Combined transcervical endometrial resection and levonorgestrel device treatment compared to transcervical endometrial resection for abnormal uterine bleed.

INTRODUCTION: Transcervical resection of the endometrium (TCRE) is a first-line surgical treatment of abnormal uterine bleeding. However, many women experience unsuccessful results, causing hysterectomy in up 17% of cases. The aim of this study was to describe the odds of hysterectomy in women with abnormal uterine bleeding, treated with TCRE and levonorgestrel intrauterine contraceptive device (TCRE + LNG-IUCD) or TCRE alone. The secondary aim was to analyze the rate of amenorrhea. MATERIAL AND METHODS: Designed as a retrospective cohort study, and conducted at Odense University Hospital, Denmark, the study included women with abnormal uterine bleeding, who underwent TCRE from January 2013 to December 2015. The decision of treatment with respect to LNG-IUCD was at the woman's discretion. Data were collected from medical records and a self-reported retrospective bleeding-pattern questionnaire. A multivariate regression model was used, enabling adjustment for potential and identified confounders. RESULTS: Out of 432 women, 276 (62%) consented to inclusion and of these, 16 (4%) were excluded. In total 88 (34%) received combined treatment and 172 (66%) received TCRE alone. Ten women (11%) treated with TCRE + LNG-IUCD underwent hysterectomy, compared with 27 (16%) treated with TCRE alone (OR = 0.69, 95% CI 0.28-1.56; P = .34). Multivariate analysis disclosed a significant effect of TCRE + LNG-IUCD (OR = 0.35, 95% CI 0.13-0.97; P = .04) on hysterectomy. The presence of fibromas was shown to increase the odds of treatment failure, resulting in hysterectomy (OR 2.69, 95% CI 1.15-6.31; P = .02). Furthermore, the incidence of amenorrhea was 59% in the TCRE + LNG-IUCD group and 36% in the TCRE alone group (OR = 2.56, 95% CI 1.46-4.49; P < .01). CONCLUSIONS: The study showed significantly lower odds of hysterectomy in the TCRE + LNG-IUCD group when adjusted for confounders. Combination treatment improves the bleeding patterns significantly compared with monotherapy with TCRE.

Factors associated with receiving surgical treatment for menorrhagia in England and Wales: findings from a cohort study of the National Heavy Menstrual Bleeding Audit.

OBJECTIVE: To examine the factors associated with receiving surgery for heavy menstrual bleeding (HMB) in England and Wales. DESIGN: National cohort study. SETTING: National Health Service hospitals. PARTICIPANTS: Women with HMB aged 18-60 who had a new referral to secondary care. METHODS: Patient-reported data linked to administrative hospital data. Risk ratios (RR) estimated using multivariable Poisson regression. PRIMARY OUTCOME MEASURE: Surgery within 1 year of first outpatient clinic visit. RESULTS: 14 545 women were included. At their first clinic visit, mean age was 42 years, mean symptom severity score was 62 (scale ranging from 0 (least) to 100 (most severe)), 73.9% of women reported having symptoms for >1 year and 30.4% reported no prior treatment in primary care. One year later, 42.6% had received surgery. Of these, 57.8% had endometrial ablation and 37.2% hysterectomy. Women with more severe symptoms were more likely to have received surgery (most vs least severe quintile, 33.1% vs 56.0%; RR 1.6, 95% CI 1.5 to 1.7). Surgery was more likely among those who reported prior primary care treatment compared with those who did not (48.0% vs 31.1%; RR 1.5, 95% CI 1.4 to 1.6). Surgery was less likely among Asian and more likely among black women, compared with white women. Surgery was not associated with socioeconomic deprivation. CONCLUSIONS: Receipt of surgery for HMB depends on symptom severity and prior treatment in primary care. Referral pathways should be locally audited to ensure women with HMB receive care that addresses their individual needs and preferences, especially for those who do not receive treatment in primary care.

A Prospective, Multicenter, Pivotal Trial to Evaluate the Safety and Effectiveness of the AEGEA Vapor Endometrial Ablation System.

STUDY OBJECTIVE: To evaluate the safety and effectiveness of the AEGEA Vapor System (Aegea Medical System, Menlo Park, CA) for the treatment of heavy menstrual bleeding (HMB). DESIGN: A prospective, multicenter, single-arm, open-label, clinical trial. Follow-up assessments were conducted at 24 hours; 2 weeks; and 3, 6, and 12 months after the endometrial ablation procedure (Canadian Task Force Classification II-1). SETTING: A private practice and outpatient and hospital settings at 15 sites in the United States, Canada, Mexico, and the Netherlands. PATIENTS: One hundred fifty-five premenopausal women aged 30 to 50years with HMB as determined by a pictorial blood loss assessment score ≥150. Preoperative evaluation included ultrasound, sonohysterography or hysteroscopy, and endometrial biopsy. Screening inclusion allowed treatment of up to 12-cm uterine sound lengths and nonobstructing myomata. INTERVENTIONS: Endometrial ablation (120-second treatment time) was performed under varying anesthesia regimens using the vapor system from September 2014 to May 2015. MEASUREMENTS AND MAIN RESULTS: The primary effectiveness end point was the reduction of menstrual blood loss to a pictorial blood loss assessment score ≤75. Success was judged based on the Food and Drug Administration's objective performance criteria, derived from the success rates of the first 5 global endometrial ablation pivotal clinical trials. The secondary effectiveness end points included quality of life and patient satisfaction as assessed using the Menorrhagia Impact Questionnaire and the Aberdeen Menorrhagia Severity Score as well as the need for surgical or medical intervention to treat abnormal bleeding at any time within the first 12 months after treatment. All adverse events, including device- and procedure-related events, were recorded. At 12 months, the primary effectiveness end point was achieved in 78.7% of subjects exceeding the OPC (p = .0004); 90.8% of subjects were satisfied or very satisfied with the treatment. Ninety-nine percent of subjects showed improvement in quality of life scores with an average decrease in the Menorrhagia Impact Questionnaire score by 8.1, 72% had less dysmenorrhea, and 85% of women whose sex lives were affected by their menses reported improvement in their sex lives. There were no reported serious adverse device effects or any reported serious adverse events that were procedure related. CONCLUSION: The AEGEA Vapor System is a safe, effective, and minimally invasive option for performing in-office endometrial ablation under minimal anesthesia for the purpose of treating women who suffer from HMB.

Reintervention Rates After Myomectomy, Endometrial Ablation, and Uterine Artery Embolization for Patients with Uterine Fibroids.

BACKGROUND: Women with uterine fibroids (UF) may undergo less invasive procedures than hysterectomy, including myomectomy, endometrial ablation (EA), and uterine artery embolization (UAE); however, long-term need for reintervention is not well characterized. We estimated reintervention rates for 5 years and identified predictors of reintervention. MATERIALS AND METHODS: A longitudinal retrospective cohort study was conducted in women in MarketScan® Commercial Claims and Encounters (Truven Health Analytics) aged 18-49 years with UF diagnosis before myomectomy, EA, or UAE from 2008 to 2014. Patients were categorized by initial procedure (index date) and required to have ≥12 months of continuous coverage before and after. Kaplan-Meier analyses and Cox proportional hazard models were used to estimate survival without reintervention and hazard of reintervention for 5 years. RESULTS: The study included 35,631 women with myomectomy (n = 13,804: 8,018 abdominal, 941 hysteroscopic, and 4,845 laparoscopic), EA (n = 17,198), and UAE (n = 4,629). Myomectomy had the lowest 12-month reintervention rate (4.2%), followed by UAE (7.0%), then EA (12.4%; both p < 0.001 relative of myomectomy). Estimates of 5-year reintervention rates were 19% for myomectomy (17%, 28%, and 20% for abdominal, hysteroscopic, and laparoscopic, respectively), 33% for EA, and 24% for UAE. EA and UAE had adjusted hazard ratios of 2.63 (95% confidence interval [CI], 2.44-2.83) and 1.56 (95% CI, 1.42-1.72). Prior anemia, bleeding, pelvic inflammatory disease, and abdominal and pelvic pain increased the hazard of reintervention. CONCLUSION: Reintervention rate estimates ranged from 17% to 33% for 5 years after myomectomy, EA, and UAE for patients with UF. Risk of requiring reintervention should be considered during treatment selection.

Women with Newly Diagnosed Uterine Fibroids: Treatment Patterns and Cost Comparison for Select Treatment Options.

The primary objective of this study was to describe surgical treatment patterns among women with newly diagnosed uterine fibroids (UF). A secondary objective was to estimate the medical costs associated with other common surgical interventions for UF. Claims-based commercial and Medicare data (2011-2016) were used to identify women aged ≥30 years with continuous enrollment for at least 12 months before and after a new diagnosis of UF. Receipt of a surgical or radiologic procedure (hysterectomy, myomectomy, endometrial ablation, uterine artery embolization, and curettage) was the primary outcome. Health care resource utilization and costs were calculated for women with at least 12 months of continuous enrollment following a UF surgical procedure. Among women who met selection criteria, 31.7% of patients underwent a surgical procedure; 20.9% of these underwent hysterectomy. An increase was observed over time in the percentage of women undergoing outpatient hysterectomy (from 27.0% to 40.2%) and hysteroscopic myomectomy (from 8.0% to 11.5%). The cost analysis revealed that total health care costs for hysteroscopic myomectomy ($17,324) were significantly lower (P < 0.001) than those for women who underwent inpatient hysterectomy ($24,027) and those for women undergoing the 3 comparison procedures. Hysterectomy was the most common surgical intervention. Patients undergoing inpatient hysterectomy had the highest health care costs. Although less expensive, minimally invasive approaches are becoming more common; they are performed infrequently in patients with newly diagnosed UF. The results of this study may be useful in guiding decisions regarding the most appropriate and cost-effective surgical treatment for UF.

Economic Evaluation of Global Endometrial Ablation Versus Inpatient and Outpatient Hysterectomy for Treatment of Abnormal Uterine Bleeding: US Commercial and Medicaid Payer Perspectives.

Every year, abnormal uterine bleeding (AUB) exacts a heavy toll on women's health and leads to high costs for the US health care system. The literature shows that endometrial ablation results in fewer complications, shorter recovery and lower costs than more commonly performed hysterectomy procedures. The objective of this study was to model clinical-economic outcomes, budget impact, and cost-effectiveness of global endometrial ablation (GEA) versus outpatient hysterectomy (OPH) and inpatient hysterectomy (IPH) procedures. A decision tree, state-transition (semi-Markov) economic model was developed to simulate 3 hypothetical cohorts of women who received surgical treatment for AUB (GEA, OPH, and IPH) over 1, 2, and 3 years to evaluate clinical and economic outcomes for GEA vs. OPH and GEA vs. IPH. Two versions of the model were created to reflect both commercial health care payer and US Medicaid perspectives, and analyses were conducted for both payer types. Total health care costs in the first year after GEA were substantially lower compared with those for IPH and OPH. Budget impact analysis results showed that increasing GEA utilization yields total annual cost savings of about $906,000 for a million-member commercial health plan and about $152,000 in cost savings for a typical-sized state Medicaid plan with 1.4 million members. Cost-effectiveness analysis results for both perspectives showed GEA as economically dominant (conferring greater benefit at lower cost) over both OPH and IPH in the 1-year commercial scenario. This study demonstrates that, for some patients, GEA may prove to be a safe, uterus-sparing, cost-effective alternative to OPH and IPH for the surgical treatment of AUB.

Should the Risk of Invasive Cancer in Pregnancy and the Safety of Loop Electrosurgical Excision Procedure During the First 15 Weeks Change Our Practice?

OBJECTIVE: The aim of this article was to describe the outcome of women diagnosed with cervical intraepithelial neoplasia (CIN) grades 2 or 3 in pregnancy either observed or treated by loop electrosurgical excision procedure (LEEP) in the first 15 weeks of gestation. METHODS: Loop electrosurgical excision procedure during the first 15 gestational weeks compared with observation of CIN2/3. This is a retrospective analysis of a nonrandomized study at tertiary, academic, and referring centers in Israel. Ninety-three pregnant women diagnosed with CIN2/3 between 2006 and 2016 were included in this study. Fifty patients with CIN2/3 on cervical biopsy were conservatively followed-up, and 43 patients have undergone LEEP during the first 15 gestational weeks. Main outcome measures were ultimate diagnosis of invasive cancer or CIN, pregnancy outcome, and complications. RESULTS: In 5.4% of CIN2/3 during pregnancy, the final diagnosis was invasive cancer. The postpartum results of 50 women who were conservatively observed were as follows: 3 (6.0%) had cervical cancer and undergone radical hysterectomy, 33 (66.6%) had CIN2/3, and 14 (28%) had CIN1 or normal histology. The diagnoses of the 43 patients who have undergone LEEP were invasive cancer in 2 patients (4.6%) but did not undergo hysterectomy, CIN2/3 or adenocarcinoma in situ (AIS) in 38 patients (88.4%), and 3 women (7%) had CIN1 or normal histology. None of them suffered severe bleeding. Thirty-seven women continued their pregnancy, 34 (91.9%) had term deliveries, 2 (5.4%) gave birth at 34 and 36 weeks, and 1 patient had missed abortion (2.7%). CONCLUSIONS: The LEEP procedure during the first 15 weeks of pregnancy is safe. A total of 5.4% of the women with CIN2/3 during pregnancy were diagnosed with invasive cancer. It is time to reconsider the recommendations about CIN2/3 in early gestation.

Long-term incidence of hysterectomy following endometrial resection or endometrial ablation for heavy menstrual bleeding.

OBJECTIVE: To estimate the incidence of hysterectomy following endometrial resection or endometrial ablation (ERA). METHODS: The present retrospective study enrolled women who underwent ERA for benign heavy menstrual bleeding (HMB) at Aberdeen Royal Infirmary, UK, between February 1, 1990, and December 31, 1997; follow-up data to the end of 2015 were included from the pathology laboratory report system from the single pathology laboratory in the region. Data were compared between patients who did or did not require a hysterectomy after ERA. RESULTS: There were 901 patients who underwent ERA for HMB during the study period. The mean age of patients was 42.3 ± 5.7 years; of the patients included, 206 (22.9%) women underwent hysterectomy and these patients had a mean age of 40.1 years. Of the patients who had hysterectomies, 155 (75.2%) did so in the first 5 years following ERA, 31 (15.0%) did within 6-10 years, 11 (5.3%) did within 11-15 years, and 9 (4.4%) did within 16-20 years. In total, 51 (24.8%) of these patients had hysterectomies within 6-25 years of ERA. CONCLUSIONS: A significant majority of women who underwent ERA for HMB did not require hysterectomy up to 25 years after the procedure.

Simultaneous Integrated Boost Volumetric Modulated Arc Therapy in the Postoperative Treatment of High-Risk to Intermediate-Risk Endometrial Cancer: Results of ADA II Phase 1-2 Trial.

PURPOSE: A prospective phase 1-2 clinical trial aimed at determining the recommended postoperative dose of simultaneous integrated boost volumetric modulated arc therapy (SIB-VMAT) in a large series of patients with high-risk and intermediate-risk endometrial cancer (HIR-EC) is presented. The study also evaluated the association between rate and severity of toxicity and comorbidities and the clinical outcomes. METHODS AND MATERIALS: Two SIB-VMAT dose levels were investigated for boost to the vaginal vault, whereas the pelvic lymph nodes were always treated with 45 Gy. The first cohort received a SIB-VMAT dose of 55 Gy in 25 consecutive 2.2-Gy fractions, and the subsequent cohort received higher doses (60 Gy in 2.4-Gy fractions). RESULTS: Seventy consecutive HIR-EC patients, roughly half of whom were obese (47.1%) or overweight (37.1%), with Charlson Age-Comorbidity Index >2 (48.5%), were enrolled. Thirty-one patients (44.3%) were administered adjuvant chemotherapy before starting radiation therapy. All patients (n=35 per dose level) completed irradiation without any dose-limiting toxicity. Proctitis (any grade) was associated with radiation therapy dose (P=.001); not so enterocolitis. Grade ≥2 gastrointestinal (GI) and genitourinary (GU) toxicity were recorded in 17 (24.3%) and 14 patients (20.0%), respectively, and were not associated with radiation dose. As for late toxicity, none of patients experienced late grade ≥3 GI or grade ≥2 GU toxicity. The 3-year late grade ≥2 GI and GU toxicity-free survival were 92.8% and 100%, respectively, with no difference between the 2 dose levels. With a median follow-up period of 25 months (range, 4-60 months), relapse/progression of disease was observed in 10 of 70 patients (14.2%). The 3-year cumulative incidence of recurrence was 1.5% (95% confidence interval (CI): 0.2-10.7), whereas the 3-year disease-free survival was 81.3% (95% CI: 65.0-90.0). CONCLUSIONS: This clinical study showed the feasibility of this technique and its good profile in terms of acute and late toxicity at the recommended doses even in aged and frail patients.

In vitro fertilization outcomes after ablation of endometriomas using plasma energy: A retrospective case-control study.

OBJECTIVE: Ovarian endometrioma ablation using plasma energy appears to be a valuable alternative to cystectomy, because it could spare underlying ovarian parenchyma resulting in high spontaneous and overall pregnancy rates. After initial postoperative decrease, anti-mullerian hormone (AMH) level progressively increases several months after ablation. The aim of our study was to assess the outcomes of in vitro fertilization (IVF) in women managed for ovarian endometriomas by ablation using plasma energy, when compared to those in women free of endometriosis. METHODS: Retrospective preliminary case-control study, enrolling women undergoing IVF or IntraCytoplasmic Sperm Injection (ICSI), from July 2009 to December 2014. Cases were infertile women with previous ovarian endometrioma ablation using plasma energy and were matched by age, AMH level and assisted reproductive technique with controls presumed free of endometriosis. IVF/ICSI response (type of protocol, dose of gonadotrophin, number of oocytes, fertilization rate) and outcomes were compared between the two groups. RESULTS: In all, 37 cases were compared to 74 controls. Age (30.9±4.4 years vs. 31.7±4.2 years), AMH level (2.8±2ng/mL vs. 2.8±1.7ng/mL) and ART procedures (ICSI in 24.3% vs. 27%) were comparable between the two groups. Of the 37 cases, previous surgical procedures on right and left ovaries were performed in 27% and 21.6% of patients respectively, 81% of patients were nullipara. AFSr score was 73±41, while deep endometriosis infiltrated the rectum and the sigmoid colon in respectively 40.5% and 27% of patients. Despite a lower number of oocytes retrieved, cases presented better implantation rate, pregnancy and delivery rates per cycle, oocyte retrieval, transfer, and embryo, as well as superior cumulative birth rate per transfer. CONCLUSION: Ovarian endometrioma ablation using plasma energy is followed by good IVF/ICSI outcomes, suggesting that surgical procedure spares underlying ovarian parenchyma. These results consolidate those of previous studies reporting high spontaneous conception rate. Hence, ovarian endometrioma ablation using plasma energy appears to be a valuable alternative to cystectomy in patients presenting with endometriosis and pregnancy intention.

Ambulatory management of heavy menstrual bleeding.

Heavy menstrual bleeding (HMB) has significant adverse effects on the quality of life of many women, placing an economic burden on both health services and society at large. Thus, it is essential that all women with HMB have easy access to the proper diagnostic and therapeutic work-up in an outpatient fashion, avoiding the more time-consuming inpatient management. This new outpatient approach for HMB is one of the latest development of gynecological practice and can offer both diagnostic and therapeutic procedures. This manuscript aims to show the current possibilities of the modern management of HMB, which can be safely and effectively accomplished in the outpatient setting: global and directed endometrial biopsy, levonorgestrel intrauterine system insertion as well as minimally invasive surgical procedures (encompassing a variety of operative hysteroscopic procedures and second-generation endometrial ablation) are described below.

The incidence of hysterectomy, uterus-preserving procedures and recurrent treatment in the management of uterine fibroids.

OBJECTIVE: To determine the incidence of hysterectomy and uterus-preserving procedures (UPPs) among women with uterine fibroids (UFs) and the incidence of further procedures after a UPP. STUDY DESIGN: This was an observational study using a primary care database, The Health Improvement Network (THIN). Women in THIN with UFs aged 15-54 years between January 2000 and December 2009 were eligible for study. The UPPs examined were myomectomy, endometrial ablation (EA) and uterine artery embolization (UAE). Using Read codes, women were followed up until one of the following was met: there was a record of hysterectomy or UPPs, they died or the study ended (end of 2010). RESULTS: The cumulative incidence of hysterectomy or UPPs was 23.6% at 1 year, and 40.9% after the follow-up period (median 3.6 years). At the end of the follow-up period, the cumulative incidences of hysterectomy, myomectomy, EA and UAE were 33.0%, 3.9%, 6.4% and 1.9%, respectively. For women initially treated with a UPP, the cumulative incidence of second procedures was 11.5% at 1 year. At the end of the follow-up period (median 2.7 years), the cumulative incidence of further procedures was 26.1%, and the cumulative incidences of women undergoing hysterectomy, myomectomy, EA and UAE were 19.0%, 4.3%, 3.4% and 1.4%, respectively. CONCLUSIONS: Women considering UPPs for the management of UFs should be made aware that the incidence of further treatments is high, with hysterectomy being the most frequent procedure undergone.

Microwave endometrial ablation after endometrial curettage for the management of heavy menstrual bleeding.

OBJECTIVES: The aim of the present study was to evaluate the eticacy of microwave endometrial ablation after endometrial curettage, in selected patients with heavy menstrual bleeding. MATERIAL AND METHODS: Thirty-two premenopausal women with heavy menstrual bleeding underwent microwave endometrial ablation at the Department of Obstetrics and Gynecology of the University of Patras Medical School. All patients did not respond to previous medical treatment, had completed their childbearing, and did not desire future fertility. The authors chose endometrial curettage rather than hormonal pretreatment (GnRH analogs, danazol) for endometrial preparation. Posttreatment follow up protocol included physical and ultrasonographic evaluation at three, six, nine, and 12 months for the first year and yearly after. RESULTS: The authors had no cases of uterine perforation, thermal injury to adjacent organs, and infection or sepsis. During follow up, there was a gradual decrease in amenorrhea rate (90.6% - 68.8%) and in satisfaction rate (90.6% - 71.9%). Moreover during follow up, eight women underwent to total abdominal hysterectomy. Among them, seven women had uterine myomas and one woman had adenomyosis. CONCLUSIONS: Endometrial preparation with endometrial curettage seems to be a good alternative to hormonal pretreatment. It has the advantage of avoiding delays, side effects, and cost of hormonal pretreatment. Moreover, microwave endometrial ablation after endometrial curettage is successful and highly acceptable.

[Analysis from the French DRG-based information system (PMSI) of conservative surgical treatment for abnormal uterine bleeding in 2008-2010]. / Analyse des traitements chirurgicaux conservateurs des pathologies de l'endomètre en France de 2008 à 2010 dans les établissements de santé. Analyse des données du programme médicalisé des systèmes d'information (PMSI).

OBJECTIVE: To evaluate the conservative surgical treatment for abnormal uterine bleeding from the Medicalized Information System Program (PMSI). MATERIALS AND METHODS: The diagnosis codes were selected from 10th version of the international classification disease. A transversal and longitudinal descriptive analysis was performed from hospital stays, patient's characteristics, medical procedures between 2008-2010. RESULTS: Nineteen thousand six hundred and seventy-nine patients were admitted in hospital (public or private) for treatment of abnormal uterine bleeding. Endometrial ablation increased by 16,7%, 10.2% for first generation technique (G1) and 63.5% for second generation techniques (G2). G2 were used in 15% of indications. The median age was respectively 45.2±6.4 years old versus 45.8±4.9 years old for G2. The median length of hospital stay was 1.6 ±1with 69% of patients in ambulatory care. The likelihood to have a hysterectomy in the 3 years follow-up was higher after G1 than G2 treatments (P=0.0034) for the patients above 40 years old. In longitudinal study, defined only by endometrial hyperplasia, 11,532 patients were included and only 8.2% had been treated by G2. CONCLUSION: In spite of the international guidelines since 2008, 85% of patients treated with first generation surgical technique. The failure rate defined by a re-ablation or a hysterectomy is higher after G1. This result must be discussed in relationship with cost effective aspects.

Rates of subsequent surgery following endometrial ablation among English women with menorrhagia: population-based cohort study.

OBJECTIVE: To assess the risk of further surgery amongst women who had an initial endometrial ablation (EA) for the treatment of heavy menstrual bleeding (HMB). DESIGN: A retrospective cohort study using a national administrative database. SETTING: Population-based study of hospital care in the English National Health Service. POPULATION: A cohort of 114,910 women who had EA for HMB between January 2000 and December 2011. METHODS: Multiple Cox regressions were performed to identify the risks of a further procedure, adjusted for age, social deprivation, year and type of initial EA, and presence of fibroids/polyps. MAIN OUTCOME MEASURES: Time to repeat EA or hysterectomy after initial surgery. RESULTS: Of 114,910 women undergoing EA, 16.7% had at least one subsequent procedure within 5 years. Higher rates of subsequent surgery were associated with younger age at initial EA, with women aged under 35 years having an adjusted hazard ratio of 2.83 (95% CI 2.67-2.99), compared with women aged over 45 years. Women who had radiofrequency ablation were less likely to have subsequent surgery as compared with first-generation techniques (HR 0.69, 95% CI 0.63-0.76). The rate of a subsequent hysterectomy within 5 years was 13.5%. Younger women (OR 0.59, 95% CI 0.51-0.69) and those who had balloon, microwave, or radiofrequency ablation were less likely to have a second EA procedure, rather than a hysterectomy. CONCLUSIONS: One in six women have further surgery after EA for HMB, which is a higher rate than reported in clinical trials. This risk of further surgery decreases with age.