Endometrial ablation is a minimally invasive gynecological surgical procedure that ablates or destroys the endometrium, or lining, of the uterus. This destruction causes the formation of scar tissue, preventing the endometrium from regrowing. The decrease in regrowth is intended to reduce the amount of bleeding. Endometrial ablation is typically used to address abnormal uterine bleeding, which can be a symptom of multiple health conditions. Endometrial ablation does not cure any medical conditions, it is used to reduce symptoms that conditions cause. This procedure can cause patients to experience permanent side effects and long-term complications. There are very limited surgical treatments to address abnormal uterine bleeding, the only other option being hysterectomy. It is estimated that around 500,000 patients undergo endometrial ablation procedures each year. This procedure is usually performed by a gynecologist.
Endometrial ablation is typically done in a minimally invasive manner with no external incisions. Slender tools are inserted through the vagina and into the uterus. In some forms of the procedure, one of these tools may be a camera (hysteroscope) to assist with visualization. Other tools include those that harness electricity, high-energy radio waves, heated fluids, or cold temperature to destroy the endometrial lining.
The procedure is almost always performed as an outpatient treatment, either at a hospital, ambulatory surgery center, or physician's office. Patients will most commonly undergo local and/or light sedative anesthesia, or if necessary, general or spinal anesthesia.
Due to the uterine changes that take place after undergoing ablation, patients are unlikely to be able to become pregnant after the procedure, and in pregnancies that do occur, complication risk is high. To reduce the associated mortality risks, it is often recommended for patients to adhere to birth control methods after undergoing endometrial ablation.
History and origins Early evidence of endometrial ablation exists suggesting the use of chemical astringents to control uterine hemorrhaging occurring during childbirth. Astringents were replaced with techniques like electricity, gamma rays, and steam during the 19th century.
Endometrial ablation as it is thought of most typically today originated in the 1980s with the introduction of the rollerball method. Success rates and patient complications were highly subjective to the skill of the surgeon performing the procedure.
First Generation Techniques: Hysteroscopic methods.
Second Generation Techniques: Thermal balloon and microwave.
Third Generation Techniques: NovaSure, also known as bipolar radiofrequency, cerene cryotherapy. The NovaSure is currently the most used technique for the majority of the endometrial ablations.
Medical uses Typical medical uses for endometrial ablation include but are not limited to:
Endometriosis Adenomyosis Polyendocrine metabolic ovarian syndrome (PMOS) Uterine fibroids Uterine polyps
As previously mentioned, endometrial ablation does not cure any conditions, rather, it is used to control abnormal uterine bleeding. Abnormal uterine bleeding is frequently a symptom of the aforementioned conditions, thus endometrial ablation may be suggested to patients with these conditions as an attempt to treat this symptom.
Indications The primary indication for endometrial ablation is abnormal uterine bleeding, including chronic heavy menstrual bleeding, in premenopausal patients. Other primary indications include but are not limited to:
Heavy menstrual bleeding that interferes with the patient's quality of life Abnormal uterine bleeding without uterine abnormalities Abnormal uterine bleeding with fibroids with a diameter of less than 3 centimeters
Abnormal menstrual bleeding may appear as heavy menstrual bleeding, irregular menstrual bleeding, abnormal bleeding during sexual activities, or spotting in between periods. Abnormal menstrual bleeding can cause significant physical, social, and emotional toll on the body. In some patients, it limits their ability to participate in work, school, or regular activities normally. If heavy menstrual bleeding reaches the point to where it interferes with the patient's ability to function in day-to-day life, treatment is recommended. Pelvic pain is often a co-morbid symptom to abnormal uterine bleeding, ranging from mild to extreme. 10 to 30% of people assigned female at birth of reproductive age report abnormal uterine bleeding, and 1 in 7 report pelvic pain lasting for at least 6 months. According to Mayo Clinic, the best indicated candidate for an endometrial ablation is at least the age of 40.
Before endometrial ablation is recommended, patients with heavy menstrual bleeding may choose to undergo alternative treatment options prior. Common treatment options include hormonal treatment through form of medication and birth control. The first line of treatment prior to ablation is typically a levonorgestrel-releasing intrauterine system, also known as an IUD (intrauterine device). The IUD must be hormonal, and not copper. This treatment reports a blood loss reduction ranging from 71 to 95%. Other forms of birth control offered include oral contraceptives that contain progestins. This treatment is not as effective as the IUD, with blood reduction rates ranging from 35 to 69%. If birth control is stopped or the IUD is removed, abnormal bleeding is likely to resume.
Contraindications Endometrial ablation is not suitable for every patient. Medical professionals work closely with patients to determine the best treatment options by taking into account each patient's individual situation, needs, and desires as well as the most up-to-date clinical guidelines to determine if the procedure is suitable for the patient. Contraindications include but are not limited to the following:
History of cesarean section Pregnancy or desire for pregnancy Endometrial carcinoma Cervical cancer Acute pelvic infections Retained intrauterine device, such as an IUD Uterine anomalies
Preparation and planning Before undergoing endometrial ablation, patients will go through a pre-procedure evaluation and risk assessment. Components of this often include informed consent, anesthesia evaluation, and a pregnancy test. A preliminary check for pregnancy and cancer is required before undergoing this procedure. All patients will undergo endometrial sampling to test for endometrial carcinoma, as this is an absolute contraindication to endometrial ablation. Any intrauterine devices like IUDs must be removed. An examination of the uterus via ultrasound or hysteroscopy is typical. Some patients may also require further assessment of the uterus through hysteroscopy or saline infusion sonohysterography. Depending on the treatment that is chosen, endometrial ablation is sometimes conducted after treatment with hormones, such as norethisterone or Lupron to reduce the thickness of the endometrium. Patients may discuss options regarding pain management with their medical provider. The procedure can last between 5 and 20 minutes, depending on the technique used.
Procedure Endometrial ablation may be done in-office or in an operating room. The procedure begins with cervical dilation, which temporarily stretches the cervix to make room for the ablation instruments and/or hysteroscope to enter the uterus. Dilation can be induced medically with pharmacologic agents, or mechanically with a series of metal tools of increasing diameter. After sufficient dilation, the ablation instrument is introduced into the uterine cavity, which is used to partially or fully destroy the endometrial lining. A hysteroscope may be used to assist in visualization of this process and/or ensure that final results are adequate.
The technique utilized to remove or destroy the endometrium varies with endometrial ablation operations. Options consist of:
Ablation with cryotherapy – The uterus is probed with a chilled probe. The uterine lining is destroyed when the extreme cold at the probe's tip freezes it into pieces. The procedure can be monitored via ultrasound. It takes roughly six minutes to complete one freezing cycle. The size and shape of the uterus will determine how many cycles are required. Water-thermal ablation – For roughly 10 minutes, warm fluid is delivered into the uterus. The uterine lining is destroyed by the heat. This technique has the benefit of being usable in patients who have uteri that are shaped differently due to abnormal tissue growth. Lesions inside the uterus or uterine fibroids are two conditions that can lead to the uterus becoming misshapen. Ablation with Radiofrequency – A flexible, triangular device inside the uterus is opened using a specialized tool. The uterine lining is destroyed by radiofrequency energy released by the ablation device in 1 to 2 minutes. After that, the device is taken out of the uterus. Ablation using Electrocautery – The uterus is visualized using a thin scope. A tool is passed through the scope, such as a wire loop, a probe with a rollerball tip, or a probe with an electrode tip. The uterine lining is removed or destroyed by the device using electric current. General anesthesia is required for electrocautery ablation. This ablation technique is less frequently employed than other techniques. Radiofrequency Ablation – The uterus is filled with a device. The uterine lining is destroyed by the device's use of microwave energy.
After the ablation procedure is complete, any concomitant procedures that patients have opted for will also be completed. A common procedure after endometrial ablation is IUD insertion, as effective contraception following endometrial ablation is highly recommended. Other concomitant procedures may include myomectomy and/or tubal ligation.
Endometrial ablation is often an outpatient procedure that does not require an overnight hospital stay. Patients may experience cramping, vaginal discharge, and/or urinary changes during the recovery process.
Post-procedure Directions following an endometrial ablation procedure vary based on level of sedation or use of anesthesia. Most patients undergo a dilation of the cervix so that medical instruments can be inserted smoothly into the uterus. To avoid infection risk afterward, patients should avoid inserting anything vaginally like tampons, as well as swimming or soaking in the bath, hot tub, etc. for at least two weeks following the procedure. These activities may risk bacteria entering the vagina, cervix, and uterus. Patients may prefer to use hygiene products for light bleeding for a few weeks post-procedure. If fever or heavy bleeding occurs and does not stop, patients should contact their medical provider. Pain levels vary between patients as they may experience mild to heavy cramping and pelvic pain for up to several days. Pain medication is typically administered. Nausea may persist for some time after undergoing anesthesia and as a side effect of the pain medication. Proper hydration is critical. Patients might attend a follow-up or post-operative appointment for this procedure at the direction and discretion of their medical provider.Newton-Wellesley Hospital. (n.d.). POST-OPERATIVE INSTRUCTIONS ENDOMETRIAL ABLATION.
Cost The cost of an endometrial ablation varies. In the United States, the average patient cost range is between $5,951 and $7,676, depending on technique used and whether or not there were complications during the procedure.
Technique
Several treatment options are available, all of which work by inserting tools into the cervix to destroy the ablate the endometrium. Edited version of the original CME article that appeared in The Female Patient. 2005; 30(12):35-40. Commonly used ablation systems include: