Can Endometrial Ablation Replace Hysterectomy in Cases of Heavy Menorrhagia?

Only after three months will it become clear what the effect of the procedure was. Usually after six weeks you call in the doctor’s office, probably to have the uterus sounded in order to see whether a cervical stenosis is setting in. (If it is, there may be more bleeding with the first period.) Usually, one or two additional dilatations are also in order within a month or two.

You should be “up and running” (not literally, though!) within a day or two. Sometimes the recovery time will be longer, a week or two. Compared to several months needed to regain full health after a hysterectomy, endometrial ablation is real picnic!

Endometrial ablation (sometimes misspelled as “oblation” or “ablasion”,  also called uterine ablation and uterus ablation) is the technique to stop heavy bleeding during the period.

The normal loss of blood during the period is around 25 ml, and anything above 80 ml is just too large. Besides anemia (anaemia) and the problems it can bring you, losing so much blood may make your life unbearable. Many women escribe this not as having a period but as downright hemorrhaging. It is difficult to live when you

.   cannot sleep,
.   cannot move because of the blood,
.   cannot go to work for several days or even for a whole week.

It is exactly in this situation when you say “I can’t live like this anymore, doctor, do anything, just save me now!” The next
thing you know, you’re discussing various kinds of surgery, most of them you did not even know to be existing, all up to hysterectomy. If you’re lucky, and fall into one of the groups of patients described below, you can settle for a “smaller” surgery such as endometrial ablation.

Remember this: if you talk to a healer, he will offer you a healing. If you talk to the surgeon, he will offer you a surgery. I suggest you do both and only then decide what to do. If there is one piece of advice that I would like you to carry on with you after reading this site, this would be it.

How to Perform Endometrial Ablation

Nature expects you to get pregnant every month. Your body gets ready for that and if the pregnancy does not happen, as is usually the case, the overgrowing endometrium is torn away and goes out. The objective test of menorrhagia is when more than 80 ml of blood is lost per menstruation, over several menstrual cycles. It is very difficult to measure the lost blood, so usually subjective measures are used, such as flooding, passing of clots, the number of pads or tampons used. If the patient is in hospital, her haemoglobin values could also be monitored.

Often the bleeding will be painful, but that may not be the biggest problem. At least, there are ways to fake or relieve pain, but if the abnormal bleeding persists, what is the woman to do? Up to 10 or 15 years ago, hysterectomy would have been the only solution. Today, there are many means to execute ablation, for instance:

 

. Laser ablation
. Thermal ablation
. Novasure endometrial ablation
. Hydrothermal ablation
. Electrosurgical Technique (Roller Ball or Barrel)
. Operative Hysteroscopy (see the Endometrial Ablation For Fibroids Video)
. Radio frequency ablation
. Thermal baloon ablation
. Microwave ablation
. Cryo ablation

Endometrium is the innermost layer of the uterus and if it can be removed, most of the menstrual bleeding should stop. That is the idea behind endometrial ablation — remove the endometrium, leave the rest of the uterus intact and let the life merrily roll on!

In the beginning, in the 1990′s, the gynecologists expected to end all the excessive bleeding in this way, actually, to introduce the patient into the state of amenorrhea. In practice, after ablation, you still get periods, but light or almost non-existant (that would be the best case scenario). The worst case scenario is when you have adenomyosis in the uterus, meaning the lining grows deeply into the muscle of the uterus. Ablation cannot go that deeply, so even after endometrial ablation, some of the lining is still there. That may cause the problems to continue, all up to the full hysterectomy. In some cases, women opt for a repeated ablation.

Are You a Good Candidate for Endometrial Ablation?

 

. Of course, first you should have an intractable menorrhagia, one that does not respond to standard therapies, such as hormone replacement and dilatation and curettage (D&C).
.   It should be as certain as possible that there is no other pathology which could produce menorrhagia — polyps, submucous fibroids etc.
.   If you have premalignant or malignant endometrium, ablation is out of the question.
.   You must be sure that you do not want any more children.
.  You cannot undergo a hysterecomy for any other reason.

Also, ablation will be out of the question if you fall into one of the following categories:

 

.   If there is a history of endometrial cancer of pre-cancerous histology.
.   You have an active genital or urinary infection.
.   You have an active pelvic inflammatory disease.
.   You have an active intrauterine device.
.  If endometrium is weak, perhaps because of a previous caesarian section or because of a previous transmural myomectomy.

The Possible Outcome of Endometrial Ablation

In most cases, if the patient is well chosen and if the doctor knows his or her job, heavy menorrhagia transcends into light menzes or no bleeding at all. Many practising gynecologists say that their most satisfied patients are exactly women with this problem — the bleeding is gone, life goes back to normal, the uterus and the ovaries are still there.

A total amenorrhea after ablation is rare, so you will be more pleased with the outcome if you (and the doctor) aim at hypomenorrhea — small bleeding. In some cases, the lining of the uterus can come back, say after 5 or more years. If you are nearer to menopause, ablation will serve you better in this regard. Theoretically, the presence of the lining could mean more bleeding or even a pregnancy, so if you know for sure that you do not want any more children, it is possible to combine ablation with some kind of sterilization. Failing that, after ablation, you should use a reliable method of contraception.

If there are tumors in the uterine cavity, the surgeon may try to expel them as well, since the instruments are there already. In some cases, the surgeon may opt for simultaneous laparoscopy — you will have to talk to your doctor about all these possibilities and try to reach a mutual understanding of the protocol before the operation.

Children After Endometrial Ablation?

In very rare cases, curious situations may develop. In some patients, the endometrium grows back, and then a repeated ablation may be in order. An even more unfortunate development is when a woman undergoes an endometrial ablation and then, a few years after that, meets a man that she would like to have children with… Then you see posts such as

“Can the endometrium grow again? See, I have just met a man, he’s kind of cute. We were talking about kids the other day, he looked at me slowly, as if measuring me and said yes, he liked them.”

Gynecological forums can easily be the saddest kind of forums that you will ever go to. The finality of it all, the ending of being a woman, the untold desire for more children and more luck with another man… This is exactly the reason this site exists, to teach you the alternative way and to heal you if there still is time in your particular case.

Preparation for Endometrial Ablation

The doctor may put you on GnRH, which is a replacement hormone. Its main role here is to shrink the uterine volume by 40% to 60%. If there are fibroids inside, they will shrink as well. It takes three months of treatment for maximal decrease of the uterus. Once you stop taking this, the uterus will return to about 88% of its previous size. The main benefit of this drug is to decrease blood loss and to decrease the size of the fibroids, if there are any. The fibroids would then be easier to remove either using laparoscopy, laparotomy or hysteroscopy.

The usual names for the GnRh drugs are Lupron, Synarel, Antagon etc. They are expensive and change your menstrual cycle. Theoretically, you should have the endometrial ablation immediately after the menstrual bleeding is over, but that is just not practical in normal circumstances. The day prior to surgery, the doctor may place a laminaria to gradually dilate your cervix the night before your surgery. Laminaria is a small piece of dried seaweed, it opens the cervix in order to minimize cervical tears during the operation.

After the Endometrial Ablation

Endometrial ablation is a minor surgery, but a surgery nevertheless. It is usually an outpatient procedure, meaning you come in for the surgery, get total anesthesia, and after the procedure is finished (usually, 15 to 45 minutes), they take you a recovery room (1 or 2, sometimes up to 4 hours for the effects of anesthesia to wear off). If everything is OK, you should be home the very same day. Here are some of the symptoms you may or may not have after endometrial ablation:

. Frequent  urination during the first 24 hours after the operation. It is normal.
Bloody, watery (serosanguinous) discharge for up to 6-8 weeks after the operation. Your body is trying to heal, so actually it is a good sign.
. Cramping of the uterus. May be painful, but should stop after the first 24 hours. You may take some drugs to relieve pain.
. Nausea, vomiting or any other mild reaction to the anesthesia.
. Anesthesia, however, may produce more serious problems, such as cardiac arrest or pulmonary arrest — your heart stops or the breathing stops. Fortunately, this occurs only rarely.

Only after three months will it become clear what the effect of the procedure was. Usually after six weeks you call in the doctor’s office, probably to have the uterus sounded in order to see whether a cervical stenosis is setting in. (If it is, there may be more bleeding with the first period.) Usually, one or two additional dilatations are also in order within a month or two.

You should be “up and running” (not literally, though!) within a day or two. Sometimes the recovery time will be longer, a week or two. Compared to several months needed to regain full health after a hysterectomy, endometrial ablation is real picnic!

Other Risks of Endometrial Ablation

Apart from the risks that anesthesia brings in by itself, the most common risks of endometrial ablation are

. uterine perforation and
. fluid overload.

The device the operator is using may perforate the uterus and damage the bowels, or produce some kind of hemorrhage. Especially vulnerable are the cornu of the uterus, where the endometrial lining is thinner by default. The surgeon will often treat these parts of the uterus only lightly, so the lining there may still be present after the surgery. That means there will still be some bleeding during the periods, although never as much as it used to be before the operation.

Depending on the technique used, there may be fluid during the operation in the uterus. Rarely, it will overload the patient’s body, note however that there are recorded cases of even death because of this. A good strategy is to give Lassix 40 mg in the recovery room, in order to prevent pulmonary congestion.

Interview Your Doctor First

You’d think your doctor should interview you, but here I suggest the opposite. That fact is, there are many methods for endometrial ablation but so far none of them has proved to be better than the others. It more depends on the skills of the operator. He or she should be genuinely conversant with the methods and instruments needed for your type of surgery. Always ask the surgeon

. what methods does he or she usually use for endometrial ablation,
. what is the rate of success and why,
. are there any other methods that someone else in his office or hospital uses and how successfully etc.

It is your body after all, and realize that you have the right to a second (or third, or fourth or …) opinion if you don’t like what the first doctor is suggesting.

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