What Is Hysteroscopic Endometrial Ablation?

Until recently, if you suffered from heavy and prolonged periods, your doctor would usually recommend either hormone medications, dilatation and curettage (D&C) or a hysterectomy.

Hysteroscopic endometrial ablation is a relatively new procedure that aims to reduce heavy menstrual flow by destroying the lining of the uterus (endometrium). This minimally invasive procedure has proven to be very effective in reducing the amount of bleeding and the associated pain in women suffering from heavy, prolonged periods (also known as menorrhagia).

After hysteroscopic endometrial ablation, most women notice a substantial reduction in their periods. For some, periods stop completely.

Who Can Have The Operation?

You may be a suitable candidate for hysteroscopic endometrial ablation if you meet the following criteria:

• Your menstrual problems are not controlled by medical treatments such as birth control pills or an intrauterine device (IUD).
• You have unusually heavy periods, sometimes defined as soaking a pad or tampon every two hours or less.
• Bleeding that lasts longer than eight days.
• A low red blood cell count from excessive blood loss (anaemia).
• Childbearing has been completed.
• Pregnancy is excluded.
• There is no other underlying pelvic pathology or medical condition which could cause the menstrual disturbance, e.g. endometriosis (a condition in which endometrial tissue is found in various locations in the pelvic cavity).
• You are not medically fit enough for a hysterectomy.

When Should You Not Have The Operation?

Due to the nature of the procedure, a hysteroscopic endometrial ablation is not suitable for women who plan to have children. Although pregnancy is unlikely to occur after endometrial ablation, it can still occur. Unplanned pregnancies after ablation are unpredictable, high-risk and should be avoided. Pregnancy can be avoided by taking birth control medication or, preferably, having an IUD (e.g. Mirena) fitted.

Endometrial ablation is not recommended for women after menopause. It is also not recommended for women who have:

• Certain uterus conditions, e.g. endometrial hyperplasia
• Cancer of the uterus, or an increased risk of cancer of the uterus
• An active pelvic infection
• A desire for future pregnancy 

Are There Alternatives To Surgery?

Before undertaking the procedure, you should consider the alternatives. The symptoms of heavy menstrual bleeding are often alleviated by using a variety of oral medications or oral contraceptives. Having an IUD (intra-uterine device, such as a coil or Mirena) inserted by your gynaecologist can also help reduce bleeding.

Previously, a D&C was often performed to scrape the lining of the uterus to help manage the symptoms of heavy periods. This method was not a curative procedure as the lining of the uterus (endometrium) would regrow. This procedure, when performed to decrease menstrual flow, has largely been replaced with hysteroscopic endometrial ablation.

A hysterectomy is also an option but should be carefully considered as you will not be able to have children afterwards. A hysterectomy, which removes the uterus, is a major operation with a long recovery time.

How Is A Hysteroscopic Endometrial Ablation Performed?

During hysteroscopic endometrial ablation, the lining of the uterus (endometrium) is destroyed. The endometrium produces your monthly menstruation (periods).

Before you have the operation, your doctor may suggest taking a course of hormones for several weeks. These hormones help to thin the lining of the uterus (endometrium), making the operation easier and quicker.

Endometrial ablation is usually performed under a general anaesthetic and takes between 10 and 30 minutes, depending on which method is used. This is normally a day procedure, and you should be able to go home the same day.

 

The Procedure: A Hysteroscopic Endometrial Ablation

No cuts are needed for endometrial ablation. To begin the procedure, the neck of the womb (cervix) is dilated, after which a hysteroscope (a small viewing telescope with slender tools) is inserted into the uterine cavity through the vagina. The tools vary, depending on the method used to remove (ablate) the endometrium. Methods may include extreme cold, heated fluids, microwave energy or high-energy radio frequencies.

Often, gas or fluid is used to inflate the uterus to give the surgeon a clear view of your uterus. Fluid might be injected into the uterus in order to clear out any blood or mucous.

 

Endometrial Ablation Methods

The size and condition of your uterus, as well as your overall health, will play a role in which the endometrial ablation method is used. These may include:

Electrocautery (Or Diathermy)

This method uses an electrically heated ball that can be rolled across the lining.

Heated Balloon (Balloon Therapy)

A deflated silicone balloon is placed inside your uterus and then filled with heated fluid which is inflated to fit the shape of your uterus.

Cold (Cryoblation) Therapy

During this procedure, a tube with a cold tip creates tiny ice balls that freeze parts of the uterus lining, destroying it.

Laser Thermal Ablation

This method uses a high-energy beam of light to destroy the lining of the uterus.

Microwave Endometrial Ablation (MEA)

This method uses a small applicator which releases microwaves that heat the lining of your uterus, thereby destroying parts of it.

Radiowaves (Radiofrequency)

A wand-like instrument with a mesh tip is inserted into your uterus. The mesh releases radio waves that heat and destroy parts of the endometrium.  

Recovering From Hysteroscopic Endometrial Ablation

You are normally able to go home the same day of your surgery and return to your normal activities after two to four days. Most women can return to work after about a week. You may experience some mild period-like pain for which simple pain-relief tablets can be taken.

You are likely to experience some bleeding or discharge for up to four weeks. If the discharge smells, changes colour or causes pain, you may have an infection and you should contact your doctor. It is advisable to use sanitary towels instead of tampons while recovering to reduce the risk of infection.

Your doctor will advise you as to when you can resume routine activities, regular exercise, and sex. You should not have sex until the bleeding and discharge have stopped.

What Are The Benefits Of The Operation?

Hysteroscopic endometrial ablation is a quick and relatively painless operation. It requires a short anaesthetic and results in a quick recovery and resumption of your normal routine.

Studies show that up to 95% of women are happy with the result. In 20 to 40% of the cases, periods stop altogether while other women will only continue to have light periods after the operation.

What Are The Risks Of The Operation?

As with any operation, endometrial ablation is not without risks. These complications, although rare and seldom serious, can include:

• accidental perforation of the uterus
• haemorrhage during or after the operation
• excessive absorption of the irrigating fluid and
• infection

About 10% of women may still require a hysterectomy after having ablation due to recurrent bleeding, the development of fibroids or adenomyosis later in life.