Endometrial ablation for fibroids under study. (Off-Label Treatment).

SCOTTSDALE, ARIZ.--You can heat it, poach it, zap it, freeze it, or microwave it. There are more ways than ever to globally ablate the endometrium.

Introduced in the 1990s as alternatives to hysterectomy for women with dysfunctional uterine bleeding, global endometrial ablation technologies are indicated for the treatment of menorrhagia due to benign causes in premenopausal women who do not wish to become pregnant.

Off-label use of the technologies to treat postmenopausal women or patients with submucous fibroids generated controversy during a lively panel discussion at an international congress on uterine fibroids Sponsored by the American Association of Gynecologic Laparoscopists. Global ablation has been studied mainly in premenopausal women with no fibroids or fibroids that are 2 cm or less. Fibroids appear predominantly in premenopausal women.

Panelists noted that one of the greatest fears they had concerning use of global ablation techniques for fibroids was that a lesion that's missed or left in place might turn out to be a sarcoma rather than a fibroid. One physician in the audience described two recent cases of uterine lesions that appeared benign on ultrasound but on hysteroscopy were found to be leiomyosarcomas, one of which was lethal.

"When in doubt, take it out," or at the very least take a generous sample for pathology analysis before performing global ablation, said Dr. George A. Vios, professor of ob.gyn. at the University of Western Ontario, London. He performed 2,650 hysteroscopic endometrial ablations from 1990 through 2002; approximately 300 of these procedures were done in women with fibroids. In two cases, the suspected fibroids turned out to be sarcomas. "That's about 1%" of suspected fibroids, he noted.

Among all women, nearly 1% had some kind of uterine malignancy including the two sarcomas, 13 endometrioid adenocarcinomas, one atypical polypoid adenomyoma, and one cervical adenocarcinoma.

Six reports in the medical literature describe a total of eight uterine sarcomas detected after endometrial ablation that were missed on preoperative evaluations with ultrasound and endometrial biopsy. To avoid missing sarcomas, use hysteroscopy for evaluation and biopsy suspicious lesions before ablation, he urged.