THE ENDOMETRIAL ABLATION PROCEDURE – SIDE EFFECTS AND GENERAL INFORMATION
Endometrial Ablation is a method of controlling menorrhagia (heavy periods) by destruction of the endometrium (lining of the uterus). It is performed by resecting or cauterising the endometrium to remove all the glands, leaving only myometrium (muscle) and fibrous tissue, so that there is no regeneration each month. It eliminates the need for hysterectomy in many women with abnormal bleeding, unless there is serious disease present. In many women after the age of 35, and sometimes earlier, the hormones controlling menstruation are out of balance, and this causes abnormal periods, which can be heavy, painful irregular and prolonged. They are also often accompanied by severe PMS, which causes mood swings, depression and even menstrual migraines. These symptoms are often incapacitating. Although controlled by the hormones, PMS is actually caused by chemicals released from the endometrium, which in effect, poison the system. In most cases, there is no pathological disorder present, and this condition is called Dysfunctional Uterine Bleeding. In the past, after conservative measures had failed, hysterectomy was the only option. This involves several days in hospital with a 4-6 week recuperation and a higher risk of complications, both short and long term.
AIM OF THE OPERATION
After menstruation, the endometrium is 1 mm thick and consists of a basal layer of glands. Under the influence of hormones, the endometrium increases to 4-5 mm, ready to receive a fertilised egg. If this does not eventuate, the endometrium is shed, and this is termed menstruation. The aim of the operation is to remove the final 1 mm of the basal layer, so that there are no glands from which the endometrium can regenerate.
There have been some so-called second generation techniques developed for those gynaecologists not trained in operative hysteroscopy, including such methods as hot balloons and microwaves, but the gold standard remains Endometrial Resection. A telescope encased in a metal sleeve (Hysteroscope) is passed into the cavity of the uterus (womb) through he cervix (neck of the womb). A continuous flow of fluid under slight pressure is used to distend the cavity for better vision and to wash out any blood that may be present. There is a metal loop on the end of the Hysteroscope, which can be moved back and forth. When activated, it is used to resect or cut out the endometrium down into the myometrium.
Fig 1 Hysteroscopic view of the endometrial ablation procedure
A Laparoscopy is also used to monitor the procedure, to make it safer and more effective. A telescope is passed into the abdomen through the navel, and carbon dioxide gas is used to push the bowel out of the way, to minimise the risk of injury to the bowel and other organs. Also, by monitoring the procedure from above, one can resect more deeply into the myometrium, thus increasing the long-term success rate by removing the roots of any glands that have grown into the myometrium. Finally, the outer part of the uterus at the insertion of the Fallopian Tubes can be cauterised or clipped to prevent any further pregnancies.
While the procedure can be performed at any time of the month, the optimum time is at the tail end of the period, when the endometrium is as thin as possible. If the procedure can only be performed at a certain time, drugs or hormones can be prescribed to prevent the build up of the endometrium. The operation is performed as a Day Procedure. Your stomach must be empty i.e. nothing to eat or drink after midnight the night before. A pre-operative diagnostic hysteroscopy and curette may be performed in the office to rule out any abnormal pathology. A Scan may also be necessary.
A general anaesthetic is used and you are unable to drive home, and must either be picked up or take a taxi home. In some cases, an overnight stay is necessary.
AFTER THE OPERATION
In some cases, at the end of the operation, there is significant bleeding and a catheter is inserted into the uterus to apply pressure. This is removed after 4 hours. There is some pain for 2-3 days, and analgesics may be necessary, but you should be fit to resume normal activities on the 4th day. There is a watery, initially blood-stained, discharge for 2-3 weeks, although occasionally it may last 4-6 weeks.
RESULTS OF THE OPERATION
The author has performed almost 2000 procedures. The following results are now being achieved:
• Dysfunctional Uterine Bleeding: 97% success, with 85% having no bleeding at all, and 12% having scanty periods. Only 3% require further treatment, such as repeat ablation of hysterectomy.
• Fibroids: 88% success, with 76% having no bleeding and 12% scanty periods
The operation is irreversible, but has no effect on ovarian or sexual function. As an added bonus, in most cases, PMS, dysmenorrhoea and menstrual migraines are either eliminated or markedly improved.
Complications are rare, especially when compared with other operations such as hysterectomy. Significant infection has occurred in about 1:400 cases, requiring intravenous antibiotics, and there have been 2 cases of a secondary haemorrhage occurring 2-3 weeks following the procedure. The following complications have been reported in the literature:
• Perforation of the uterus and damage to internal organs
• Excessive bleeding requiring immediate hysterectomy
• Excessive absorption of fluid affecting the electrolytes
Contraception is not guaranteed, and there have been rare cases of pregnancy where resection alone was performed. With this techniques, the fallopian tubes are cauterised, thus further reducing the risk. It must be realised that the operation is irreversible, and you are no longer able to fall pregnant or bear children. It is thus only suitable for women who have finished their family.
Endometrial Ablation represents a major advance in Gynaecology. It offers a relatively simple alternative to hysterectomy for the control of dysfunctional uterine bleeding and pre-menstrual symptoms.
Important legal notice: This information is to be taken as a guide only and is not intended as an alternative to advice from your doctor. The Gold Coast Gynaecology legal disclaimer and waiver of liability applies to this document for more information please see http://www.goldcoastgynaecology.com.au/100048.php. This document was written by Dr David S. Browne 2003 and subsequently modified by Dr Samir M. Henalla 2010.