Endometrial Ablations

Overview

The ablation of the endometrium in women with excessive menstrual bleeding has been utilized for well over a century, and the many methods of providing thermal energy have been refined over the years to provide a safe and successful therapeutic strategy. 

Endometrial ablation, regardless of method, decreases monthly blood loss consistently, improves general and menstruation-related quality of life, and avoids hysterectomy in 4 of 5 women who receive the operation. When patients are chosen carefully, results are improved and the risk of significant consequences is reduced.

Endometrial Ablations definition

Endometrial ablation is a minimally invasive gynecologic surgical treatment that is used to treat abnormal uterine bleeding in women who have achieved the desired parity. Heavy, irregular, or intermenstrual bleeding is considered abnormal uterine bleeding.

The ablation is intended to remove the uterine cavity's endometrial lining. Heavy monthly bleeding was commonly treated with a hysterectomy in the past, but endometrial ablation is favorable in that it can be done rapidly as an outpatient operation, is generally painless, and requires little recovery time. It might be an alternative for women who do not want to undergo severe surgery, such as a hysterectomy.

Endometrial ablation is most commonly used in women who have severe monthly bleeding, have failed medicinal therapy, and do not want to have a hysterectomy. The most prevalent cause of heavy menstrual bleeding is dysfunctional uterine hemorrhage, also known as adenomyosis. The technique is nearly often performed as an outpatient procedure, either in a hospital, an ambulatory surgical center, or a physician's office.

Endometrial ablation is generally conducted under local and/or mild sedative anesthesia, or, if necessary, general or spinal anesthesia. Patients often leave the treatment center within one hour of the surgery and spend one day recuperating at home before returning to their daily routines.

Anatomy and Physiology

To identify the proper care, the cause of abnormal uterine bleeding must be evaluated prior to undergoing endometrial ablation. There are several causes of AUB, which may be categorized using the term PALM-COEIN, a generally approved nomenclature devised by the International Federation of Gynecology and Obstetrics (FIGO).There are structural causes of abnormal bleeding, including :

• Polyp, 
• Adenomyosis, 
• Leiomyoma, or
• Malignancy. 

The non-structural causes of abnormal bleeding include

• Coagulopathy, 
• Ovulatory dysfunction, 
• Endometrial,
• Iatrogenic, and 
• Not yet classified.

A transvaginal ultrasound, saline infusion sonogram, or hysteroscopy is used to diagnose structural abnormalities and to evaluate the size and location of the uterus. Endocrinopathies, underlying bleeding diseases such as von Willebrand disease, or iatrogenic reasons, such as different contraceptive techniques or drugs such as anticoagulants, can all be non-structural causes of AUB.

Endometrial hyperplasia or malignancy is an underlying cause of abnormal uterine bleeding that must be investigated with a histological sample of the endometrium before an endometrial ablation.

The uterine cavity's endometrial lining is divided into two layers: functional and basal. The functional layer is responsible for the physiologic tasks of proliferation, pregnancy maintenance, and menstruation, whereas the basal layer is involved in functional layer renewal. Uterine ablation procedures obliterate the endometrial lining, destroying both the functional and basal layers.

By removing these layers, the endometrium is unable to recover, resulting in menstrual suppression. Necrosis, fibrosis, and inflammation are frequent histological findings of the uterine cavity following endometrial ablation. 

Heavy menstrual bleeding

Heavy menstrual bleeding is a fairly typical issue. Approximately one in every three individuals who have their period seek therapy for severe menstrual bleeding. A heavy or excessive menstruation is one with bleeding of more than 1/3 cup (80 ml). If you experience the following symptoms on a regular basis, you may be suffering from excessive menstrual bleeding:

• Change your saturated pads or tampons frequently (for example, every hour for several hours in a row).
• Wear more than one pad at a time or need to use both a tampon and a pad.
• Bleed for longer than a week during your period.
• Have symptoms associated with anemia (low red blood cell count), such as tiredness or shortness of breath.
• Avoid or miss activities, work, or social events due to your menstrual bleeding.

Indications

Endometrial ablation, a less invasive surgical procedure in HMB, should be investigated as a therapy option for women who do not want a hysterectomy. Endometrial ablation, on the other hand, is not without problems or failure. 

Endometrial ablation has been shown in studies to have similar efficacy and cost-effectiveness to hysterectomy in the short term, but with long term follow up women ultimately require definitive management with hysterectomy for persistent bleeding or pain to improve outcomes. Proper patient selection, thorough preoperative evaluations including ultrasound and histological sampling, and realistic patient expectations must be addressed before performing the procedure.

Appropriate patient selection is critical for endometrial ablation therapy of abnormal uterine bleeding. Women of reproductive age who have reached their desired parity but are experiencing excessive monthly bleeding owing to a benign reason that has a substantial impact on their quality of life are candidates for endometrial ablation.

AUB that is not due to a structural reason, hyperplasia or cancer, and failure or intolerance to medication therapy should also be considered. The ideal patient has AUB that is connected to the endometrium, as defined by the FIGO classification system, and does not want to be treated definitively with a hysterectomy.

Finally, the architecture of the uterus must be considered, including the length of the cavity (no more than 11cm) and the shape of the cavity. A preoperative transvaginal ultrasound or saline infusion ultrasonography can provide this information. A benign endometrial biopsy must be acquired prior to executing an endometrial ablation.

Contraindications

Contraindications to the procedure include:

• Pregnancy or fertility preservation
• Endometrial hyperplasia or uterine malignancy
• Active pelvic infection
• Intrauterine device
• History of transmyometrial uterine surgery including classical cesarean section or myomectomy
• Uterine anomaly such as septate, bicornuate, or unicornuate uterus
• Relative contraindications: postmenopausal state, uterine cavity length greater than 10 cm to 12 cm, severe myometrial thinning, or severe uterine retroflection or anteflexion 

Preparation

Prior to performing an endometrial ablation, it is critical to address the patient's expectations regarding post-procedure menstrual bleeding. The objective is to reduce severe menstrual bleeding and thereby improve the patient's quality of life. Endometrial ablation may not be appropriate for women who want amenorrhea. Amenorrhea rates ranged from 15% to 72% 12 months following the treatment.

Because pregnancy after ablation poses a significant risk, it is vital to get counseling on future fertility and adequate contraception. Before the operation, as previously said, the uterine histology with endometrial biopsy and anatomy, including size, location, and cavity shape, should be evaluated using various ultrasound modalities. Endometrial ablation is often performed as an outpatient surgery under anaesthetic.

Types of endometrial ablation

There are different types of endometrial ablation, but they all involve destroying the lining of your uterus.

• Microwave: Microwaves are released via a little applicator, which heats the lining of your uterus, destroying sections of it. The procedure takes between three and five minutes.
• Radiowaves (radiofrequency): Inside your uterus, a wand-like tool with a mesh tip unfurls just enough to allow radio waves to reach the lining. The mesh emits radio waves, which heat and damage the lining. The procedure takes between one and two minutes.
• Electricity (electrosurgery): A resectoscope is a tiny, tube-like device with a viewing lens that contains a wire loop, roller ball, or laser that emits electricity. Parts of your uterine lining are destroyed by the voltage. The viewing lens allows your doctor to see into your uterus and monitor the electrical currents that are causing sections of the lining to scar. This is the least frequent form of ablation and may necessitate anesthesia. You'll almost certainly need to visit a hospital for electrosurgery.
• Heated fluid (hydrothermal): A thin, flexible tube (hysteroscope) with a viewing lens that allows the doctor to look inside your body transfers room-temperature saline into your uterus. Once inside, the saline is heated to a high enough temperature to damage the lining. It takes roughly ten minutes to complete the operation. This type of ablation is effective for uteruses with uneven shapes.
• Heated balloon (balloon therapy): A little balloon is attached to a narrow tube (catheter). A heated fluid is fed through the tube and into the balloon. The heat causes the balloon to expand and make contact with the uterine lining. The heat from the balloon damages the uterine lining that it comes into contact with. The procedure takes between two and ten minutes.
• Cold (cryoblation): A chilly tip of a tube generates small ice balls that freeze and damage the uterine lining. The procedure takes between 10 and 20 minutes.

Technique

Endometrial ablation is discussed using two techniques: resectoscopic and non-resectoscopic. Both treatments include inserting a device into the endometrial cavity and injuring the uterine lining using various ways or energy.

First Generation Technique

• Resectoscopic Endometrial Ablation

This technique is performed under hysteroscopic guidance using a rollerball, monopolar, or bipolar loop electrode. The endometrium is desiccated to the level of the basalis layer using thermal energy. The major disadvantage to resectoscopic endometrial ablation is operator expertise and safety. 

Second Generation Techniques

• Nonresectoscopic Systems 

There are already several technologies available that do not require the use of a resectoscope to destroy the endometrium. The devices employed are global in nature, treating the whole endometrial cavity. Thermal fluid, microwave or bipolar radiofrequency electrical radiation, laser thermotherapy, and cryoablation are examples of second-generation treatments. These alternatives have gained popularity because to their ease of use, safety, and similar results to resectoscopic procedures. 

Complications

Postoperative complications include:

• Distention fluid overload
• Infection
• Uterine trauma: including lacerations to the cervix, perforation of the uterus. With uterine perforation, there is the risk of injury to surrounding organs/structures or rarely fistualization
• Lower tract thermal injury: burns of the cervix, vagina, and vulva
• Pregnancy-related complications including premature birth, abnormal placentation, intrauterine growth restriction, malpresentation, and perinatal mortality
• Obstructed hematometra leading to cyclic pain due to residual endometrium 
• Patients who have had a previous bilateral tubal ligation and endometrial ablation may develop post ablation tubal sterilization syndrome. This illness is characterized by cyclic pelvic discomfort caused by endometrial overgrowth and uterine cornua distension with obstructed fallopian tubes.
• Patient dissatisfaction with resulting menstrual bleeding
• Subsequent difficulty evaluating the endometrium due to scarring and changes seen on imaging after ablation can lead to missed or delayed diagnosis of uterine carcinoma.
• Reoperation with definitive hysterectomy within 5 years due to bleeding and/or pain 

Clinical Significance

In general, most people have a positive outcome when it comes to managing excessive menstrual bleeding. When it comes to selecting a technique, both first and second generation are proven to have comparable efficacy in terms of outcomes. At 12 months following a nonresectoscopic endometrial ablation, 82 percent to 97 percent of patients had less menstrual bleeding, and 85 percent to 98 percent were happy with their results. After 5 years, however, there is a failure rate of 5% to 16% of patients who require a repeat procedure with a complete hysterectomy to relieve chronic pelvic discomfort or bleeding.

• Compared to oral therapy:  Within two years of starting oral medication, 58 percent of women had surgery. When compared to oral treatment, endometrial ablation was more successful in managing excessive menstrual bleeding.
• Compared to Levonorgestrel intrauterine device (IUD): At two years, the effectiveness of medical therapy in reducing excessive menstrual bleeding was comparable to nonresectocopic endometrial ablation. The IUD has several advantages, including non-surgical in-office administration without anesthesia, fertility preservation, contraception, and superiority over oral drugs.
• Compared to Hysterectomy: Treatment with hysterectomy provides benefits such as amenorrhea and long-term treatment of severe menstrual flow. Increased hospitalization, complications, and recovery time are among disadvantages of hysterectomy. At one, two, three, and four years of follow-up, a comprehensive Cochran review found that repeat surgery owing to treatment failure was more common after endometrial ablation than after hysterectomy.

Can I still get pregnant after having endometrial ablation?

Pregnancy is unlikely following ablation, although it is possible. If it happens, the chances of miscarriage and other complications skyrocket. If a woman still want to become pregnant, she should avoid this treatment.

Endometrial ablation patients should utilize birth control until they reach menopause. Sterilization may be a viable strategy for preventing conception following ablation. A woman who has undergone ablation retains all of her reproductive organs. Cervical cancer screening and pelvic examinations are still required on a regular basis.

What should I expect after the procedure?

Depending on the type of pain medication utilized, recovery takes roughly 2 hours. The sort of pain treatment employed is determined by the type of ablation technique, the location of the operation, and your preferences.

Some minor side effects are common after endometrial ablation:

• Cramping, like menstrual cramps, for 1 to 2 days
• Thin, watery discharge mixed with blood, which can last a few weeks. The discharge may be heavy for 2 to 3 days after the procedure.
• Frequent urination for 24 hours
• Nausea

When you can exercise, have sex, or use tampons, consult your ob-gyn. In most circumstances, you should be able to return to work or your typical activities within a day or two. Follow-up visits should be scheduled to assess your progress. It may take many months to feel the full benefits of ablation.

When should I see my healthcare provider?

Monitor your recovery. Call your provider if you have symptoms that give you pause, such as:

• Fever.
• Trouble peeing.
• Intense cramping.
• Heavy bleeding. If you’re using more than one pad per hour, go to the emergency room.
• Discharge from your vagina that’s smelly.

Make an appointment with your healthcare practitioner if you're still having heavy periods or spotting after two to three months to check on your recovery. Keep any appointments that your clinician suggests following your endometrial ablation.

Conclusion 

In the treatment of severe menstrual bleeding, patient-centered care is essential. The research stresses the improvement in quality of life in patients who get medication or surgical therapy for severe menstrual bleeding. It has been discovered that women with HMB have a worse quality of life that is similar to losing half a year of full health. Gynecologists and midlevel doctors deal with severe menstrual bleeding on a regular basis in the clinic. It is critical to collaborate with the patient to choose the optimal therapy choice for improving quality of life.

Endometrial ablation is a surgical treatment performed in women who have excessive monthly flow to remove (ablate) or destroy the endometrial lining of the uterus. Endometrial ablation is not indicated for women who want to have children because to the risk of complications.

For patient safety and overall team performance in the operating room, physicians must coordinate care with preoperative and postoperative nursing, anesthesia, radiology, and endometrial ablation device representatives.