Scope: Endometrial ablation techniques for heavy menstrual bleeding

Objective: to establish the clinical and cost effectiveness of endometrial ablation (EA) techniques for heavy menstrual bleeding, in relation to alternative interventions including hysterectomy and to provide guidance to the NHS in England and Wales 1.

Background: Heavy menstrual bleeding (HMB, also known as menorrhagia) is a significant cause of morbidity in pre-menopausal women. It is clinically defined as greater than, or equal to 80 mls blood loss per menstrual cycle over several cycles. However, in practice it is usually defined by the woman's subjective assessment of blood loss. According to Royal College of Obstetricians and Gynaecologists, one in 20 women in the UK aged 30-49 years consult her GP each year with HMB.

Removing the uterus (hysterectomy) provides a radical treatment for HMB, however there are potential post/peri-operative complications as well as significant emotional implications associated with this procedure. Once referred to a gynaecologist, 60% of women with HMB will have a hysterectomy within five years. According to HES data for 2000/01, 47,000 hysterectomies (codes Q07 and Q08) were performed in England (HES data), with 18% of those coded for HMB (codes N92.0 and N92.4). About half of all women who have a hysterectomy for HMB are believed to have a normal uterus removed.

The Technology: HMB can be treated by destroying the inner layer of uterus (endometrium), known as endometrial ablation (EA), which can be done using a range of techniques. The principle is to remove the whole-thickness of endometrium and some of the underlying muscular layer (myometrium) to ensure complete removal of the endometrial basal glands. Ablation is more likely to be successful if the endometrium is thin; and there are several pre-operative medical therapy options to suppress endometrial growth.

First-generation EA techniques, introduced almost 20 years ago, are now commonly used in clinical practice. The most widely used approach is to combine transcervical resection of endometrium (TCRE) (using loop diathermy electrode) with roller-ball ablation (using an electrode with a movable ball or cylinder). All first-generation EA techniques require direct visualisation of endometrium by using a hysteroscope.

The second-generation EA techniques have recently been introduced with the aim of providing simpler, quicker and more effective treatment options for HMB. These include fluid-filled thermal balloon EA, radiofrequency (thermoregulated) balloon EA, hydrothermal EA, 3D bipolar radiofrequency EA, microwave EA, diode laser hyperthermy, cryoablation and photodynamic therapy. Visualisation of the endometrium is often not necessary when performing second-generation EA techniques. The most frequently used second-generation EA techniques in UK clinical practice are fluid-filled thermal balloon EA and microwave EA.


The thermal ablation technologies to be appraised are the fluid-filled thermal balloon endometrial ablation techniques and microwave endometrial ablation.


Women with heavy menstrual bleeding (menorrhagia)

Current standard treatments (comparators)

Comparators include transcervical endometrial resection (TCER), roller-ball and hysterectomy. Head-to-head comparisons will also be considered. Additional information will be sought, comparing TCER and rollerball with hysterectomy, for the completeness of the appraisal.

Other considerations

Patient preferences and the acceptability of different types of ablation techniques should be evaluated.

If the evidence allows, the appraisal will attempt to identify particular groups of women for whom this treatment is particularly appropriate.

1 The Department of Health remit to the Institute is "to advise on the clinical and cost-effectiveness of thermal endometrial ablation for heavy menstrual bleeding, in relation to alternative interventions including hysterectomy."

This page was last updated: 30 March 2010