Endometrial Ablation: Past, Present, and Future Part II.

Endometrial ablation (EA) is the most commonly performed surgical procedure for the management of abnormal uterine bleeding unresponsive to medical therapy. In well-selected subjects, EA provides a safe, inexpensive, and convenient alternative to hysterectomy with a rapid return to normal function. The first generation of EA techniques were introduced in 1886 by Professor Sneguireff of Moscow. He was the first to apply super-heated steam to the uterine cavity to vaporize the endometrial basalis. This method-known as atmocausis-was refined by Ludwig Pincus of Danzig in 1895, and he went on to perform over 800 procedures. As the 20th century brought forth other energy sources-electricity, X-ray, radium, and even cryogenics-they were each used, in turn, to accomplish endometrial ablation. In 1981, Dr. Milton Goldrath successfully performed EA by co-locating a neodymium-doped yttrium aluminum garnet (Nd:YAG) laser with a rod-lens hysteroscope to achieve photovaporization of the endometrium. The accomplishment of EA under direct visualization defined the second generation of EA. The challenges and risks of second-generation technology, however, was soon apparent, and though this practice continues today, it appears to be confined to a relatively small number of devoted and highly-skilled sub-specialists. The late 1990s saw increasing interest in safe, affordable, and easily-mastered EA technology. The result was a return to blind technology but modified with a variety of features that brought unprecedented safety to EA, even permitting its selected in-office application. This third generation of EA techniques and devices has propelled the growth of EA in the 21st century. Although much has been accomplished in the quest for safe, affordable, convenient, and easily-mastered EA, the future requires refinement of patient selection criteria, management strategies for late-onset endometrial ablation failures (LOEAFs), as well as minimally invasive methods for reducing them.