Endometrial ablation refers to minimally invasive surgical procedures designed to treat abnormal uterine bleeding in women who have completed childbearing. There are different ways physicians perform endometrial ablation. After the ablation, the residual endometrium is beneath the scar, and this prevents further bleeding. In the past, a hysterectomy was frequently done for menorrhagia, but this procedure can be done quickly, in an office, is relatively painless, and has minimal downtime. It may be an option for women who do not want a hysterectomy.
Endometrial ablation is indicated for the treatment of heavy menstrual bleeding or perceived menorrhagia in premenopausal women who no longer desire future fertility. It is best reserved for women with ovulatory bleeding. It is also for patients with normal sized uteri.
It is important to evaluate the endometrial cavity both structurally and histologically. An ultrasound is typically performed before ablation. This provides information on the length of the uterus as well as any structural abnormalities that may be present, and that may contraindicate the procedure. For example, depending on the size, submucosal leiomyomas may be a contraindication for the procedure. If there is suspicion for uterine cavity abnormalities, a saline infusion sonogram (SIS) or in-office hysteroscopy may be necessary to determine the situation and also determine if this should be addressed before ablation. An endometrial biopsy should be performed and reviewed before endometrial ablation to rule out hyperplasia or cancer. This also provides an assessment of the uterine length which affects the effectiveness of ablation and determines whether a patient is a candidate for the procedure. If hyperplasia or cancer is present and endometrial ablation is performed, it may interfere with future evaluations of the uterine lining, and therefore, it should be avoided. One should also ensure that the patient has a recent or an up to date PAP smear before the ablation. If necessary, an abnormal PAP will need to be evaluated before the ablation is done.
Apart from the standard consent process for any surgical procedure, certain, important points need to be highlighted when the patient is agreed to this procedure. It is important that patients understand that following endometrial ablation, pregnancy is not advisable given possible pregnancy complications. Patients should, therefore, have a reliable contraceptive method (be it sterilization or another method) after the ablation. It is also important to emphasize that endometrial ablation is not a contraceptive method. The patient should also understand that the goal of endometrial ablation is normalization of their cycle, not amenorrhea. In patients with anovulatory bleeding, if an ablation is performed, it will not change the pattern or timing of the bleeding.
Contraindications to the procedure include:
It is important to obtain tissue before the ablation. An endometrial biopsy is usually not well tolerated in the office setting, but dilatation and curettage should be done instead to obtain cells for cytology. If any suspicious or obvious lesion is present, ablation should not be done until a biopsy has been obtained. Once the patient is positioned, several laser devices can be used to ablate the endometrial tissues. There is usually no need for anesthesia, but if the patient feels uncomfortable, regional anesthesia is an option.
There are two major techniques:
Resectoscopic Endometrial Ablation
Typically, this is performed with the use of a rollerball or monopolar or bipolar loop electrode. The endometrium is desiccated to the level of the basalis layer using thermal energy. With the rollerball, no tissue is removed. With the loop electrode, the tissues are resected and sent to pathology.
Global endometrial ablation (GEA)
Many devices do not require the use of a resectoscope currently available to accomplish the destruction of the endometrium. They have become popular due to its ease of use and similar outcomes to resectoscopic techniques. Some of these GEA procedures can be performed in the office.
Postoperative complications include:
Overall, most patients have a satisfactory outcome. Unlike a hysterectomy, the procedure does not require hospital admission and is associated with much fewer complications. Data to compare the different methods of endometrial ablation are difficult because of lack of patient homogeneity and lack of controls. In any case, most methods have a success rate of over 90%.
Compared to oral therapy: by 5 years: only 10% of those on medical therapy continued receiving medical treatment, 77% had surgery. Of those who underwent resectoscope ablation, 27% had further surgery. Those who were randomized to oral medical therapy were significantly less likely to satisfied than those undergoing ablation.
Compared to Mirena IUD: quality of life and satisfaction measures were similar for both groups at 1 year. Ablation may be more effective at 1 year, but by years 2 and 3, there was no difference.
Reoperation rates at 4 to 5 years: 18% to 38%