Overview of Endometrial Ablation
Endometrial ablation is a type of minor surgery used by gynecologists (doctors specializing in the female reproductive system) to reduce heavy, irregular, or bleeding between periods. This kind of unusual bleeding from the uterus (the womb) is quite common, affecting between 10% and 30% of women who are still in their childbearing years.
This procedure is intended for women who no longer want to have children, and works by destroying the endometrium, which is the layer inside the uterus that sheds during menstruation leading to periods. By damaging this layer, it can’t grow back, which lessens the amount of blood lost during periods.
There are a few different methods for doing endometrial ablation, all with their own pros and cons, but all designed to decrease heavy bleeding. If these methods don’t work, the other surgical option is to remove the uterus in a procedure called a hysterectomy. However, endometrial ablation is a preferred alternative treatment because it keeps the uterus intact and has fewer complications, less pain, quicker recovery, and shorter surgery time compared to a hysterectomy.
Anatomy and Physiology of Endometrial Ablation
Endometrial ablation is a procedure that doctors use to help treat excessive or prolonged menstrual bleeding. Before this procedure, it’s critical for a doctor to identify the causes of abnormal bleeding from the uterus to ensure proper treatment. There are several potential causes for this condition, collectively known by the abbreviation PALM-COEIN, as named by The International Federation of Gynecology and Obstetrics (FIGO). This name signifies polyps (growths), adenomyosis (tissue growth inside the uterus causing enlargement), leiomyoma (fibroids), malignancy (cancer); coagulopathy (problems with blood clotting), ovulatory dysfunction (issues with ovulation), endometrial conditions (related to the inner lining of the uterus), iatrogenic (caused by medical treatment), and unclassified conditions.
Your doctor may use various techniques such as transvaginal ultrasound, endometrial biopsy, saline infusion sonogram, or hysteroscopy to determine any structural abnormalities and to get details about the size and the position of the uterus. Non-structural issues might be influenced by hormonal imbalances, inherited bleeding disorders such as von Willebrand disease, or side effects from medication, including blood thinners. Endometrial hyperplasia (abnormal growth of uterus lining) or cancer may also be the cause of abnormal uterine bleeding, so it is important to rule these out before performing an endometrial ablation.
The inner lining, or endometrium, of your uterus consists of two layers named the functional layer and the basal layer. The functional layer performs important roles such as preparing the uterus for pregnancy, helping maintain a pregnancy, and shedding during your period. The basal layer plays a role in regrowing the functional layer. In an endometrial ablation procedure, these layers are destroyed. As a result, the regrowth of the uterus lining is reduced or completely stopped. This leads to a decrease in menstrual flow or sometimes complete absence of periods. After endometrial ablation, the uterus often shows signs of natural tissue breakdown, scarring, and inflammation.
Why do People Need Endometrial Ablation
Endometrial ablation is a procedure used to treat heavy or irregular bleeding from the uterus. This procedure can be a good fit for patients whose daily lives are significantly affected by heavy menstrual bleeding, that isn’t caused by a serious condition, and who don’t want to have a hysterectomy (surgery to remove the uterus).
There are few important factors that doctors consider when deciding if endometrial ablation is the best treatment option for you. You might be a good candidate for this procedure if:
- You’ve had heavy or irregular menstrual bleeding that significantly affects your quality of life and you don’t want to have any more children.
- Your heavy or irregular menstrual bleeding is not caused by cancer or abnormal cell growth in the lining of the uterus (known as hyperplasia), confirmed through a biopsy (a test that checks for abnormal cells).
- You’ve tried other treatments for heavy or irregular menstrual bleeding, but they didn’t work or caused unwanted side effects.
- You have small non-cancerous growths in your uterus known as fibroids that are less than 3 cm in diameter.
- You can’t have surgery because of health reasons or other conditions that make surgery riskier.
- You have a uterus that, based on an initial examination or specific tests like transvaginal ultrasound or saline infusion sonogram, is less than 10 cm long and has a smooth shape.
Each person’s situation is unique, so your doctor will consider all these factors and work with you to decide the best course of treatment.
When a Person Should Avoid Endometrial Ablation
There are certain conditions where a procedure known as endometrial ablation, which is a method to treat heavy or long menstrual periods, may not be suitable. These include situations such as:
– If you’re pregnant or hope to have children in the future.
– If you have excessive growth of the lining of your uterus (a condition known as ‘endometrial hyperplasia’) or cancer of the uterus.
– If you have cervical cancer.
– If you have an ongoing infection in the pelvic area.
– If you have a device known as an intrauterine device (commonly known as an IUD) implanted and it has not been removed.
– If you’ve had certain types of operations on the uterus, including cesarean sections (which is when a baby is delivered through a surgical opening in the stomach and uterus).
– If you have certain types of abnormalities of the uterus, such as a septate, bicornuate, or unicornuate uterus, which mean that the shape or size of the uterus is not typical.
There are also conditions where endometrial ablation may still be possible but has to be performed with caution. These are referred to as relative contraindications and they include:
– Being in a postmenopausal state, which is when menstruation naturally stops due to age.
– If you have growths known as submucous leiomyomas or fibroids in the uterus.
– If the inner part of the uterus, known as the uterine cavity, is longer than 11 cm.
– If you have very thin muscle layer of the uterus (myometrium).
– If your uterus is severely tilted forward or backward.
Who is needed to perform Endometrial Ablation?
Doing an endometrial ablation, which is a procedure to treat some problems in the lining of the uterus, usually needs a specially trained doctor known as a gynecologist and a helper or assistant. This procedure can be done in a place where patients don’t need to stay overnight (outpatient setting) or in a specialized room for operations (operating room).
Preparing for Endometrial Ablation
Before doing a procedure called endometrial ablation, doctors need to talk to the patient about what they expect their periods to be like after the procedure. The aim of this treatment is to reduce heavy menstrual bleeding, which can help improve the patient’s day-to-day life. However, patients who hope to stop their periods altogether might not be the best candidates for endometrial ablation, because it’s not always guaranteed to completely stop periods. In fact, studies have shown that between 15% to 72% of patients report completely stopped periods 12 months after the procedure.
Another important point to discuss with patients is the risk associated with future pregnancies and the necessity of reliable birth control methods. This is because getting pregnant after this procedure can be risky. Prior to the procedure, doctors should also take a small sample of the tissue from the lining of the uterus (endometrial biopsy) to examine it. They should also use ultrasound scans to check the size, position, and shape of the patient’s uterus.
Endometrial ablation can be done either in the doctor’s office without general anesthesia (anesthesia that puts you to sleep), or it can be done in a hospital as an outpatient procedure with general anesthesia. Therefore, discussions about anesthesia should be adjusted according to where the procedure is going to be performed.
How is Endometrial Ablation performed
Endometrial ablation is a treatment that eliminates or damages the basal layer of the uterus lining. This lining itself is known as the endometrium. Doing so aids in preventing the return growth of the uterus lining which can lead to heavy menstrual bleeding.
Originally, heavy menstrual bleeding was managed with either medications or a serious surgical procedure known as a hysterectomy (in which the womb is removed). However, current treatments focus specifically on addressing the endometrium, the uterine lining, which triggers the bleeding. These modern approaches may involve either getting rid of the endometrial lining through a method known as resection or destroying it with heat energy in a process known as ablation. Both these methods have proved successful in reducing or entirely stopping menstrual bleeding.
Recent scientific reviews have found that the two main types of treatment approaches, known as first-generation and second-generation, both have equal success rates in managing symptoms of heavy menstrual bleeding. However, the second-generation technique appears to demonstrate lower instances of complications such as cervical lacerations (cuts to the neck of the womb), hematometra (the pooling of blood in the uterus), and fluid overload.
Over the past years, there have been significant advancements in the techniques related to endometrial ablation. This led to creating less invasive options compared to a hysterectomy that also helps treat severe menstrual bleeding. Initially, they were categorized into first and second-generation techniques based on whether a device known as a hysteroscope was used during the procedure. Newer third generation techniques have improved on these earlier methods even more.
First-generation techniques like laser photovaporization, rollerball ablation, and transcervical resection were developed to manage heavy menstrual bleeding. But these procedures needed a skilled surgeon, general anesthesia, and operation theatre conditions. They also held a risk of complications like excessive bleeding and tearing or puncturing of the uterus wall.
These shortcomings led to the development of second-generation techniques which are easier, equally effective, and linked to lower rates of complications. Some new techniques don’t even require visualization of the endometrium which were common in procedures like thermal balloon, microwave, hydrothermal, bipolar radiofrequency, and cryotherapy techniques. As a result, these procedures have become more accessible, affordable, and have made a substantial impact on women’s treatment choices for heavy and abnormal uterine bleeding conditions.
The third-generation techniques aim to enhance the effectiveness and safety of the endometrial ablation procedure. These new methods ensure a better distribution of heat over the surface of the endometrium. However, even with these advancements, the selection of technique usually depends on the availability of specific equipment and the surgeon’s experience. Therefore, there is still room for more research to optimize the outcomes and boost patient satisfaction with these techniques.
Possible Complications of Endometrial Ablation
Endometrial ablation is a procedure used to treat heavy periods. The first versions of this technique had a 4.4% rate of complications, but modern versions (second- and third-generation techniques) have brought down this rate to about 1%. However, complications can still happen post-surgery, including:
– Damage to organs in the lower abdomen
– Inflammation or infection of the lining of the uterus (endometritis) or the muscle layer of the uterus (myometritis)
– Cuts or abnormal narrowing of the cervix
– Spread of infection in the pelvic region (pelvic sepsis) or the formation of an abscess (pocket of pus)
– Pelvic inflammatory disease, which is an infection of the reproductive organs
– Blood pooling in the uterus (hematometra) or excessive bleeding that requires a blood transfusion
– Problems like too much or not enough body fluid, or harmful levels of glycine (a substance used in the procedure)
– Issues like blockage of the bowel, loss of bladder control, or ongoing pelvic pain
– Serious complications like gas bubbles in the bloodstream (gas embolism), burns from the procedure (thermal injury), or severe bleeding (hemorrhage)
– Formation of scar tissue inside the uterus (intrauterine adhesions) or abnormal connections between the bladder and uterus (vesicouterine fistula)
Complications can also happen if you get pregnant after the procedure, like having a baby born too early, problems with how the placenta attaches, low growth rates for the baby, or death of the baby before or just after birth.
Also, in some cases, having endometrial ablation and a certain type of sterilization procedure at the same time can lead to long-term pelvic pain from pieces of the uterine lining growing back and causing swelling in the uterus.
Lastly, having endometrial ablation treatment could make it harder to diagnose uterine cancer in the future.
What Else Should I Know About Endometrial Ablation?
Heavy menstrual bleeding was earlier managed with medications or a surgical removal of the uterus, known as a hysterectomy. However, newer options are now available that focus on managing the uterine lining, called the endometrium, which is responsible for the bleeding. These new treatments involve either removing the endometrium or destroying it using heat, a method known as ablation. These procedures have been successful in reducing or sometimes even stopping menstrual bleeding.
The previous methods were more invasive, required the surgeon to be highly skilled and experienced. The newer methods are much simpler, less invasive and have become popular alternatives to hysterectomy in managing heavy menstrual bleeding. Most patients have reported satisfaction with the outcome. Almost everyone, 82% to 97%, showed a decrease in menstrual bleeding within a year after the ablation procedure and 85% to 98% were satisfied with the outcome.
Owing to these developments, there has been a significant decrease in the number of hysterectomies performed for heavy menstrual bleeding. However, long-term studies show that some women may still require a hysterectomy after ablation, especially in the years immediately following the procedure. Ablation failure rates range from 5% to 16% within 5 years of the procedure, with some patients requiring a definitive hysterectomy to treat constant pelvic pain or bleeding.
Comparing ablation to nonsurgical treatments, the LNG-IUS, a type of intrauterine contraceptive device, is most effective for reducing menstrual blood loss, offering a 71% to 95% reduction in blood loss. This effectiveness makes LNG-IUS comparable to hysterectomy in improving life quality. Other medicines like tranexamic acid and long-cycle progestogens are also effective, but to a lesser degree, with reductions in menstrual blood loss ranging from 26% to 87%, depending on the specific treatment. Oral contraceptives also offer substantial reductions of blood loss.
Endometrial ablation is an extremely effective way of controlling bleeding. It provides better bleeding control at short-term follow-ups compared to oral medications. However, this difference diminishes over extended periods. It does not allow for future pregnancies and is usually considered when less invasive treatments fail or preserving fertility isn’t a priority.
Overall satisfaction with treatment outcomes varies between medical and surgical options. The LNG-IUS is associated with high satisfaction rates, comparable to those observed with more invasive surgical options. In contrast, while oral medications may be suitable for some women, they may not maintain high satisfaction over the long term. Endometrial ablation generally yields higher satisfaction rates in the short term.
LNG-IUS and oral contraceptives are noninvasive and carry fewer immediate risks compared to surgery. However, they may be associated with ongoing bleeding, light bleeding, or hormonal side effects. Endometrial ablation, being a surgical procedure, carries risks associated with surgery. It is not suitable for women who wish to have children in the future since it typically results in permanent changes to the endometrial lining.
Comparing endometrial ablation and hysterectomy, a hysterectomy ensures the cessation of menstruation but is a major surgery with a significant recovery time and risks. On the other hand, endometrial ablation is a less invasive option with a quicker recovery time, although it may not always be as effective and the patient may eventually require further surgery. The choice between the two often depends on the patient’s preference for a less invasive procedure versus the certainty of results.