Original Research

Postablation Risk Factors for Pain and

Subsequent Hysterectomy
Kayla M. Wishall, MD, Joan Price,
and Carl R. Della Badia, DO

MD, MPH,

Nigel Pereira,

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 developed 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

From the Department of Obstetrics and Gynecology and the Division of

Minimally 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 Gynecology, November 1014, 2013, Washington, DC.
The authors thank Irene Grias, DO, for development of the study design and
editorial assistance.
Corresponding author: Kayla M. Wishall, MD, Department of Obstetrics and
Gynecology, 245 N 15th Street, MS 495, 16th Floor, New College Building,
Philadelphia, PA 19102; e-mail: Kayla.Wishall@drexelmed.edu.
Financial Disclosure
Dr. Della Badia is a research investigator for AbbVie. The other authors did not
report any potential conflicts of interest.
2014 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/14

904

VOL. 124, NO. 5, NOVEMBER 2014

MD,

Samantha M. Butts,

MD, MSCE,

abnormalities on imaging, including leiomyoma, adenomyosis, thickened endometrial strip, and polyps, quadrupled 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 indications (P,.001).
CONCLUSION: Patient characteristics should be considered 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

ndometrial ablation is one of the less invasive surgical options for women with menorrhagia. The
first-generation techniques included roller ball ablation, bipolar endometrial resection, and laser ablation,
all of which required visualization of the cavity for the
entirety of the procedure.1 Second generation, nonhysteroscopic techniques have since been developed
that require less skill and can be performed in the
office.2,3 These are devices that destroy the endometrium blindly by various methods, including heated
water in a balloon, bipolar radiofrequency, cryoablation, microwave energy, and circulating hot fluid.
These techniques offer an alternative to hysterectomy
for women who are poor surgical candidates or who
wish to avoid major surgery. Head-to-head comparisons of first- and second-generation ablation techniques with hysterectomy have found higher numbers
of repeat operations with ablation, less patient satisfaction, and lower rates of amenorrhea. Although hysterectomy guarantees amenorrhea, it has a longer
recovery time, greater cost, and much higher complication rate.46
Postablation pain has been described after endometrial ablation and variously attributed to hematometra

OBSTETRICS & GYNECOLOGY

and hematosalpinx.79 Postablation tubal sterilization

syndrome has been described in patients with a history
of tubal ligation in which pain develops as a result of
remnant endometrium at the cornua.8,9 It has traditionally been thought that adenomyosis is responsible for
pain after ablation, although several studies have not
found an association between adenomyosis on preoperative imaging and hysterectomy.1013 However, the sensitivity for identifying adenomyosis on ultrasound has
been found to range from 53% to 85%.14
Although continued bleeding is a common cause
for ablation failure, postablation pain is experienced by
a substantial number of patients, and many of these
patients request a hysterectomy.13 One prior study specifically looked at risk factors for pain after endometrial
ablation and found that a history of dysmenorrhea,
smoking, tubal ligation, and younger age were all associated with developing pain.13 The aim of this study
was to identify prognostic factors that put women at
risk of dissatisfaction as a result of pain and subsequent
rates that these women request a hysterectomy.

MATERIALS AND METHODS

The institutional review boards of Drexel University
and the University of Pennsylvania granted approval
to conduct this study before data collection. A
retrospective chart review investigating factors associated with pain and hysterectomy after endometrial
ablation was undertaken. Data on consecutive patients
were gathered for all endometrial ablations performed
at Hahnemann University Hospital and the Hospital
of the University of Pennsylvania hospitals from
January 2006 to May 2013 and entered into the
database by two of the authors (K.M.W. and J.P.).
The earlier time point marks the advent of electronic
medical records at Hahnemann University Hospital
and was chosen for ease of data collection. At both
sites, office endometrial ablations are captured in the
same electronic medical record as operating room
procedures. All patients older than 18 years of age
were included. Patients were excluded if they had
a history of coagulopathy, the procedure was miscoded, or the procedure was aborted. Ablation
techniques included a ThermaChoice balloon, microwave, circulating hot water, and bipolar radiofrequency,
First-generation techniques were not delineated as
a result of their rarity. Patients were identified using
the International Classification of Diseases, 9th Revision
code for endometrial ablation (68.23) and Current
Procedural Terminology codes for hysteroscopy with
endometrial ablation, endometrial ablation without
hysteroscopic guidance, and endometrial cryoablation
with ultrasonic guidance (58563, 58353, and 58356,

VOL. 124, NO. 5, NOVEMBER 2014

respectively). Data were abstracted from medical records including operative reports, all follow-up office
visits, radiology, and pathology reports.
Our primary outcome was the development of
new or worsening pain after endometrial ablation.
Independent variables included type of ablation, date
of ablation, age at the time of ablation, parity, selfreported race, number of prior cesarean deliveries,
history of tubal sterilization, body mass index, development of pain after ablation, findings on radiologic
imaging, and endometrial stripe thickness. The secondary outcome was hysterectomy after ablation. In
cases in which a hysterectomy was performed, additional data collected included interval from ablation to
hysterectomy, indication, and findings on surgical
pathology. By abstracting data from every subsequent
clinic visit after endometrial ablation, we identified
postablation pain when the patient reported to the
clinician pain that was new or worse after the procedure that lasted at least 2 months beyond the initial
postoperative visit. Patients were defined as lost to
follow-up if they did not return more than 6 weeks
postoperatively.
Continuous variables were expressed as mean6
standard deviation, and categorical variables were expressed as number of cases (n) and percentage of
occurrence (%). Odds ratios (ORs) with 95% confidence intervals (CIs) for pain and hysterectomy were
also calculated. Backward stepwise logistic regression
was used to analyze the effect of categorical variables
on the probability of pain or hysterectomy after ablation, and the final analysis included significant variables along with race, history of dysmenorrhea, and
history of tubal sterilization. Fishers exact tests and
independent t tests were used where appropriate. Cox
proportional hazards model was used to evaluate time
to hysterectomy. Statistical significance was set at
P,.05. Statistical analysis was performed using IBM
SPSS Statistics for Windows 20.0.

RESULTS
A total of 388 patients were identified using International Classification of Diseases, 9th Revision and
Current Procedural Terminology codes. Eighty-eight
patients were excluded for the reasons listed previously (Fig. 1). Records were incomplete or unavailable for 71 patients, 10 patients had a history of
coagulopathy, and in seven cases, the procedure was
aborted or unable to be completed. There were 30
patients (10.0%) who were lost to follow-up, leaving
a total of 270 for follow-up and analysis. Table 1 summarizes the overall demographics of the study population and those who were available for analysis.

Wishall et al

Postablation Pain and Hysterectomy

905

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

Wishall. Postablation Pain and Hysterectomy. Obstet Gynecol 2014.

Table 1. Baseline Demographics of the Study

Population (N5300)

Demographic
Age (y)
BMI (kg/m2)
Race
White
Nonwhite
Parity
Dysmenorrhea
Chronic pelvic pain
Endometriosis
Tubal sterilization
Cesarean delivery
Findings on imaging
Leiomyoma
Adenomyosis
Uterine size (cm)
Ablation method
Thermal balloon
Bipolar
radiofrequency
Microwave
Hydrothermal
First generation
Ablation location
Hospital
Office*

Patients
With No
Follow-up
(n530)

Patients With
Follow-up
(n5270)

42.666.5
36.067.4

43.765.7
31.068.2

.29
.01

14 (47.0)
16 (53.0)
2.361.0
17 (57.0)
2 (6.7)
2 (6.7)
19 (63.0)
9 (30.0)

157 (58.1)
113 (41.9)
2.261.3
136 (50.4)
22 (8.1)
7 (2.6)
93 (34.4)
88 (32.6)

.25
.25
.68
.57
1.00
.22
.01
.84

9 (30.0)
2 (6.7)
7.164.9

107 (39.6)
37 (13.7)
9.763.5

.33
.39
.01

10 (33.0)
17 (57.0)

117 (43.3)
109 (40.3)

.33
.12

0 (0)
1 (3.3)
1 (3.3)

16 (5.9)
11 (4.1)
4 (1.5)

.38
1.00
.41

27 (90.0)
3 (10.0)

217 (80.4)
35 (14.4)

.32
.78

BMI, body mass index.

Data are as mean6standard deviation or n (%) unless otherwise
specified.
* Done by either the thermal balloon or bipolar radiofrequency.

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Wishall et al

Postablation Pain and Hysterectomy

Differences between the populations were seen in

BMI (P5.01), history of tubal sterilization (P5.01),
and uterine mean size on imaging (P5.01).
Thermal balloon and bipolar radiofrequency
were used most often (Table 1). Of those ablations
done in the office, most were bipolar radiofrequency
(n527 [73%]) with the rest being thermal balloon
(n510 [27%]). Conversely, for procedures in the operating room, most were done by thermal balloon
(n5117 [49.4%]) with bipolar radiofrequency for 99
cases (39.8%). This difference was statistically significant (P5.004). For all patients, the most common
imaging finding was leiomyoma (n5104 [34.7%]) followed by no specific findings (n591 [30.3%]), suspected adenomyosis (n523 [7.7%]), both leiomyoma
and adenomyosis (n517 [5.7%]), thickened endometrial stripe (n510 [3.3%]), polyp (n58 [2.7%]), and
leiomyoma and polyps (n52 [0.7%]). For 45 patients
(15%), either no imaging was performed preoperatively or a report was not available.
Overall, 62 (23.0%) patients developed worsening
or new pain after ablation (Fig. 1). For six (9.7%) of
these patients, either no imaging was performed as
part of the preoperative workup or the report was
not available. Of those patients who had imaging,
the most common findings were leiomyomas in 31
(50.0%), no significant pathology in 14 (22.6%), adenomyosis in 13 (21.0%), and both leiomyomas and
adenomyosis in six (9.7%). There were no significant
differences in patient characteristics between patients
who developed pain and those who did not (Table 2).
The relationship between developing pain and several
variables is shown in Table 3. A history of dysmenorrhea gave 74% higher risk of developing postablation
pain (adjusted OR 1.74, 95% CI 1.062.87; P5.03) as
Table 2. Comparison of Patients With and Without
Postablation Pain
Patient Characteristic
Age (y)
BMI (kg/m2)
Race
White
Nonwhite
History of tubal
sterilization
Parity
No. of cesarean deliveries
Endometrial stripe (mm)

Pain
(n562)

No Pain
(n5208)

46.966.3
31.769.1

48.365.6
30.567.9

.05
.26

29 (46.8)
33 (53.2)
29 (46.8)

126 (60.6)
82 (39.4)
69 (33.2)

.06

2.361.2
0.661
9.865.7

2.261.3
0.660.9
8.765.6

.66
.60
.17

.06

BMI, body mass index.

Data are mean6standard deviation or n (%) unless otherwise specified.
Independent t test was used.

OBSTETRICS & GYNECOLOGY

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

OR (95% CI)

Age younger than 40 y

Race (white vs nonwhite)
BMI (kg/m2) higher than 30
Location 1 (hospital 1 vs 2)
Location 2 (office vs operating room)
Dysmenorrhea
Cesarean delivery
Parity more than 4
Thermal balloon vs bipolar radiofrequency
Any radiographic findings
History of tubal sterilization

1.52
0.52
0.86
1.46
1.04
2.11
1.05
0.89
1.78
1.89
1.88

(0.832.80)
(0.290.92)
(0.481.54)
(0.822.58)
(0.452.44)
(1.153.90)
(0.571.91)
(0.392.07)
(0.943.38)
(0.963.72)
(1.053.35)

P
.17
.03
.61
.20
.92
.02
.88
.79
.08
.07
.03

Adjusted OR (95% CI)

1.45
0.55
1.29
1.32
0.58
1.74
1.03
0.91
1.27
0.99
2.06

(0.782.63)
(0.340.89)
(0.782.14)
(0.822.12)
(0.271.25)
(1.062.87)
(0.621.71)
(0.451.83)
(0.762.11)
(0.591.69)
(1.143.70)

P
.25
.014
.32
.26
.15
.03
.92
.79
.82
.99
.02

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

BMI, body mass index.

Data are mean6standard deviation, n (%), or median (range)
unless otherwise specified.

(30.4%) patients with continued bleeding tried hormone therapy before hysterectomy, whereas 16
(69.6%) declined medical management. For those patients with pain postablation, five (19.2%) tried analgesics (nonsteroidal antiinflammatory drugs) without
relief. The most common radiologic imaging findings
for those patients who had a hysterectomy were as
follows: leiomyomas, 24 (48.0%); adenomyosis, nine
(18.0%); and no specific findings for 13 (26.0%). Imaging reports were not available for eight (15.6%) patients, and pathology reports were available for all
but one patient. The most common histopathologic
diagnosis was leiomyomas in nine (17.6%) patients,
adenomyosis in six (11.8%) patients, and both leiomyoma and adenomyosis in 23 (45.1%) patients. No
specific findings were found in six specimens (11.8%),
hyperplasia in three (5.9%), polyps in two (3.9%),
smooth muscle tumor of unknown malignant potential in one (2.0%), and malignancy in one specimen
(2.0%). Of the patients with hyperplasias discovered
on histologic analysis, two had endometrial biopsy by
Pipelle sampling before hysterectomy, which showed
benign pathology. The other patient had no sampling
before hysterectomy. Malignancy was identified by
Pipelle sampling preoperatively for one patient.
Of ablations performed in the operating room,
the most common reasons for failure were bleeding
and pain with nine cases each (25.0%). The next most
common reason was both bleeding and pain for six
(16.7%). Those done in the office failed mostly
because of pain (n55 [56%]), then bleeding (n52
[22.2%]), and bleeding and pain (n51 [1.1%]). The
difference between ablation location and indication
for hysterectomy was not significant (P5.61).
Time to hysterectomy for all indications ranged
from 32 to 3,122 days (mean [standard deviation] 786
[675], median 619 days). The shortest time was for

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Wishall et al

well as a history of tubal sterilization, which more than

doubled the risk (adjusted OR 2.06, 95% CI 1.143.70;
P5.02). White women were 45% less likely to develop
pain after ablation than nonwhites (adjusted OR 0.55,
95% CI 0.340.89; P5.014). There was no difference in
rates of pain after thermal balloon (25.4%) and bipolar
radiofrequency ablation methods (16.0%) (adjusted OR
1.27, 95% CI 0.591.69; P5.99).
Fifty-one patients (18.9%) underwent hysterectomy after ablation (Fig. 1; Table 4). Pain was the
most common indication for hysterectomy (n516
[31.4%]). Other indications included continued bleeding among 13 (25.5%) patients, both pain and bleeding for 10 patients (19.6%), uterine prolapse (n56
[11.8%]), hyperplasia (n54 [7.8%]), postmenopausal
bleeding (n51 [2%]), and malignancy (n51 [2%]).
Regarding treatment after a failed ablation, seven
Table 4. Patient Characteristics for Those Who Did
and Did Not Require Hysterectomy After
Endometrial Ablation
Patient
Characteristic
Age (y)
BMI (kg/m2)
Race
White
Nonwhite
History of tubal
sterilization
Parity
No. of cesarean
deliveries
Endometrial stripe
(mm)

Hysterectomy No Hysterectomy
(n551)
(n5249)

42.965.4
31.568.9

43.765.9
30.968.2

.38
.70

30 (58.8)
21 (41.2)
21 (41.2)

141 (57.6)
104 (42.4)
92 (37.6)

.99

2 (09)
0 (04)

2 (06)
0 (04)

.99
.93

8.464.7

9.165.7

.49

.74

Postablation Pain and Hysterectomy

907

malignancy at 32 days. For the indication of pain,

hysterectomies were performed at a range of 1611,795
days (803 [457], median 745 days). Hysterectomies for
both continued bleeding and pain were performed at
a mean of 848 days (standard deviation 602, median
698, range 193179). Time to hysterectomy for the
indication of bleeding ranged from 55 to 3,122 days
(824 [876], median 776 days). A Kaplan-Meier curve
showing the time to hysterectomy for those patients
who and did not develop pain reveals the time to hysterectomy as significantly shorter in patients who developed pain (P,.001; Fig. 2). Additionally, a history of
cesarean delivery was significant for a shorter time to
hysterectomy (hazard ratio 2.28, 95% CI 1.194.36;
P5.013; Table 5).
Table 6 shows the relationship between different
variables and the risk of hysterectomy after ablation.
Patients with a history of cesarean delivery were more
than twice as likely to have a failed ablation (adjusted
OR 2.33, 95% CI 1.055.16; P5.037). Any abnormal
uterine findings on radiologic imaging, including leiomyoma, adenomyosis, thickened endometrial stripe,
and polyps before ablation, conferred an almost four
times higher risk for hysterectomy (adjusted OR 3.96,
95% CI 1.2512.56; P5.02). However, there were too
few cases among the hysterectomies to analyze specific
imaging findings (n527). We also identified ablations
performed in the operating room as 76% less likely to
lead to hysterectomy (adjusted OR 0.24, 95% CI 0.07
0.77; P5.016). The rate of hysterectomy for thermal
balloon ablation was no different than that for bipolar
radiofrequency (16.7% compared with 13.4%, adjusted

OR 1.14, 95% CI 0.562.30; P5.71). Nonwhite race

was not a risk factor for hysterectomy.
We also compared the indications for hysterectomy for those patients with a history of cesarean
delivery. For the indication of continued bleeding,
seven (53.8%) patients had a history of cesarean
delivery, whereas for patients with both bleeding and
pain, 11 (47.8%) had a history of cesarean delivery.
Comparing this with any other indication in which 10
had a history of cesarean delivery (35.7%), statistical
significance was not reached (P5.56).

DISCUSSION
In this study, we aimed to determine risk factors for
pain and for hysterectomy after ablation. Pain developed in 23.0% of patients, similar to the 20.8% seen by
Thomassee et al.13 Risk factors for postablation pain
in the current study included nonwhite race, history of
tubal sterilization, and history of dysmenorrhea. The
percentage of procedures leading to hysterectomy in
our cohort (18.9%) is similar to other studies.15,16
Thomassee et al13 found tubal sterilization as a risk
factor for pain. Despite the finding that a history of
tubal ligation conferred a higher risk of postablation
pain, we did not find that it led to an increased risk of
hysterectomy. The pain may not be severe enough to
require definitive treatment or it may resolve over
time. We also saw that a history of dysmenorrhea
was associated with postablation pain. Other studies
have shown that dysmenorrhea is associated with higher rates of treatment failure.12,13,17 Women may persist
with the same level of dysmenorrhea as preablation and

Fig. 2. Kaplan-Meier survival curve

showing difference in time to hysterectomy in patients who did and
did not develop pain after endometrial ablation. Mean survival time
(pain), days: 1,372.0; 95% confidence 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 Hysterectomy. Obstet Gynecol 2014.

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OBSTETRICS & GYNECOLOGY

Table 5. Univariate and Multivariate Analysis of Time to Hysterectomy by the Cox Proportional
Hazards Model
Univariate Analysis
Variable
Age (y)
Younger than 40 vs older than 40
History of dysmenorrhea
Yes vs no
Location
Office vs operating room
Race
White vs nonwhite
History of cesarean delivery
Yes vs no
Postablation pain
Yes vs no
History of tubal sterilization
Yes vs no

Multivariate Analysis
P

HR (95% CI)

HR (95% CI)

1.42 (0.802.53)

.237

0.78 (0.391.59)

.495

1.60 (0.882.92)

.122

1.30 (0.682.51)

.432

0.65 (0.311.35)

.245

0.48 (0.211.07)

.073

1.35 (0.772.39)

.295

1.51 (0.762.99)

.236

1.94 (1.103.41)

.022

2.28 (1.194.36)

.013

3.34 (1.905.86)

,.001

2.77 (1.435.37)

.003

1.27 (0.722.23)

.416

1.20 (0.602.37)

.608

HR, hazard ratio; CI, confidence interval.

be dissatisfied that the procedure does not eliminate it.

Patients who developed postablation pain requested
a hysterectomy within a significantly shorter time than
those without pain (Fig. 2; Table 5). Bleeding after ablation is often treated first with other methods such as
hormones that may lengthen the time to hysterectomy.
It is also possible that health care providers do not feel
they can treat chronic pelvic pain effectively and offer
definitive management more quickly.
The finding that white race decreased the risk for
pain was surprising, and the cause for this is unknown.
In our population, most nonwhite patients are African
American who as a population has higher rates of
leiomyomatous uteri.18
Consistent with Shavell et al,19 we found that
a history of cesarean delivery is a risk factor for hysterectomy. This has been postulated to be the result

of abnormal bleeding after cesarean delivery from

a distorted lower uterine segment, although we did
not find statistical significance when comparing history
of cesarean delivery by indication.20 The presence of
leiomyoma or adenomyosis has been suggested as
a cause for ablation failure, and we found that any
findings on imaging are associated with hysterectomy.10,11 Because these are the most common imaging
findings, an analysis of each specific type of pathology
may identify one as a risk factor.
A procedure done in the operating room
decreased the risk for hysterectomy. Ablations done
in the office may not be as thorough as those done in
the operating room out of concern for patient comfort.
Patient selection for location is unlikely to affect this
result because patients with lower pain tolerance
would opt for an operating room procedure.

Table 6. Multivariate Logistic Regression to Evaluate the Effect of Specific Variables on the Probability of
Hysterectomy After Endometrial Ablation
Variable
Age older than 40 y
Race (white vs nonwhite)
BMI (kg/m2) higher than 30
Location 1 (hospital 1 vs 2)
Location 2 (office vs operating room)
Dysmenorrhea
Cesarean delivery
Parity more than 4
Thermal balloon vs bipolar radiofrequency
Any radiographic findings
History of tubal sterilization

OR (95% CI)
1.85
1.03
1.19
0.79
0.55
1.52
1.55
0.61
1.14
1.37
1.07

(0.983.51)
(0.561.90)
(0.652.19)
(0.431.47)
(0.241.27)
(0.792.93)
(0.832.92)
(0.231.64)
(0.572.30)
(0.662.82)
(0.571.99)

P
.06
.93
.58
.46
.55
.21
.17
.33
.71
.40
.84

Adjusted OR (95% CI)

1.63
1.46
1.00
1.81
0.24
0.98
2.33
1.02
1.14
3.96
1.07

(0.883.02)
(0.633.42)
(0.951.05)
(0.506.52)
(0.070.77)
(0.412.32)
(1.055.16)
(0.751.38)
(0.562.30)
(1.2512.56)
(0.472.39)

P
.598
.380
.847
.367
.016
.094
.037
.91
.71
.02
.88

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

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The type of ablation did not affect the rates of pain

or hysterectomy despite the difference between the
proportions of thermal balloon and bipolar radiofrequency used in the operating room and office. This
suggests ablation technique did not affect the outcome.
Few studies have made direct comparisons among
second-generation techniques, and results are mixed
regarding risk of treatment failure and ablation type.21
Two cases of Pipelle sampling failed to diagnose
hyperplasia preoperatively. Assessment of the endometrium after ablation may be compromised.22 There
is evidence that the feasibility of Pipelle sampling is
decreased, and the reliability of postablation is not
well defined.23 Given this, patients with persistent
postmenopausal bleeding or a high risk for malignancy should have a more thorough assessment.
The strengths of our study were the large sample
size, the diversity of the patient population, and the
inclusion of two large urban hospitals. The follow-up
time for most patients was significant, and careful
review of each follow-up visit was performed to assess
procedure outcome. The main limitation of our study is
its retrospective design, preventing the use of objective
measures of pain such as an analog pain scale.
However, the patients reported increased pain after
the procedure, and patient satisfaction with the procedure is clinically relevant even if it is not corroborated
with an analog scale. The percentage of patients lost to
follow-up is another limitation of the study. There were
significant differences between these patients and the
patients with follow-up in regards to BMI, history of
tubal sterilization, and uterine size, though this is not
likely to negatively affect the final analysis (Table 1).
Uterine size and BMI were not significant risk factors
for pain or for hysterectomy (Table 3, Table 4). The rate
of postablation pain and hysterectomy may actually be
underestimated since the group lost to follow-up had
a higher percentage of tubal sterilization.
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