Endometrial Ablation - Questions And Answers
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Expert Forum by Michael P.H. Lau, MD, FACS, FACOG
One of the most effective alternatives to hysterectomy for patients with heavy menses is the procedure of endometrial ablation. Endometrial ablation can actually be done in the office without anesthesia, with virtually no discomfort and no recovery down time. If a woman has only heavy periods with no other associated problems and she has completed her family already, she should consider the option of endometrial ablation instead of hysterectomy as a form of treatment for heavy bleeding.
To understand whether endometrial ablation is the treatment of choice, the following discussion in the Question and Answer format will be helpful.
What causes heavy menstrual bleeding?
Menstrual flow is the result of the shedding of the endometrium, the lining of the uterine cavity, in the form of blood mixed with broken down tissue. Each month, the ovaries produce estrogen and progesterone in an orderly sequence to prepare the endometrium to receive a potential pregnancy. If the pregnancy does not occur, the ovaries will stop the hormone supply and the endometrium will break down at the end of the menstrual cycle, leading to menstrual bleeding. Normally, the menses should come about once a month, lasting 3 to 5 days, and on an average measuring about 80 cc of menstrual flow in total per period. 80 cc would correspond to about less than 6 tablespoons of blood flow.
One would consider menses abnormal if it comes too frequently, more than once a month; too long, lasting more than 5 days; too heavy, totaling more than 80 cc per period; or having too many blood clots with the flow. The abnormal menses can be due to hormonal imbalance from the ovaries; blood clotting disorders; abnormalities such as a fibroid tumor in the uterus; or frequently of unknown reasons. Abnormal menses may or may not be associated with pelvic pain.
How does endometrial ablation work?
Since menstrual flow is a result of the breaking down of the endometrium, the lining of the uterus, eliminating or greatly reducing the endometrium should eliminate or greatly reduce the menstrual flow. Many energy forms have been used to destroy the endometrium. Starting in the late 70s, laser was used. In the 80s, Dr. Lau and a few other gynecologists across the U.S. started to do Rollerball endometrial ablation. Using a rollerball guided by a hysteroscope (an instrument to look into the uterine cavity) through the cervix, the lining of the uterine cavity was systematically ablated. The actress Raquel Welch had the procedure done and went back to work within days, and making national news. However, Rollerball ablation has been difficult for most gynecologists to adopt due to the technical skill requirement. Less than 15% of gynecologists in the U.S. perform Rollerball endometrial ablation. The technique of global endometrial ablation was then developed and popularized, based on the concept that endometrial ablation can be done using an energy form that can ablate the whole endometrium without the technical challenge. Almost all of the global endometrial ablation modalities use heat energy to destroy the endometrium, including the following:
- Hot water circulating within the uterine cavity
- Placement of a hot water balloon in the uterine cavity
- Deployment of a metal mesh within the uterine cavity and applying radiofrequency electric energy
- The use of microwave energy to systematically ablate the endometrium - Dr. Lau is the first surgeon to use microwave endometrial ablation in the U.S. after FDA approval.
Alternatively, endometrial ablation can be performed by freezing the endometrium using a cryoprobe. Since freezing does not cause as much discomfort as heat energy, cryoablation (freezing ablation) can be done in the office without anesthesia or just with local anesthesia.
Who are suitable candidates for endometrial ablation?
Endometrial ablation is indicated for women with abnormally heavy or prolonged menstrual periods. But first and foremost, the woman must have completed childbearing before she should have endometrial ablation. Endometrial ablation will destroy the endometrium and thus it cannot support a pregnancy. Even though endometrial ablation by itself does not prevent pregnancy, conception after endometrial ablation would result in miscarriage, ectopic pregnancy, or pregnancy loss that would make pregnancy dangerous after endometrial ablation, and thus contra-indicated.
A candidate contemplating endometrial ablation to treat her abnormal menstrual flow should first make sure that her abnormal menstrual bleeding is not due to a general bleeding disorder, hormonal imbalance that can be treated by hormone therapy, or some intrinsic problem of the uterus such as a fibroid tumor that should be addressed with fibroid removal instead. If a woman has other associated problems, such as severe pelvic pain, one might need to investigate other treatment options since endometrial ablation usually does not eliminate pelvic pain such as that caused by pelvic endometriosis or an ovarian cyst.
If a woman has heavy and prolonged menstrual bleeding, has completed her childbearing already, and has none of the associated conditions mentioned above, then she could be an ideal candidate to have endometrial ablation to eliminate or greatly decrease excessive menses.
What are the steps needed to have endometrial ablation?
The first step is to schedule a consultation. Dr. Lau will go over in detail one’s history and do a physical examination to evaluate the possible causes of excessive menses. If indicated, he can perform a pelvic ultrasound right in his office to exclude other pelvic pathologies such as fibroid tumors or ovarian cysts. Dr. Lau will then explain in detail all the treatment options available to take care of the problem and answer all questions. If it is decided that endometrial ablation is the treatment of choice, then it can be scheduled. The patient should have a current normal pap smear. Also, a simple office endometrial biopsy will be performed to make sure that there is no unexpected pathology of the endometrium before the endometrial ablation.
How does one decide on which method of endometrial ablation to use?
Dr. Lau is a pioneer in endometrial ablation and an expert in most of the available endometrial techniques. The choice of the endometrial ablation method depends on the unique situation of each woman. For example, if a woman has a fibroid tumor in her uterus distorting the cavity, Dr. Lau will perform a minimally invasive hysteroscopic procedure to remove the fibroid through the cervix and then perform a Rollerball endometrial ablation after that to take care of the excessive menses problem. Rollerball endometrial ablation can also be used for uteri that are larger than the upper limit of usage for the global endometrial ablation methods since the surgeon can see the procedure visually to direct the ablation.
For patients that just require endometrial ablation, the most ideal method is Her Option endometrial cryoablation procedure performed in the office setting. Using the freezing probe, the endometrial ablation can be done in the doctor’s office with no anesthesia or just local anesthesia to the cervix. Patients can walk in, have the endometrial ablation done and walk out. Many can return to work the next day. Since no general anesthesia is required, the risk of the procedure is very minimal.
What is successful endometrial ablation?
In experienced hands, most of the endometrial ablation methods will give similar success rates. Success implies that the patient is satisfied by the decrease in excessive menstrual symptoms as a result of the endometrial ablation. More specifically, up to 50% of patients will have no menses at all after the procedure or just have scanty spotting that requires only changing a light pad a day for a couple of days. Another 30% to 35% of patients after the endometrial ablation will notice a great decrease in the menstrual flow to a normal level or less than a normal level. For example, a woman who used to change her menstrual pad every hour for 5 days may now need to change her pad only a couple of times a day for 3 days. About 15% of patients may notice only a little change of the menstrual flow after the procedure. Endometrial ablation can be repeated if necessary, using Rollerball endometrial ablation.
Does one go through menopause right after endometrial ablation?
No, endometrial ablation does not cause menopause. Since endometrial ablation only treats the lining of the uterine cavity, it does not affect the ovaries. The ovaries are the organs that produce the female hormone estrogen and progesterone. The cessation of the hormone production around the age of 50 years results in menopausal symptoms. Since endometrial ablation does not affect the ovaries at all, the patient will have no change in her hormone function and she will not go through menopause right after the endometrial ablation, but she will go through menopause at the usual age of around fifty, like other women. After endometrial ablation, a woman might not have monthly menses, so she does not have the typical symptoms of missing periods as an indication for menopause. If a woman is around the age of fifty and feels hot flashes or night sweats, a simple blood test will tell her whether her hormonal level is menopausal or not.
Does endometrial ablation affect sexual function?
Since endometrial ablation leaves the uterus intact, there should be no effect on any issue of uterine and pelvic support or sexual function.
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