In which cases should endometrial destruction be performed during an operative hysteroscopy? Clinical practice guidelines from the French College of Gynaecologists and Obstetricians (CNGOF) - 21/06/21

Doi : 10.1016/j.jogoh.2021.102188

L. DION ^a,^⁎ , A. AGOSTINI ^b, F. GOLFIER ^c, G. LEGENDRE ^d, C. TOUBOUL ^e, M. KOSKAS ^f
^a Department of Gynaecology, Rennes University Hospital, 16 Bd de Bulgarie, 35000 Rennes, France
^b APHM, Department of Obstetrics and Gynaecology, 147 Bd Baille, 13005, Marseille, France
^c CHU Lyon, Department of Obstetrics and Gynaecology, 69000, Lyon, France
^d CHU Angers, Department of Obstetrics and Gynaecology, 49000, Angers, France
^e APHP.6 Sorbonne Université, Tenon Hospital, Department of Obstetrics and Gynaecology, 4 rue de la Chine, 75020, Paris, France
^f APHP, Hôpital Bichat - Claude-Bernard, Department of Obstetrics and Gynaecology, 46 rue Henri-Huchard, 75018, Paris, France

^⁎Corresponding author: Department of Gynaecology, Rennes University Hospital, 16 Bd de Bulgarie, 35000 Rennes, FranceDepartment of GynaecologyRennes University Hospital16 Bd de BulgarieRennes35000France

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Abstract

Objective

To provide guidelines from the French College of Obstetricians and Gynaecologists (CNGOF), based on the best evidence available, concerning the impact of endometrial destruction on bleeding and endometrial cancer risk reduction in patients candidates for operative hysteroscopy.

Methods

Recommendations were made according to AGREE II and the GRADE® (Grading of Recommendations Assessment, Development and Evaluation) systems to determine separately the quality of evidence (QE) and in the level of recommendation.

Results

In a retrospective study comparing the incidence of endometrial cancer in 4 776 patients with menorrhagia treated with endometrial destruction vs 229 945 patients with a medical treatment. There was a non-significant reduced risk of developing endometrial cancer (HR, 0.45; 95% CI, 0.15-1.40; p = .17). In premenopausal women, five studies compared the incidence of endometrial cancer in patients treated with endometrial ablation/destruction (EA/D) to the incidence of endometrial cancer in a comparable population of women from national registers, all of which show reduced risk of endometrial cancer after endometrectomy. In case of menopausal metrorrhagia, the prevalence of endometrial cancer is 9%, by analogy with the results found in premenopausal patients, the combination of endometrial ablation during operative hysteroscopy seems justified. In a retrospective cohort of 177 non-menopausal patients treated with myomectomy for metrorrhagia and/or menorrhagia, a significantly better control of bleeding at 12 months was found when myomectomy was combined with endometrectomy using roller-ball (OR: 0.18 [95% Cl 0.05–0.63]; p = 0.003).

Conclusion

In premenopausal women with heavy menstrual bleeding, when an operative hysteroscopy is performed, it is recommended to propose an endometrial ablation/destruction in order to prevent the risk of endometrial cancer, (QE3) and to prevent recurrence of bleeding (QE2). In menopausal women, it is probably recommended to also perform an endometrial ablation/destruction in case of operative hysteroscopy in order to prevent the risk of endometrial cancer (QE1).

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