Ellen L. Brock
History of present illness
A 47-year-old married gravida 4, para 4 woman presents for an urgent visit due to severe pelvic pain worsening over the last 24 hours that has not responded to ibuprofen. Approximately 18 months prior she had undergone an endometrial ablation for menorrhagia, and she had been amenorrheic after the abla- tion until 3 months ago when she experienced a heavy painful menstrual bleed. Subsequently, she has had monthly menses accompanied by right-sided pain that was severe enough on one occasion to warrant an emergency room evaluation.
Her past medical history is unremarkable. Her obstetric/
surgical history is significant for two prior vaginal deliveries followed by two Cesarean deliveries, with a tubal ligation performed during the second. She is on no medications, drinks alcohol socially, and works full time as a lawyer. Her review of symptoms is negative other than the pelvic pain as described.
Physical examination
General appearance:Alert-and-oriented woman appearing in mild distress
Vital signs:
Pulse 69 beats/min
Blood pressure: 131/69 mmHg Respiratory rate: 16 breaths/min BMI: 37 kg/m2
Chest:Clear
Cardiac:Normal auscultation
Abdomen:Soft, no palpable masses, pain noted with palpation in the right lower quadrant
Pelvic:
External genitalia: Normal Vagina: Normal
Cervix: Normal
Uterus: Upper normal size; uterine tenderness noted in both adnexal/cornual regions
Ovaries: Without palpable masses
Imaging:Transvaginal ultrasound shows a normal uterus with a small amount offluid in the endometrial cavity.
Adnexa appeared normal
How would you manage this patient?
Cyclic pelvic pain following endometrial ablation can be related to a central hematometra, a cornual hematometra,
post-ablation tubal sterilization syndrome (PATSS) or endo- metriosis. This patient’s history of a prior tubal ligation makes the diagnosis of PATSS more likely.
Because of this patient’s new onset bleeding, she initially underwent a hysteroscopic examination to rule out malig- nancy. The cavity was contracted with no visible endomet- rium, and no endometrial tissue was identified in curettings.
She continued to have severe debilitating pain and underwent laparoscopic hysterectomy with bilateral salpingectomies. At surgery she was found to have a normal appearing uterus and ovaries, and mildly dilated proximal tubal segments, consistent with the diagnosis of PATSS (Fig. 43.1).
Postoperatively the patient did well, and her pain completely resolved. Pathology confirmed intraluminal blood in the prox- imal tubal segments with acute and chronic inflammation.
Post-ablation tubal sterilization syndrome
Post-ablation tubal sterilization syndrome (PATSS) was ini- tially described as a long-term complication following resecto- scopic endometrial ablation. Subsequently, cases have been reported with all currently available types of global endomet- rial ablation devices (hot water balloon, free circulating hot water, bipolar radio-frequency array, cryoablation, and micro- wave ablation). Destruction of the endometrial surface results
Fig. 43.1 Operative photograph from laparoscopic hysterectomy in the patient with post-ablation tubal sterilization syndrome. The proximal tubal stumps are moderately dilated, afinding that varies according to timing within the menstrual cycle.
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
in scarring and contracture of the endometrial cavity, produ- cing an absolute or relative outflow obstruction. Because the cornual portion of the endometrium may be spared during an ablation procedure due to difficult access and thinness of the myometrium in that area, functioning cornual endometrium often persists. In the presence of an outflow obstruction, retro- grade bleeding can occur with distention of the proximal fallopian tubal segment. The tube is occluded distally due to prior sterilization and, thus, the symptom of cyclic pain ensues. The cyclic pain of PATSS develops months to even years following endometrial ablation. The delay in presenta- tion is thought to be related to the progression of endometrial scarring over many months following ablation, and the likeli- hood that outflow tract obstructions can develop months to years after the procedure [1].
PATSS occurs in approximately 10% of women undergo- ing endometrial ablation after a prior tubal sterilization, with reported incidences in various studies of up to 33%. It is not yet known whether PATSS occurs more or less frequently with global ablation devices than with resectoscopic or rollerball techniques. A recent Cochrane review of ablation complica- tions showed no difference in the incidence of hysterectomy following ablations done with first- versus second-generation devices in thefirstfive years following ablation, with a modest decrease in hysterectomy following global endometrial abla- tion after thefirstfive years [2].
The diagnosis of PATSS can be difficult. Hematosalpinx may be visible in the proximal tubal stump if ultrasound imaging studies are performed during a woman’s menses.
Between menstrual cycles, however, the hematosalpinx may lessen significantly or may reabsorb altogether and may not be visible. T2-weighted MRI imaging can identify blood sequestered in the cornual and tubal regions. The diagnosis should be suspected whenever a patient with a prior history of a tubal ligation presents after ablation with new-onset unilateral or bilateral pelvic pain. The differential diagnosis will also include a central or cornual hematometra. Central hematometra can occur when there is occlusion of the lower uterine segment or cervix, with persistent functioning endometrium proximally. Cornual hematometra can occur when the proximal tubal segments and the distal endometrial canal are occluded, with persistence of functioning cornual endometrium. Adenomyosis can also be responsible for post-ablation cyclic pain. More rarely, adnexal abscesses or endometriosis have been reported following ablation, presum- ably due to either rupture orfistula formation of the proximal tubal stump.
The first patients presenting with PATSS were managed with attempts at relieving the outflow obstruction hysterosco- pically, or by laparoscopic salpingectomy. However, many treatment failures have been reported for salpingectomy, leading most experts to recommend hysterectomy with salpin- gectomy as the treatment of choice [3]. Differentiating PATSS from central hematometra is important, since the latter can be
managed by dilatation of the cervix and drainage of the blood collection. Differentiation from other entities presenting as cyclic pain following ablation is less critical from a practical standpoint, as most of these women will require hysterectomy.
As the primary purpose of endometrial ablation is to avoid hysterectomy, it is desirable to find techniques to prevent endometrial contracture and outflow obstruction after abla- tion, or to use mechanisms of sterilization that carry less risk for PATSS development. Some authors have recommended a partial ablation technique, wherein either the anterior or pos- terior surface (but not both) of the endometrium is destroyed.
The presence of intact endometrium on the opposite surface will theoretically prevent cavity obliteration due to scarring.
This method has not been widely adopted, given the guaran- teed persistence of menses and the primary use of global ablation devices in current practice. Other authors have advocated for methods of sterilization that occlude the tube at the cornu. All currently used laparoscopic tubal sterilization devices are recommended for use in the tubal midsegment only. Solutions would involve either laparoscopic salpingec- tomy for sterilization, or transcervical sterilization. Transcer- vical sterilization in a patient desiring ablation should be done at least three months prior to the ablation procedure to allow for the three-month hysterosalpingogram documentation of tubal occlusion.
As an alternative to endometrial ablation, the levonorges- trel intrauterine device (LNG-IUD) can also be an effective treatment for managing heavy menstrual bleeding. It has com- pared favorably with both systemic therapy and endometrial ablation. While the reduction in menstrual blood loss with the LNG-IUD is less than with ablation, there is no difference in effect on hemoglobin, and satisfaction rates with both methods are high [4].
This patient’s tubal ligation was performed remote from her presentation with menorrhagia. Given her history of tubal ligation and her relatively young age, she had been counseled preoperatively about long-term sequelae of ablation, including PATSS. She had also been offered a LNG-IUD for manage- ment of her menorrhagia, but had declined.
Key teaching points
Women with a history of a tubal ligation are at an estimated 10% risk for developing post-ablation tubal sterilization syndrome (PATSS) after an endometrial ablation.
PATSS results when functioning cornual endometrium persists following ablation. In the presence of outflow obstruction, retrograde bleeding can occur with distention of the proximal fallopian tubal segment that has been occluded more distally by a prior sterilization procedure.
Preoperative diagnosis of PATSS is difficult. Unless there is demonstrated central hematometra (which can be relieved
by cervical dilatation), women with cyclic pain after ablation will generally require hysterectomy for definitive management.
There is insufficient evidence for recommending any specific ablation device or technique for decreasing the risk of PATSS.
References
1. McCausland A, McCausland V. Long- term complications of endometrial ablation: Cause, diagnosis, treatment, prevention.J Minim Invasive Gynecol 2007;12:399–406.
2. Lethaby A, Penninx J, Hickey M, Garry R, Marjoribanks J. Endometrial
resection and ablation techniques for heavy menstrual bleeding.Cochrane Database Syst Rev2013, Issue 8. Art.
No.: CD001501. DOI: 10.1002/
14651858.CD001501.pub4.
3. American College of Obstetricians and Gynecologists. Endometrial ablation.
Practice Bulletin No. 81.Obstet Gynecol 2007;109(5):1233–48.
4. Lethaby A, Cooke I, Rees MC.
Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding.Cochrane Database Syst Rev2005, Issue 4. Art. No.:
CD002126. DOI: 10.1002/14651858.
CD002126.pub2.
Case 43: Cyclic pain after endometrial ablation