Although endometrial ablation now is viewed as a viable alternative to hysterectomy in women with medically intractable dysfunctional bleeding, complete removal of endometrial tissue is not assured. There are case reports of endometrial cancer diagnosed following theoretically complete endometrial ablation.
The investigators reviewed the charts of 3,769 patients, seen at a single center, who had hysteroscopic endometrial resection as treatment for abnormal uterine bleeding in the years 1994–2005. Four of these women, 1.06 per 1000, developed endometrial cancer after complete endometrial ablation. All of them had histologic evidence of endometrial polyps at the time of endometrial resection. In addition, all 4 women had risk factors for endometrial cancer such as obesity or arterial hypertension. Endometrial cancer was diagnosed in 852 patients seen during the same period.
This experience, along with literature reports, shows that in rare cases endometrial cancer may develop after endometrial ablation by resection. The interval may be considerable. In cases of high-stage cancer, patients may present with recurrent bleeding. Cancer cannot be ruled out even when resection appears to be complete because some endometrial pockets are invariably left in place in the uterine cavity. Scarring and synechiae may mask physiological or pathological bleeding. The risk is increased by hypertension, obesity, or concurrent hormone replacement therapy. The investigators recommend annual ultrasonographic assessment when one or more of these risk factors are present. If the sonographic findings are suspicious, hysteroscopy is indicated. If intrauterine adhesions make hysteroscopy difficult to perform, hysterectomy may be advisable.