Hysteroscopic Endometrial Ablation

This guide has been written to assist you to help women understand hysteroscopic endometrial ablation so that they can make an informed decision about the operation. Dr Alan Lam provides answers to some of the questions asked during the doctor-patient interview.

You may have found that tablet treatment does not adequately control he problem, produces intolerable side effects or the problem returns whenever you try to stop your medications.

A D&C is meant to exclude unsuspected disease of the uterus and is not a curative procedure, while s hysterectomy is a major operation from which you may need several weeks to fully recover.

Hysteroscopic endometrial ablation is a relatively new operation which may be suitable for you.

What does hysteroscopic endometrial ablation involve?

This is most often a day-stay procedure in which the lining layer of the uterus (endometrium), from which monthly menstruation occurs, is destroyed. After the neck of the womb (cervix) is dilated, a small viewing telescope (hysteroscope) is introduced into the cavity which is kept expanded and clear by a fluid solution.

The endometrium may be removed in strips using a diathermy resecting loop ( a loop of wire heated by an electric current) or destroyed by a diathermy roller-ball ( a heated rotating ball at the end of  a wire) or by laser energy. The outcome seems to be the same no matter which method is employed. The diathermy resection method is quicker, however, and produces strips of the lining layer for pathology examination.

Who may benefit from hysteroscopic endometrial ablation?

Your doctor will assess you thoroughly by taking a detailed history and making a careful general and internal examination. This will be followed by investigations which may include a Pap smear, a biopsy of the endometrium and blood tests. You may be advised to have a D&C and/or hysteroscopy (examination of the cavity of the womb) to exclude unsuspected disease of the uterus.

In general, you may be suitable for this operation if:

1. Your menstrual problems are not controlled by medical treatment and are severe enough to justify hysterectomy.
2. Childbearing has been completed.
3. Pregnancy and malignancy are excluded.
4. There is no other pelvic pathology to cause the menstrual disturbance, e.g. endometriosis ( a condition in which tissue resembling the endometrium is found in   various locations in the pelvic cavity).
5. You are not medically fit enough for the major operation of hysterectomy.

What happens before the operation?

In preparation for the operation, your doctor may ask you to take a hormone preparation such as Danazol for several weeks before the operation. This is to help thin the endometrium, making the operation easier and quicker.

Admission to hospital takes place either on the day prior to or in the morning on the day of the operation. Pre-medication may be given to help induce drowsiness. The operation is usually carried out under general or regional anaesthetic.

What happens after the operation?

In most instances, you are able to go home on the same day or the following morning of the operation. You may experience some mild period-like pain for which simple pain-relief tablets are adequate. Some vaginal period-like bleeding in the first one or two days is normal. This should gradually change to a dark-brown discharge over a period of 2 to 4 weeks. You may resume all normal activities as soon as you feel fit. Sexual activity should wait till the bleeding and discharge settle.

What are the risks associated with this operation?

Like any operation, endometrial ablation is not without risks. Complications that may arise include accidental perforation of the uterus, haemorrhage during or after the operation, excessive absorption of the irrigating fluid and infection. Fortunately, these complications rarely occur and are seldom serious. Where perforation of the uterus or haemorrhage occur, further procedures such as laparoscopy (inspection of the interior of the abdomen through a small incision) or laparotomy (surgery of the abdomen) may be required.

How does hysteroscopic endometrial ablation compare with hysterectomy?

It is a day-stay only, quick and relatively painless operation. This means a short anaesthetic, quick recovery and hence early resumption of normal routine. An medical alternative to endometrial ablation is the use of Mirena IUD. While hysterectomy is a cure for menorrhagia, it is a major surgical procedure with greater risk profile compare to endometrial ablation. 

What is the consequence of Endometrial Ablation on pregnancy?

You should only choose to undergo endometrial ablation once childbearing is completed and a safe method of contraception is followed. Although pregnancy is unlikely to occur after endometrial ablation, this can still occur no matter what happens to your periods (even amenorrhoeic women can still conceive). The outcomes of unplanned pregnancies  after ablation are  unpredictable, high-risk  and may be unhealthy. Consequently, you should discuss with your doctor to ensure that you have a reliable method of contraception in place (such as using Mirena IUD, undergoing tubal ligation at the same time of ablation or ensuring that your partner has had or will undergo vasectomy). Regular Pap smears should be continued.

Will I be cured?

Follow-up of women who have had this operation over the past several years shows that 90 to 95% are happy with the result. In 20 to 40% of the cases, periods stop altogether. The rest have regular scanty to light periods only, so that no other treatment is required.

In some women, the lining layer of the uterus may re-grow after some time, resulting in recurrence of the original problem. If this occurs, it is possible to have the operation repeated with similar success.

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

Modified Extract from “Patient Management” Journal, O & G Page, June 1992, pgs 75-76