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    The MIGS approach to fixing failed endometrial ablation


    Preoperative evaluation


    Often the diagnosis of EA failure is straightforward: a history of gradually increasing vaginal bleeding, worsening cyclic pelvic pain, or both. The pain—typically lasting 3–4 days—may be unilateral, bilateral, or suprapubic, and is often described as “sharp,” “stabbing,” “cramping,” or “labor-like.” Diagnostic delay is often considerable when these symptoms are not accompanied by vaginal bleeding.

    Physical examination

    The pelvic examination—best performed while the patient is symptomatic—often reveals exquisite uterine tenderness, sometimes accompanied by adnexal tenderness. Adnexal tenderness is far more common than is PATSS, which often signifies cornual hematometra.

    Sonographically assisted pelvic examination

    Sonographically assisted pelvic examination allows a physician to correlate U/S findings with physical signs. The timing of this exam is critical, because hematometra are often evanescent and may disappear during the early proliferative phase of the cycle. The presence of a central or cornual hematometra (Figure 1) is an important finding and is strongly associated with cyclic pelvic pain. However, the absence of a demonstrable hematometra does not exclude the diagnosis of EA failure. U/S also may be useful for diagnosis of PATSS. Other assessments—endometrial biopsy, saline infusion sonography, hysterosalpingography, and magnetic resonance imaging—have been shown to have little merit in the evaluation of women who present with delayed-onset EA complications.

    Patient selection

    A physician who suspects an EA failure must consider several factors before offering the patient RHS. Although evidence-based guidelines are lacking, I believe that several patient selection criteria may be helpful (Table).



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