BlueCross BlueShield of Tennessee Medical Policy Manual

Endometrial Ablation

DESCRIPTION

Menorrhagia is defined as menstrual periods with abnormally heavy or prolonged bleeding.  Metrorrhagia is defined as uterine bleeding at irregular intervals, particularly between the expected menstrual periods.  Menometrorrhagia is prolonged or excessive uterine bleeding occurring irregularly and more frequently than normal; thus a combination of metrorrhagia and menorrhagia.  Ablation or destruction of the endometrium is used to treat these conditions in women who fail standard therapy (e.g., hormone therapy and/or dilatation and curettage). It is considered a less invasive alternative than hysterectomy; however, as with hysterectomy, the procedure is not recommended for women who wish to preserve fertility.

Techniques for endometrial ablation are generally divided into two categories: those that do and do not require hysteroscopic procedures.  Other terminology for these categories of techniques include first-generation versus second-generation procedures and resectoscopic versus non-resectoscopic.

The following techniques require hysteroscopic guidance: Nd-YAG laser; electrosurgical ablation using an electrical rollerball or electrical wire loop; hydrothermal ablation; and microwave ablation.

The following techniques do not require hysteroscopic guidance: Thermal fluid-filled balloon; cryosurgical; instillation of heated saline; and radiofrequency ablation.

POLICY

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

The following are brief descriptions of examples of second-generation endometrial ablation procedures:

Balloon Endometrial Ablation: (e.g., ThermaChoice) involves the use of a balloon at the tip of a catheter tube that is filled with fluid and inflated until it conforms to the walls of the uterus. A probe in the balloon heats the fluid to destroy the endometrial lining. After eight minutes the fluid is drained out and the balloon is removed. Hysteroscopic guidance is not required for this procedure.

Electric Wand Ablation:(e.g., NovaSure System) involves inserting a slender wand up through the cervix. A triangular mesh-like device is the passed through the wand and expands to fit the uterus. Electrical energy is passed through it for about 90 seconds and the mesh and wand are then withdrawn. Hysteroscopic guidance is not required for this procedure.

Cryoablation: (e.g., Her Option uterine cryoablation therapy system) involves placing a liquid nitrogen probe into the uterus to destroy tissue by freezing. Ultrasound is used to guide the procedure.

Hot Saline: (e.g., the Hydro-Therm-Ablator [HTA] system). This method involves the use of hot saline to destroy the uterine lining. This device is a closed loop system designed to ablate the endometrial lining of the uterus by recirculating heated saline within the uterus. This is not a "blind" procedure but uses hysteroscopy so that the surgeon can view the uterus.

Laser Ablation:Endometrial laser ablation (ELA) uses a distention media delivered into the uterus. After the uterus has been distended, a laser is used to destroy the lining of the uterus. This is not a blind procedure, but uses hysteroscopy so that the surgeon can view the uterus.

Smoking is not considered a contraindication to hormone therapy.

SOURCES 

American College of Obstetricians and Gynecologists (ACOG). (2013). Endometrial ablation. Frequently asked questions. Retrieved December 19, 2016 from https://www.acog.org/-/media/For-Patients/faq134.pdf?dmc=1&ts=20161220T1533207941.

American College of Obstetricians and Gynecologists (ACOG). (May, 2007; reaffirmed 2012). Endometrial ablation. Retrieved May 15, 2015 from the National Guideline Clearinghouse (NGC: 10918).

Angioni, S., Pontis, A., Nappi, L., Sedda, F., Sorrentino, F., Litta, P., et al. (2016). Endometrial ablation: first – vs. second-generation techniques. Minerva Ginecologica, 68 (2), 143-153. Abstract retrieved December 20, 2016 from PubMed database.

BlueCross BlueShield Association. Medical Policy Reference Manual. (8:2016). Endometrial ablation (4.01.04). Retrieved December 13, 2016 from BlueWeb. (18 articles and/or guidelines reviewed)

BlueCross BlueShield of Tennessee network physicians. July 2008.

Daniels, J., Middleton, L., Champaneria, R., Khan, K., Cooper, K., Mol, B., et al. (2012). Second generation endometrial ablation techniques for heavy menstrual bleeding: network meta-analysis. BMJ, 2012 Apr 23;344:e2564. Abstract retrieved December 20, 2016 from PubMed database.

Laberge, P., Leyland, N., Murji, A., Fortin, C., Martyn, P., Vilos, G., et al. (2015). Endometrial ablation in the management of abnormal uterine bleeding. Journal of Obstetrics and Gynaecology Canada, 37 (4), 362-379. Abstract retrieved December 20, 2016 from PubMed database.

National Institute for Health and Clinical Excellence. (April 2004; last updated March 2014). Fluid-filled thermal balloon and microwave endometrial ablation techniques for heavy menstrual bleeding. Retrieved December 16, 2016 from www.nice.org.uk/guidance/ta78.

National Institute for Health and Clinical Excellence. NICE Pathways. (July, 2015). Treatment options for heavy menstrual bleeding. Retrieved December 17, 2015 from http://pathways.nice.org.uk/pathways/heavy-menstrual-bleeding.

U. S. Food and Drug Administration. (2001, April). Center for Devices and Radiological Health. New Device Approvals: HerOption™ Uterine Cryoablation Therapy™ System - P000032. Retrieved July 20, 2010 from http://www.accessdata.fda.gov/cdrh_docs/pdf/p000032a.pdf.

U. S. Food and Drug Administration. (2001, April). Center for Devices and Radiological Health. New Device Approvals: Hydro ThermAblator® Endometrial Ablation System - P000040. Retrieved July 20, 2010 from http://www.accessdata.fda.gov/cdrh_docs/pdf/p000040a.pdf.

U. S. Food and Drug Administration. (2001, September). Center for Devices and Radiological Health. New Device Approvals: Microsulis Microwave Endometrial Ablation (MEA) System - P020031. Retrieved July 20, 2010 from http://www.accessdata.fda.gov/cdrh_docs/pdf2/P020031a.pdf.

U. S. Food and Drug Administration. (2003, September). Center for Devices and Radiological Health. New Device Approvals: NovaSure™ Impedance Controlled Endometrial Ablation System - P010013. Retrieved July 20, 2010 from http://www.accessdata.fda.gov/cdrh_docs/pdf/P010013a.pdf.

ORIGINAL EFFECTIVE DATE:  3/1985

MOST RECENT REVIEW DATE:  6/21/2017

ID_BT

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