Endometrial Ablation or Resection

Endometrial ablation/resection uses hysteroscopy to view the uterine cavity and an electric or a laser device to heat and destroy the endometrium.

In either endometrial ablation or resection, the entire lining of the uterus (the endometrium) is removed or destroyed. Resection uses surgical techniques to remove the lining; ablation generally uses either vaporization or coagulation to destroy the uterine lining. These procedures benefit those women who have very heavy menstrual bleeding but do not have any other underlying uterine problems, such as hyperplasia of the endometrium, or cancer. Neither ablation nor resection is useful for women with large fibroids, but either may be effective when small fibroids are present. It should be noted that, although the uterus itself is left intact, fertility is not preserved. Consequently, a tubal ligation may be performed at the same time if indicated.

An office hysteroscopy is usually performed to determine if a patient is a good candidate for the procedure. Many times a single injection of Depo-Leupron is given one month prior to the procedure. This causes the lining of the uterus to thin out which facilitates the actual surgery. Endometrial ablation usually takes 15 to 45 minutes, and the patient can go home the same day, although a general anesthetic is usually required.

Although variations of the procedure are often discussed as if they are the same, they differ significantly. Some physicians argue that resection is more difficult, but when it is performed skillfully, resection has much better results (control of bleeding in up to 88% of patients) than roller ball ablation (40% to 55%) and newer ablation techniques (3% to 30%). Resection also allows a surgeon to take tissue samples for examination.

Visualization of the uterine cavity is made possible by filling the cavity with fluid. If any resection or cauterization is performed, a special substance such as glycine, sorbitol, or mannitol, is added to the fluid that does not conduct electricity. This prevents accidental burn injuries to the rest of the uterus, but in rare instances, can cause excess water in the bloodstream with a subsequent abnormal drop in sodium levels. This can be a serious event resulting in mental confusion and even convulsions. We have developed strict guidelines to control for excessive fluid absorption. Other rare complications of endometrial ablation or hysteroscopy resection, include perforation of the uterus, injury to the intestine, hemorrhage, or infection.

Other uterine ablation procedures have been developed which involve "blind techniques" to destroy the lining of the uterus. These techniques, such as cryoablation and thermal ablation however, have not been shown to be as effective as the original electrosurgical ablation.

Anesthesia may cause nausea and even vomiting for a few hours following the operation. Patients may experience frequent urination for the first day after the procedure and blood-tinged, watery vaginal discharge for more than a month. Any cramping can usually be relieved using over-the-counter painkillers. It takes about three months to determine whether the procedure has been effective. There should be a follow-up appointment about two weeks after the procedure.One study compared hysterectomy with two successive endometrial ablation procedures in women. The group treated with endometrial ablation had fewer and less serious complications and a quicker recovery. Many studies comparing hysterectomy with endometrial ablation have found no difference in sexual or emotional adjustment after a year. With ablation, however, the effectiveness of the procedure may decline over years; menstruation returns in about a third of women. One concern with ablation treatment is that, because the procedure does not remove the uterus, women still have a risk for endometrial cancer (although the risk is reduced), whereas the risk is eliminated with hysterectomy. In addition, endometrial ablation alters the uterine wall, and may make early detection of cancerous changes difficult. Long term studies using this treatment are still needed.In summary, endometrial ablation is a safe and moderately effective tool in controlling abnormal uterine bleeding in women who have finished their childbearing. An important aspect of the recovery is that it allows women to return to their usual lifestyle in a few days, as opposed to 4-6 weeks for hysterectomy.