What is endometrial ablation?
Ablation of the endometrium (the mucous membrane that lines the uterus (like a type of carpet)) involves the complete removal of the endometrium in order to reduce bleeding during the menstrual cycle (for example in the case of heavy and prolonged bleeding, called menorrhagia).
Curettage procedures used to be performed to scrape away the surface of the endometrium. Using general anesthesia, a special loop would be used to scrape away at the lining. Nowadays however this procedure is less frequently used because it is a technique without the possibility of viewing the affected area and as a result only about 60% of the endometrium would be likely removed with the thickest parts of the mucous membrane still remaining. Membrane regrowth could occur during the menstrual cycle and so this technique is not considered to be the most efficient. If we use an analogy, it is as if one mowed a lawn, and whilst the lawn is certainly trimmed, it just grows again after a few days… and so the bleeding symptoms return.
Endometrial ablation involves the complete removal of the ‘lawn’ including some of the ‘root system and soil’, much like the rolls of lawn used in a sports stadium. Technically speaking the endometrium and some of the myometrium (a number of millimeters of uterine muscle upon which the endometrium generates) are removed. This is so that once the area is healed no mucous membrane regrowth occurs. This procedure compromises a patient’s fertility and it is therefore only indicated for women who no longer wish to fall pregnant.
The parts that are removed are systematically analysed, the results are returned 7 days later and are analysed to determine the nature of the lesions.
Although endometrial ablation compromises fertility it is not a contraceptive technique. Contraceptive precautions should be discussed and taken if required after this procedure.
The endometrial ablation procedure
This procedure is similar to other operative hysteroscopy procedures. It is carried out under light general anesthesia and lasts between 10 and 30 minutes. After this procedure pain is not generally experienced although some light bleeding may occur for two to three weeks. Patients can return to their normal activities on the day after the procedure. Sexual intercourse and bathing are to be avoided for about two weeks.
Endometrial ablation can be carried out with other operative hysteroscopy procedures such as removal of polyps and myomas. Success with endometrium removal is improved when combined with these operative hysteroscopy procedures.
Endometrial ablation results are generally good scoring 88% success overall. The best results (96%) are obtained during endometrial hyperplasia and polyp removal. The least successful results (74%) occur when combined with adenomyosis.
In fact adenomyosis is not a question of a diseased mucous membrane of the uterus, rather it is a thickening of the uterine muscle wall. Endometrial ablation thins this muscle tissue and so partially treats adenomyosis. Nevertheless the part of the thickened muscle that remains is abnormal in nature and has a high treatment failure rate (26%).
Even given this failure rate, 3 out of 4 patients will not require subsequent surgical treatment.
Thus endometrial ablation can confidently be indicated as the first line of treatment. More generally it is when endometrial removal treatment fails, or when the adenomyosis is extensive, or when other medical treatments and operative hysteroscopy are ineffective that hysterectomy is indicated as the appropriate treatment.
When is an endometrial ablation performed?
Endometrial ablation is considered each time a patient experiences heavy or prolonged menses and that medical treatments have been ineffectual. It is a credible alternative to hysterectomy especially since it can be performed on an outpatient basis in a matter of a few hours. Patients can return to their regular activities on the day following the intervention. It should be noted that removal of the endometrium reduces a woman’s level of fertility.
Cases that benefit from endometrial ablation:
- Endometrial hyperplasia,
- Multiple polyps,
- Fibromas or myomas,
- Surface layer adenomyosis
- Hormone related menorrhagia (heavy or prolonged menses)
- Patients in the stages of peri or post menopause
What happens after an endometrial ablation?
After the endometrium is removed patients can return home after having spent only a few hours in the medical facility. Patients can return to their professional activities the day after the procedure. Some light bleeding may occur for 10 to 15 days or even for up to 3 weeks, though this is rare. The fragments that are removed are analysed and the results indicate the exact nature of the lesions. The results are returned in 7 days.
Subsequently, a patient should experience regular though lighter periods. In some cases (although rare) periods may disappear or be extremely light. This absence is not the onset of menopause, since the procedure does not impact the patient’s ovaries. It is just there is not enough mucous membrane remaining for the bleed to be of any significant volume. Given that the patient would have been experiencing heavy or prolonged bleeds then this result corresponds with the objectives of the procedure.