Universityand the University of Pennsylvania granted approvalto conduct this study before data collection. Aretrospective chart review investigating factors asso-ciated with pain and hysterectomy after endometrialablation was undertaken. Data on consecutive patientswere gathered for all endometrial ablations performedat Hahnemann University Hospital and the Hospitalof the University of Pennsylvania hospitals fromJanuary 2006 to May 2013 and entered into thedatabase by two of the authors (K.M.W. and J.P.).The earlier time point marks the advent of electronicmedical records at Hahnemann University Hospitaland was chosen for ease of data collection. At bothsites, office endometrial ablations are captured in thesame electronic medical record as operating roomprocedures. All patients older than 18 years of agewere included. Patients were excluded if they hada history of coagulopathy, the procedure was mis-coded, or the procedure was aborted. Ablationtechniques included a ThermaChoice balloon, micro-wave, circulating hot water, and bipolar radiofrequency,First-generation techniques were not delineated asa result of their rarity. Patients were identified usingthe International Classification of Diseases, 9th Revisioncode for endometrial ablation (68.23) and CurrentProcedural Terminology codes for hysteroscopy withendometrial ablation, endometrial ablation withouthysteroscopic guidance, and endometrial cryoablationwith ultrasonic guidance (58563, 58353, and 58356,

respectively). Data were abstracted from medical re-cords including operative reports, all follow-up officevisits, radiology, and pathology reports.

Our primary outcome was the development ofnew or worsening pain after endometrial ablation.Independent variables included type of ablation, dateof ablation, age at the time of ablation, parity, self-reported race, number of prior cesarean deliveries,history of tubal sterilization, body mass index, devel-opment of pain after ablation, findings on radiologicimaging, and endometrial stripe thickness. The sec-ondary outcome was hysterectomy after ablation. Incases in which a hysterectomy was performed, addi-tional data collected included interval from ablation tohysterectomy, indication, and findings on surgicalpathology. By abstracting data from every subsequentclinic visit after endometrial ablation, we identifiedpostablation pain when the patient reported to theclinician pain that was new or worse after the pro-cedure that lasted at least 2 months beyond the initialpostoperative visit. Patients were defined as lost tofollow-up if they did not return more than 6 weekspostoperatively.

Continuous variables were expressed as mean6standard deviation, and categorical variables were ex-pressed as number of cases (n) and percentage ofoccurrence (%). Odds ratios (ORs) with 95% confi-dence intervals (CIs) for pain and hysterectomy werealso calculated. Backward stepwise logistic regressionwas used to analyze the effect of categorical variableson the probability of pain or hysterectomy after abla-tion, and the final analysis included significant varia-bles along with race, history of dysmenorrhea, andhistory of tubal sterilization. Fishers exact tests andindependent t tests were used where appropriate. Coxproportional hazards model was used to evaluate timeto hysterectomy. Statistical significance was set atP,.05. Statistical analysis was performed using IBMSPSS Statistics for Windows 20.0.

RESULTS

A total of 388 patients were identified using Interna-tional Classification of Diseases, 9th Revision andCurrent Procedural Terminology codes. Eighty-eightpatients were excluded for the reasons listed pre-viously (Fig. 1). Records were incomplete or unavail-able for 71 patients, 10 patients had a history ofcoagulopathy, and in seven cases, the procedure wasaborted or unable to be completed. There were 30patients (10.0%) who were lost to follow-up, leavinga total of 270 for follow-up and analysis. Table 1 sum-marizes the overall demographics of the study popu-lation and those who were available for analysis.

VOL. 124, NO. 5, NOVEMBER 2014 Wishall et al Postablation Pain and Hysterectomy 905

Differences between the populations were seen inBMI (P5.01), history of tubal sterilization (P5.01),and uterine mean size on imaging (P5.01).

Thermal balloon and bipolar radiofrequencywere used most often (Table 1). Of those ablationsdone in the office, most were bipolar radiofrequency(n527 [73%]) with the rest being thermal balloon(n510 [27%]). Conversely, for procedures in the oper-ating room, most were done by thermal balloon(n5117 [49.4%]) with bipolar radiofrequency for 99cases (39.8%). This difference was statistically signifi-cant (P5.004). For all patients, the most commonimaging finding was leiomyoma (n5104 [34.7%]) fol-lowed by no specific findings (n591 [30.3%]), sus-pected adenomyosis (n523 [7.7%]), both leiomyomaand adenomyosis (n517 [5.7%]), thickened endome-trial stripe (n510 [3.3%]), polyp (n58 [2.7%]), andleiomyoma and polyps (n52 [0.7%]). For 45 patients(15%), either no imaging was performed preopera-tively or a report was not available.

Overall, 62 (23.0%) patients developed worseningor new pain after ablation (Fig. 1). For six (9.7%) ofthese patients, either no imaging was performed aspart of the preoperative workup or the report wasnot available. Of those patients who had imaging,the most common findings were leiomyomas in 31(50.0%), no significant pathology in 14 (22.6%), ad-enomyosis in 13 (21.0%), and both leiomyomas andadenomyosis in six (9.7%). There were no significantdifferences in patient characteristics between patientswho developed pain and those who did not (Table 2).The relationship between developing pain and severalvariables is shown in Table 3. A history of dysmenor-rhea gave 74% higher risk of developing postablationpain (adjusted OR 1.74, 95% CI 1.062.87; P5.03) as

Table 1. Baseline Demographics of the StudyPopulation (N5300)

Demographic

PatientsWith NoFollow-up(n530)

Patients WithFollow-up(n5270) P

Age (y) 42.666.5 43.765.7 .29BMI (kg/m2) 36.067.4 31.068.2 .01Race

White 14 (47.0) 157 (58.1) .25Nonwhite 16 (53.0) 113 (41.9) .25

Parity 2.361.0 2.261.3 .68Dysmenorrhea 17 (57.0) 136 (50.4) .57Chronic pelvic pain 2 (6.7) 22 (8.1) 1.00Endometriosis 2 (6.7) 7 (2.6) .22Tubal sterilization 19 (63.0) 93 (34.4) .01Cesarean delivery 9 (30.0) 88 (32.6) .84Findings on imaging

Leiomyoma 9 (30.0) 107 (39.6) .33Adenomyosis 2 (6.7) 37 (13.7) .39

Uterine size (cm) 7.164.9 9.763.5 .01Ablation method

Thermal balloon 10 (33.0) 117 (43.3) .33Bipolar

radiofrequency17 (57.0) 109 (40.3) .12

Microwave 0 (0) 16 (5.9) .38Hydrothermal 1 (3.3) 11 (4.1) 1.00First generation 1 (3.3) 4 (1.5) .41

Ablation locationHospital 27 (90.0) 217 (80.4) .32Office* 3 (10.0) 35 (14.4) .78

BMI, body mass index.Data are as mean6standard deviation or n (%) unless otherwise

specified.* Done by either the thermal balloon or bipolar radiofrequency.

Fig. 1. Venn diagram showing selection of study population.

Wishall. Postablation Pain and Hysterectomy. Obstet Gynecol 2014.

Table 2. Comparison of Patients With and WithoutPostablation Pain

Patient CharacteristicPain

(n562)No Pain(n5208) P

Age (y) 46.966.3 48.365.6 .05BMI (kg/m2) 31.769.1 30.567.9 .26Race

White 29 (46.8) 126 (60.6) .06Nonwhite 33 (53.2) 82 (39.4)

History of tubalsterilization

29 (46.8) 69 (33.2) .06

Parity 2.361.2 2.261.3 .66No. of cesarean deliveries 0.661 0.660.9 .60Endometrial stripe (mm) 9.865.7 8.765.6 .17

BMI, body mass index.Data are mean6standard deviation or n (%) unless otherwise specified.Independent t test was used.

906 Wishall et al Postablation Pain and Hysterectomy OBSTETRICS & GYNECOLOGY

well as a history of tubal sterilization, which more thandoubled the risk (adjusted OR 2.06, 95% CI 1.143.70;P5.02). White women were 45% less likely to developpain after ablation than nonwhites (adjusted OR 0.55,95% CI 0.340.89; P5.014). There was no difference inrates of pain after thermal balloon (25.4%) and bipolarradiofrequency ablation methods (16.0%) (adjusted OR1.27, 95% CI 0.591.69; P5.99).

Fifty-one patients (18.9%) underwent hysterec-tomy after ablation (Fig. 1; Table 4). Pain was themost common indication for hysterectomy (n516[31.4%]). Other indications included continued bleed-ing among 13 (25.5%) patients, both pain and bleed-ing for 10 patients (19.6%), uterine prolapse (n56[11.8%]), hyperplasia (n54 [7.8%]), postmenopausalbleeding (n51 [2%]), and malignancy (n51 [2%]).Regarding treatment after a failed ablation, seven

(30.4%) patients with continued bleeding tried hor-mone therapy before hysterectomy, whereas 16(69.6%) declined medical management. For those pa-tients with pain postablation, five (19.2%) tried anal-gesics (nonsteroidal antiinflammatory drugs) withoutrelief. The most common radiologic imaging findingsfor those patients who had a hysterectomy were asfollows: leiomyomas, 24 (48.0%); adenomyosis, nine(18.0%); and no specific findings for 13 (26.0%). Imag-ing reports were not available for eight (15.6%) pa-tients, and pathology reports were available for allbut one patient. The most common histopathologicdiagnosis was leiomyomas in nine (17.6%) patients,adenomyosis in six (11.8%) patients, and both leio-myoma and adenomyosis in 23 (45.1%) patients. Nospecific findings were found in six specimens (11.8%),hyperplasia in three (5.9%), polyps in two (3.9%),smooth muscle tumor of unknown malignant poten-tial in one (2.0%), and malignancy in one specimen(2.0%). Of the patients with hyperplasias discoveredon histologic analysis, two had endometrial biopsy byPipelle sampling before hysterectomy, which showedbenign pathology. The other patient had no samplingbefore hysterectomy. Malignancy was identified byPipelle sampling preoperatively for one patient.

Of ablations performed in the operating room,the most common reasons for failure were bleedingand pain with nine cases each (25.0%). The next mostcommon reason was both bleeding and pain for six(16.7%). Those done in the office failed mostlybecause of pain (n55 [56%]), then bleeding (n52[22.2%]), and bleeding and pain (n51 [1.1%]). Thedifference between ablation location and indicationfor hysterectomy was not significant (P5.61).

Time to hysterectomy for all indications rangedfrom 32 to 3,122 days (mean [standard deviation] 786[675], median 619 days). The shortest time was for

Table 3. Multivariate Logistic Regression to Evaluate the Effect of Specific Variables on the Probability ofDeveloping Pain After Endometrial Ablation

Variable OR (95% CI) P Adjusted OR (95% CI) P

Age younger than 40 y 1.52 (0.832.80) .17 1.45 (0.782.63) .25Race (white vs nonwhite) 0.52 (0.290.92) .03 0.55 (0.340.89) .014BMI (kg/m2) higher than 30 0.86 (0.481.54) .61 1.29 (0.782.14) .32Location 1 (hospital 1 vs 2) 1.46 (0.822.58) .20 1.32 (0.822.12) .26Location 2 (office vs operating room) 1.04 (0.452.44) .92 0.58 (0.271.25) .15Dysmenorrhea 2.11 (1.153.90) .02 1.74 (1.062.87) .03Cesarean delivery 1.05 (0.571.91) .88 1.03 (0.621.71) .92Parity more than 4 0.89 (0.392.07) .79 0.91 (0.451.83) .79Thermal balloon vs bipolar radiofrequency 1.78 (0.943.38) .08 1.27 (0.762.11) .82Any radiographic findings 1.89 (0.963.72) .07 0.99 (0.591.69) .99History of tubal sterilization 1.88 (1.053.35) .03 2.06 (1.143.70) .02

OR, odds ratio; CI, confidence interval; BMI, body mass index.

Table 4. Patient Characteristics for Those Who Didand Did Not Require Hysterectomy AfterEndometrial Ablation

PatientCharacteristic

Hysterectomy(n551)

No Hysterectomy(n5249) P

Age (y) 42.965.4 43.765.9 .38BMI (kg/m2) 31.568.9 30.968.2 .70Race

White 30 (58.8) 141 (57.6) .99Nonwhite 21 (41.2) 104 (42.4)

History of tubalsterilization

21 (41.2) 92 (37.6) .74

Parity 2 (09) 2 (06) .99No. of cesarean

deliveries0 (04) 0 (04) .93

Endometrial stripe(mm)

8.464.7 9.165.7 .49

BMI, body mass index.Data are mean6standard deviation, n (%), or median (range)

unless otherwise specified.

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malignancy at 32 days. For the indication of pain,hysterectomies were performed at a range of 1611,795days (803 [457], median 745 days). Hysterectomies forboth continued bleeding and pain were performed ata mean of 848 days (standard deviation 602, median698, range 193179). Time to hysterectomy for theindication of bleeding ranged from 55 to 3,122 days(824 [876], median 776 days). A Kaplan-Meier curveshowing the time to hysterectomy for those patientswho and did not develop pain reveals the time to hys-terectomy as significantly shorter in patients who devel-oped pain (P,.001; Fig. 2). Additionally, a history ofcesarean delivery was significant for a shorter time tohysterectomy (hazard ratio 2.28, 95% CI 1.194.36;P5.013; Table 5).

Table 6 shows the relationship between differentvariables and the risk of hysterectomy after ablation.Patients with a history of cesarean delivery were morethan twice as likely to have a failed ablation (adjustedOR 2.33, 95% CI 1.055.16; P5.037). Any abnormaluterine findings on radiologic imaging, including leio-myoma, adenomyosis, thickened endometrial stripe,and polyps before ablation, conferred an almost fourtimes higher risk for hysterectomy (adjusted OR 3.96,95% CI 1.2512.56; P5.02). However, there were toofew cases among the hysterectomies to analyze specificimaging findings (n527). We also identified ablationsperformed in the operating room as 76% less likely tolead to hysterectomy (adjusted OR 0.24, 95% CI 0.070.77; P5.016). The rate of hysterectomy for thermalballoon ablation was no different than that for bipolarradiofrequency (16.7% compared with 13.4%, adjusted

OR 1.14, 95% CI 0.562.30; P5.71). Nonwhite racewas not a risk factor for hysterectomy.

We also compared the indications for hysterec-tomy for those patients with a history of cesareandelivery. For the indication of continued bleeding,seven (53.8%) patients had a history of cesareandelivery, whereas for patients with both bleeding andpain, 11 (47.8%) had a history of cesarean delivery.Comparing this with any other indication in which 10had a history of cesarean delivery (35.7%), statisticalsignificance was not reached (P5.56).

DISCUSSION

In this study, we aimed to determine risk factors forpain and for hysterectomy after ablation. Pain devel-oped in 23.0% of patients, similar to the 20.8% seen byThomassee et al.13 Risk factors for postablation painin the current study included nonwhite race, history oftubal sterilization, and history of dysmenorrhea. Thepercentage of procedures leading to hysterectomy inour cohort (18.9%) is similar to other studies.15,16

Thomassee et al13 found tubal sterilization as a riskfactor for pain. Despite the finding that a history oftubal ligation conferred a higher risk of postablationpain, we did not find that it led to an increased risk ofhysterectomy. The pain may not be severe enough torequire definitive treatment or it may resolve overtime. We also saw that a history of dysmenorrheawas associated with postablation pain. Other studieshave shown that dysmenorrhea is associated with high-er rates of treatment failure.12,13,17 Women may persistwith the same level of dysmenorrhea as preablation and

Fig. 2. Kaplan-Meier survival curveshowing difference in time to hys-terectomy in patients who did anddid not develop pain after endome-trial ablation. Mean survival time(pain), days: 1,372.0; 95% confi-dence interval (CI) 1,1761,567.8.Mean survival time (no pain), days:2,497.9; 95% CI 2,207.02,788.5.

Wishall. Postablation Pain and Hyster-ectomy. Obstet Gynecol 2014.

908 Wishall et al Postablation Pain and Hysterectomy OBSTETRICS & GYNECOLOGY

be dissatisfied that the procedure does not eliminate it.Patients who developed postablation pain requesteda hysterectomy within a significantly shorter time thanthose without pain (Fig. 2; Table 5). Bleeding after abla-tion is often treated first with other methods such ashormones that may lengthen the time to hysterectomy.It is also possible that health care providers do not feelthey can treat chronic pelvic pain effectively and offerdefinitive management more quickly.

The finding that white race decreased the risk forpain was surprising, and the cause for this is unknown.In our population, most nonwhite patients are AfricanAmerican who as a population has higher rates ofleiomyomatous uteri.18

Consistent with Shavell et al,19 we found thata history of cesarean delivery is a risk factor for hys-terectomy. This has been postulated to be the result

of abnormal bleeding after cesarean delivery froma distorted lower uterine segment, although we didnot find statistical significance when comparing historyof cesarean delivery by indication.20 The presence ofleiomyoma or adenomyosis has been suggested asa cause for ablation failure, and we found that anyfindings on imaging are associated with hysterec-tomy.10,11 Because these are the most common imagingfindings, an analysis of each specific type of pathologymay identify one as a risk factor.

A procedure done in the operating roomdecreased the risk for hysterectomy. Ablations donein the office may not be as thorough as those done inthe operating room out of concern for patient comfort.Patient selection for location is unlikely to affect thisresult because patients with lower pain tolerancewould opt for an operating room procedure.

Table 5. Univariate and Multivariate Analysis of Time to Hysterectomy by the Cox ProportionalHazards Model

Variable

Univariate Analysis Multivariate Analysis

HR (95% CI) P HR (95% CI) P

Age (y)Younger than 40 vs older than 40 1.42 (0.802.53) .237 0.78 (0.391.59) .495

History of dysmenorrheaYes vs no 1.60 (0.882.92) .122 1.30 (0.682.51) .432

LocationOffice vs operating room 0.65 (0.311.35) .245 0.48 (0.211.07) .073

RaceWhite vs nonwhite 1.35 (0.772.39) .295 1.51 (0.762.99) .236

History of cesarean deliveryYes vs no 1.94 (1.103.41) .022 2.28 (1.194.36) .013

Postablation painYes vs no 3.34 (1.905.86) ,.001 2.77 (1.435.37) .003

History of tubal sterilizationYes vs no 1.27 (0.722.23) .416 1.20 (0.602.37) .608

HR, hazard ratio; CI, confidence interval.

Table 6. Multivariate Logistic Regression to Evaluate the Effect of Specific Variables on the Probability ofHysterectomy After Endometrial Ablation

Variable OR (95% CI) P Adjusted OR (95% CI) P

Age older than 40 y 1.85 (0.983.51) .06 1.63 (0.883.02) .598Race (white vs nonwhite) 1.03 (0.561.90) .93 1.46 (0.633.42) .380BMI (kg/m2) higher than 30 1.19 (0.652.19) .58 1.00 (0.951.05) .847Location 1 (hospital 1 vs 2) 0.79 (0.431.47) .46 1.81 (0.506.52) .367Location 2 (office vs operating room) 0.55 (0.241.27) .55 0.24 (0.070.77) .016Dysmenorrhea 1.52 (0.792.93) .21 0.98 (0.412.32) .094Cesarean delivery 1.55 (0.832.92) .17 2.33 (1.055.16) .037Parity more than 4 0.61 (0.231.64) .33 1.02 (0.751.38) .91Thermal balloon vs bipolar radiofrequency 1.14 (0.572.30) .71 1.14 (0.562.30) .71Any radiographic findings 1.37 (0.662.82) .40 3.96 (1.2512.56) .02History of tubal sterilization 1.07 (0.571.99) .84 1.07 (0.472.39) .88

OR, odds ratio; CI, confidence interval; BMI, body mass index.

VOL. 124, NO. 5, NOVEMBER 2014 Wishall et al Postablation Pain and Hysterectomy 909

The type of ablation did not affect the rates of painor hysterectomy despite the difference between theproportions of thermal balloon and bipolar radiofre-quency used in the operating room and office. Thissuggests ablation technique did not affect the outcome.Few studies have made direct comparisons amongsecond-generation techniques, and results are mixedregarding risk of treatment failure and ablation type.21

Two cases of Pipelle sampling failed to diagnosehyperplasia preoperatively. Assessment of the endo-metrium after ablation may be compromised.22 Thereis evidence that the feasibility of Pipelle sampling isdecreased, and the reliability of postablation is notwell defined.23 Given this, patients with persistentpostmenopausal bleeding or a high risk for malig-nancy should have a more thorough assessment.

The strengths of our study were the large samplesize, the diversity of the patient population, and theinclusion of two large urban hospitals. The follow-uptime for most patients was significant, and carefulreview of each follow-up visit was performed to assessprocedure outcome. The main limitation of our study isits retrospective design, preventing the use of objectivemeasures of pain such as an analog pain scale.However, the patients reported increased pain afterthe procedure, and patient satisfaction with the pro-cedure is clinically relevant even if it is not corroboratedwith an analog scale. The percentage of patients lost tofollow-up is another limitation of the study. There weresignificant differences between these patients and thepatients with follow-up in regards to BMI, history oftubal sterilization, and uterine size, though this is notlikely to negatively affect the final analysis (Table 1).Uterine size and BMI were not significant risk factorsfor pain or for hysterectomy (Table 3, Table 4). The rateof postablation pain and hysterectomy may actually beunderestimated since the group lost to follow-up hada higher percentage of tubal sterilization.

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