What is an endometrial ablation?
Endometrial ablation is a surgical procedure that describes destruction of the endometrium. It is performed under anaesthetic in hospital, usually as a same-day procedure. The endometrium is the inside or lining layer of the uterus that is the part that sheds each month and causes menstruation (periods). This layer consists of 2 parts:
- A deep part (called the basalis)
- A superficial part (called the superficialis)
The deep part is always present and thickening of cells from this part each month causes the superficial layer to grow. In a usual cycle where pregnancy does not occur and without any hormone treatments (such as the oral contraceptive pill) the superficial part is shed and menstruation (periods) occur. The deep part is not shed and allows the process to be repeated in the following month.
Sometimes, there may be excessive bleeding at the time of menstruation (causing clots, flooding and sometimes pain with periods). Your Alana doctor will take a history, perform a physical examination and perform or arrange tests, such as an ultrasound, to find the cause for the heavy bleeding. Sometimes the cause may be a fibroid or a polyp. If one of these is present, then it is recommended to have this removed surgically. This may be performed in conjunction with an endometrial ablation, depending on your wishes. You should discuss this with your Alana doctor. In more than half of the cases where there is heavy bleeding, no cause is found and the diagnosis of abnormal uterine bleeding – endometrium (AUB -E) is made.
AUB – E is a common condition that causes heavy periods, particularly for women in their 30’s and 40’s, though it can occur at any time before or after this. One of the treatments available for AUB – E is endometrial ablation. Usually AUB is not a dangerous condition, though it may cause anaemia (low iron levels) and this may cause problems related to tiredness and fatigue. It is rarely life threatening.
What happens in an endometrial ablation?
If, after consultation with your doctor at Alana Healthcare, you decide to have an endometrial ablation, this may be performed in one of several ways. What follows are descriptions of the different methods for performing endometrial ablation. You should be aware that there are many different methods, but in scientific studies no method has been shown to be the best. This includes both the outcomes and complications associated with these different methods. The method for endometrial ablation chosen will depend on your presenting symptoms, past history (such as a history of classical caesarean delivery) and other associated medical problems (such as bleeding disorders).
NovaSure® Endometrial Ablation: This is one of the most commonly performed types of endometrial ablations in the world. During this procedure a special device is placed into the uterine cavity in a closed position and then opened out, a bit like a small and flattened umbrella. The surface of the device is wire mesh and this is attached to a generator that has a suction device in it. The lining of the uterus is sucked onto the wire mesh and an electric current is passed through the mesh. This destroys the entire endometrium (see video below, courtesy of Hologic). This is a very fast procedure (about 90 seconds) and is performed as a same-day procedure in a hospital. Following the procedure, you will have a bloody-watery vaginal discharge for 7 days up to 4 weeks (the discharge is caused by a burn inside the uterus that needs to heal). Usually you will have crampy pain like a period for 24-72 hours and you should take regular paracetamol and anti-inflammatory medications that will be prescribed. If you have increasing pain, foul or offensive discharge or fevers, you should contact your Alana doctor immediately.
Endometrial Resection: During this procedure, you will be anaesthetised (usually with a general anaesthetic) and your legs will be placed in stirrups. The cervix is identified and gently opened with graduated dilators to about 1 cm. A telescope called an operating hysteroscope is then introduced through the cervix and into the uterine cavity. Fluid is used to open up the uterine space and allow visualisation of the walls, the top (fundus) of the uterus and the areas that lead to the fallopian tubes. The first part of the procedure is to ensure that there is no abnormality in the uterine cavity. There are channels within the operating hysteroscope that allow fluid to flow into and be sucked out of the cavity, allow light into the cavity and special attachments to perform the surgery.
The attachment that allows the endometrial ablation to proceed is a wire loop connected to an electrical current that cuts through the lining of the uterus. This loop is about 4 mm across and is used to cut strips from the endometrium until it has all been removed. During the procedure it is most important to remove both the superficial and the deep parts of the endometrium to prevent regeneration of the endometrium occurring. Once the endometrium has been completely removed and the cavity is checked for any bleeding points the procedure is finished. The hysteroscope is removed from the uterus and you will be woken from the anaesthetic and taken to the recovery room.
An advantage of this technique is that it can be performed at any time of the month, without specific preparation, since the lining layer is removed and the underlying muscle layer is easily identified. A disadvantage is that it requires the tissue to be cut which may cause bleeding from the blood vessels in the muscle layer.
Endometrial Rollerball Ablation: In this method, the same procedures as for an endometrial resection are performed, however instead of cutting through the endometrium, a special ball replaces the wire loop and an electrical current is passed through the endometrial lining to destroy it. The same effect can be achieved by this technique.
An advantage of this technique is that it does not require any cutting at all and therefore women who have conditions that affect their blood or are on blood thinning medication may benefit. It may be necessary to time the procedure to just after a menstrual cycle or have medication that will keep the endometrum thin if this is the procedure chosen. You should discuss these needs with your Alana doctor.
Combined Resection and Rollerball Ablation: In this method, the endometrium is removed with the wire loop, followed by passing an electrical current into the remaining tissue with the ball electrode. Whilst this technique does not appear to offer any advantages in terms of efficacy, it does seal the blood vessels that are cut by the wire loop.
What are the outcomes following Endometrial Ablation?
The aim of any of the endometrial ablation procedures is to reduce menstrual blood flow (reduce periods). If you want to ensure that there is no menstrual bleeding following treatment, then you should not choose an endometrial ablation and should discuss hysterectomy with your Alana doctor as this is the only procedure that will guarantee no bleeding following the procedure.
Following an endometrial ablation there are four possible outcomes:
- No periods at all (called amenorrhea)
- Very light periods/spotting
- Reduced bleeding to what is acceptable
- No change in menstrual bleeding.
Overall, there is a 40% chance that you will have no bleeding at all following your endometrial ablation. This is called amenorrhea. If this occurs, then it will generally be a permanent outcome. Occasionally your periods may recur after months or even years of no bleeding or light spotting. If this occurs, then you should consult your Alana doctor, as there may be a new problem (such as the development of a fibroid, polyp or overgrowth of the uterine lining).
Your periods are likely to be reduced to spotting or very light bleeding in a further 40% of cases. Although the pattern tends to be similar from month to month, an occasional heavy bleed may occur. This can be normal and you may be advised to observe the subsequent periods for a few months to see if this is a recurring pattern.
In about 10% of cases, the bleeding is reduced to what may be considered ‘normal’ menstrual bleeding. This will prevent anaemia (low iron levels from excessive bleeding) from occurring and is a good outcome from the procedure.
The procedure is not successful in about 10% of cases. We do not understand all of the reasons for why the treatment does not work, since there may be a marked reduction in the amount of endometrium left, but the heavy bleeding remains as a symptom. If this occurs, then you should consult your Alana doctor who will advise you of the alternatives for treatment.
What are the complications of Endometrial Ablation?
There are 2 groups of complications relating to endometrial ablation:
- Intra-operative complications (complications that occur during surgery)
- Post-operative complications (complications that occur after surgery)
Intra-operative complications: operative complications are rare events, and occur about 1/2500 cases. There has not been a serious complication occur during an endometrial ablation procedure performed by or under the supervision of Associate Professor Jason Abbott.
Complications such as perforation of the uterus may occur. This means that a hole is made in the uterus. If this occurs when there is no electrical current running (e.g. there is no cutting taking place) then it is unlikely that any damage will occur and no treatment or simple observation may be suggested. If there is a possibility of damage to another organ, then further surgery such as a laparoscopy may be performed. If there is likely to be damage to another organ (very rarely) then further surgery is likely to be undertaken either immediately or in the first few days following surgery. Other organs that may be damaged include the bowel, the bladder or very rarely a large blood vessel. Usually a large incision in the abdomen (a laparotomy) will be required. Other complications that may occur include heavy bleeding that may require an overnight admission, medications, or very rarely a blood transfusion.
For some types of endometrial ablation fluid is used to allow vision of the uterine cavity. This fluid may be absorbed into the blood stream through blood vessels that are opened during the removal of the endometrium. A unique complication of endometrial ablation using fluid is that excessive absorption of this fluid may lead to an imbalance in the blood salt levels, which may cause other complications such as fluid on the lung or rarely on the brain. Your Alana doctor continuously monitors the fluid that is lost into your bloodstream using specialised equipment and will stop the procedure before salt changes are likely to be dangerous. If there is any concern, your Alana doctor may recommend a period of observation or an overnight admission with monitoring of blood salts, a catheter in the bladder and occasionally medications to get rid of excessive water. If there is excessive fluid absorption it is possible that you may require a second procedure to complete the surgery, though your safety is the main priority. The chance of requiring a second procedure when there are no fibroids is very small. If the NovaSure® technique is used, then this complication cannot occur.
Post-operative complications: Following surgery, it is normal to have vaginal bleeding for a few days to a week. Occasionally the bleeding or discharge may last for a few weeks as healing takes place. If there is an increasing amount of bleeding, bright blood loss, foul-smelling vaginal discharge or increasing pain then you should contact your Alana doctor . Infections of the uterine lining can occur and may require antibiotics. It is best to consult your doctor if you think that you have an infection following this procedure.
In the healing phase, it can take up to 6 months for your periods to settle. This is because the scarring that takes the place of the endometrium must form and stabilise. Should you have a heavy period following your endometrial ablation, then this may be completely normal. It is the pattern over a period of time that will determine your final result. Very occasionally there can be an increase in the amount of pain that you may have that occurs either with vaginal bleeding (like period pain) or without bleeding. You should let your Alana doctor know if this occurs. There are three possibilities for this pain:
- It has occurred for no obvious reason (i.e. no cause can be found)
- There can be a collection inside the uterus (like a bruise in the uterus) called a haematometra
- There may be a collection in the tubes at the time of menstruation
If you have developed pain since the surgery, then your doctor will ask you questions, perform an examination and may do some tests such as an ultrasound to find a cause. Treatment will depend on the cause, but may include taking pain medications, a simple procedure such as opening up the entrance to the uterus to let the blood out, or occasionally a hysterectomy. The chance of you avoiding hysterectomy following an endometrial ablation in the long-term and for any reason is more than 80%.
Endometrial Ablation and Fertility
Endometrial ablation is only suitable for women who have completed their family. You should not have an endometrial ablation if there is a chance that you may wish to have more children.
The procedure itself is not contraceptive, and permanent contraception at the same time as an ablation is recommended. This includes both male and female sterilisation. You should discuss your contraceptive choices with your Alana doctor. The reason that permanent contraception is recommended is that it is still possible that you could become pregnant following the procedure and this can be dangerous for both you and the baby. There is a high chance of miscarriage or ectopic pregnancy and if the pregnancy does continue, then the baby may be small due to poor blood flow and there can be serious problems associated with the placenta (afterbirth). This may be extremely dangerous. It is for these reasons that a reliable method of contraception is recommended.
Alternatives to Endometrial Ablation
If your heavy menstrual bleeding is diagnosed as abnormal uterine bleeding – endometrium (AUB – E), then there are five different treatment options for you to consider:
- Conservative treatment (no treatment).
- Medical treatment (using medications such as hormones or other tablets).
- A hormone-releasing intrauterine system (IUD)
- Endometrial Ablation
- Hysterectomy, or removal of the uterus
Many women ask what is the best treatment. We have developed a simple analogy that may help you to decide on the best treatment – the Ladder of AUB –E (see picture below). In this analogy, the options listed are like climbing the steps of a ladder. The higher up the ladder that you go, the more successful the treatment is (i.e. the more likely there is to be less bleeding or no bleeding at all), but more intervention is required. Satisfaction rates with the procedure also increase as you go up the ladder. This means that the most successful treatment is hysterectomy, though this is also the most invasive and carries the most risk and potential for complication. It is possible to move up (and sometimes down) the ladder depending on your response to treatment.
In this way, endometrial ablation can be seen to be second only to hysterectomy in terms of success at reducing bleeding and has a very high patient satisfaction rate. It is a surgical procedure that is performed as a day case with a rapid recovery time.