What Is Endometrial Ablation? – Procedure, Recovery & Pregnancy

Endometrial ablation (EA) is the medical term for uterine ablation, a name commonly used despite being incorrect. It can be defined as an endometrial destruction technique for heavy periods, which normally improves PMS (premenstrual syndrome) symptoms. It is, however, contraindicated in women planning to get pregnant in the future.

NovaSure is the brand name of the most widely used device nowadays. It uses heat to destroy the endometrium and involves fewer risks and side effects than other methods, including the thermal balloon, circulated hot water, cryotherapy and laser beam. Success rates reach up to 90%.

Definition

Endometrial ablation (EA) is a procedure commonly referred to as uterine ablation. In either case, the meaning of ablation is surgical removal. However, the latter term is used incorrectly, as it is not the uterus which is destroyed, but the uterine or endometrial lining. The procedure for the removal of a woman's uterus is called hysterectomy.

It is used to destroy the lining of the uterus, which stops the menstrual flow in many women, especially those suffering from menorrhagia or heavy menstrual periods. In other cases, monthly bleeding does not stop completely, but it is reduced to normal or lighter levels.

Heavy menstrual periods and endometrial ablation

It can be done at your doctor's office or an outpatient facility. The procedure lasts about 45 minutes and is done using either a local anesthetic or spinal anesthesia. General anesthesia might be used in some cases, although it is less common.

It is the treatment of choice after the woman has tried with medications unsuccessfully: if heavy menstrual flow is not controlled with medication, endometrial ablation solves this problem in the majority of cases. Find out the main indications and contraindications below:

Indications

As mentioned earlier, women with heavy menstrual periods are the most common candidates for undergoing endometrial ablation. It might be useful in other cases, though. The following is a list with the main indications:

• Premenopausal or perimenopausal women
• Postmenopausal bleeding of benign origin
• Anovulatory bleeding
• Blood loss due to fibroids
• Intramural or submucosal fibroids smaller than 2 cm

It should be noted that these abnormalities can be treated by means of global endometrial ablation (GEA) devices as long as the patient has a normal endometrial cavity. As for the treatment of fibroids, women should be aware that endometrial ablation does not remove fibroids.

There is a minimum preoperative criteria for patients opting to EA referral: on the one hand, they must be sure that they do not want to get pregnant in the future; on the other hand, those who want to avoid hysterectomy or retain the uterus are good candidates as well.

Contraindications

There is a common belief that endometrial ablation can treat other pathologies related to those listed above. However, patients should know that it can by no means be used in any of the following cases:

• Treatment of ovulatory dysfunction
• Uterine fibroid removal
• Desire for future fertility
• Pregnant women
• Presence of an active pelvic or urogenital infection (urinary infection, cervicitis, endometritis, salpingitis, PID...)
• Presence or suspicion of premalignant or malignant conditions of the endometrium or uterus
• High risk for endometrial cancer

Additional contraindications include problems such as uterine anomalies, hydrosalpinx, recent uterine infections, history of cesarean section, etc.

Benefits and disadvantages

Women with heavy menstrual periods see them considerably reduced following endometrial ablation. This is a major advantage, especially in cases where the patient has no alternative but to miss work, limit her daily activities or avoid certain sports due to heavy menstrual bleeding.

Symptoms derived from the PMS syndrome are significantly reduced as well. Some women report a better mood, improved energy levels or even a boost in self-confidence after seeing their menstrual flow reduced thanks to EA.

On the other hand, endometrial ablation has some drawbacks that cannot be ignored:

• Younger women are less likely to respond well. There is a chance that they might need a repeat procedure in the future.
• In some cases, the endometrial lining grows back and heavy periods might appear after a year or two.
• If a small part of the endometrium is left in place and pregnancy occurs, a high number of problems might appear.

Endometrial ablation is for premenopausal women who are finished childbearing rather than younger women planning to get pregnant in the future, as a pregnancy following the procedure can be dangerous.

Methods of surgery

Surgery is needed to perform an endometrial ablation, as it is used to surgically "destroy" (ablate) the uterine lining, that is to say, the endometrium. In some cases, the doctor might use a lighted viewing instrument called hysteroscope to see inside the uterus.

Although no incisions are required to carry it out, your doctor may do it through any of the following methods: laser beam, heat, electricity, freezing, or microwave. The tools and/or devices used in each case are explained below:

Laser beam

The doctor uses a beam of light radiation that helps destroying the uterine lining.

Heat

Thermal ablation can be done using either radiofrequency, a balloon filled with saline solution (thermal balloon ablation) or normal saline (hot free water).

Electricity

Electrical ablation consists in using electric current to cauterize the tissue of the endometrial lining. The current travels through a wire loop or rollerball.

Freezing

Also known as cryoablation. It is done with a probe that uses extremely low temperatures to destroy the endometrial tissue.

Microwave

MEA (microwave endometrial ablation) uses heat from a microwave probe to reduce or remove the thickness of the uterine lining.

The NovaSure system is an example of thermal ablation. It involves the insertion of a slender wand that extends a triangular-shaped netted device into the uterus. Radiofrequency energy is delivered through the netting for about 90 seconds to destroy the lining of the womb.

Main thermal endometrial ablation methods

Some endometrial ablation procedures require a resectoscope for resecting the endometrial tissue. It is similar to the hysteroscope but includes a built-in wire that uses electrical current for this purpose. Other techniques use ultrasound to guide the instrument.

Risks and side effects

Minor common side effects can appear after endometrial ablation. Cramping and mild abdominal bloating are frequent and usually disappear after 1-2 days. Also, a watery discharge of brown or orange color mixed with blood can appear and last a few weeks. Urinary incontinence and nausea for 24 hours are common, too.

The presence of discharge is not a concerning symptom, but an excessive or heavy bleeding beyond 2 days, the passing of blood clots or discharge with odor are abnormal side effects and might indicate that additional medical attention is required.

Potential side effects and complications after endometrial ablation

Even though the procedure has no effect on hormones, they are often the cause for certain long-terms effects. After EA, the lining cannot shed, yet the ovaries still send the hormonal signals necessary for menstruation. The problem is, the blood has nowhere to go, thereby causing pelvic pain and other problems.

Although rare, infection, pain and bleeding might appear. With certain methods, there is a small chance that the device causes burns to the vagina, bowel or vulva. Pelvic pain might be an indicator that you have developed the post-endometrial ablation syndrome.

On the other hand, because endometrial ablation procedures do not harm or affect a woman's hormonal system, patients are not expected to gain or lose weight. However, joint pain might appear, which can lead to lessened activity, thereby resulting in weight gain.

Recovery and post-op care

Usually, endometrial ablation is done as a day case operation, which means patients can go home on the same day after being kept in hospital for 3 or 4 hours afterwards, especially when general anesthesia is used. If it is done with a local anesthetic, you can leave hospital following the operation.

To avoid crampy abdominal pains, patients are usually provided with appropriate painkillers to take for 48 hours after the operation, although some women do not need anything. Taking paracetamol or ibuprofen at home to relief the pain should be enough.

In some cases, women are prescribed painkillers that contain codeine or dihydrocodeine. Side effects caused by these medications include sleepness, sickness, and constipation. Eating extra fruit and fibre might be a good idea to relieve these symptoms.

Most women can get back to normal within days, which includes continuing to do everyday domestic activities and driving. As for being able to have sex, it might take a little longer. It is advisable to wait until the discharge or vaginal bleeding has stopped.

Most women need to take some time off work, which usually does not extend longer than 2-5 days. This depends on the type of job each woman does, though: if it is a physically demanding job, you might need to return gradually.

Pregnancy after endometrial ablation

As mentioned earlier, there are times when endometrial ablation is not very effective and the uterine lining is not removed completely. It is in these cases when the patient continues to have menstrual periods either immediately or within a few years of the EA procedure. Pregnancy is more likely in these cases.

This is the reason why, sometimes, tubal ligation and endometrial ablation go hand in hand. Given that women who decide to undergo EA are asked to be totally sure that they do not wish to become pregnant in the future, opting to a permanent birth control method is possible. Using a hormonal for of contraception is another possibility. Women who manage to get pregnant after EA should know that the chances for miscarriage and pregnancy loss are higher.

If the endometrial ablation is performed correctly and the endometrial lining is fully destroyed, pregnancy is not possible. In these cases, if a pregnancy were desired, surrogacy is the only option, either with donor eggs or with the woman's own eggs in case the ovaries are still functioning.

FAQs from users

What is the cost of uterine ablation?

In comparison, endometrial ablation is more cost effective than hysterectomy. However, the overall cost depends on the method used to do it, and whether it is done at the gynecologist's office or at a hospital.

Broadly speaking, if done at the doctor's office, endometrial ablation can cost up to $2,700, while hospital operations can range from $4,500 to 5,500 on average.

What are the success rates of endometrial ablation?

The vast majority of patients who undergo endometrial ablation—up to 90%—are highly satisfied with the results. By satisfied we mean that the patient sees a significant decrease in excessive menstrual flow or PMS symptoms as a result of EA.

In general, about 50% of patients will have no menstrual periods after the procedure, or just have a mild spotting, while another 30-35% notice a great reduction in the menstrual flood to normal or lighter levels.

Global endometrial ablation methods prevent 75% of hysterectomies, with another 25% ends up with hysterectomy. On the NHS, the failure rate for endometrial ablation is about 25-35% and, in case of failure, you may be offered a repeat treatment.

Can endometrial ablation be reversed?

No, the damage caused to the uterine lining is permanente and reversal is not possible. Keep in mind that EA involves applying energy to the lining, which causes enough damage to the cells to eliminate the menstrual bleeding. However, in a percentage of EA procedures, the endometrial lining is not completely removed and menstrual flow appears years later (about 5 years).

Is uterine ablation a good option to treat adenomyosis?

It depends on the depth of adenomyosis (abnormal presence of endometrial tissue within the myometrium). The deeper it is, the better the outcomes. In general, patients with only minimal endometrial penetration (less than 2.5 mm), called superficial adenomyosis, often have good results after endometrial ablation.

Conversely, patients with deep adenomyosis usually continue to have problems and require hysterectomy. The depth of adenomyosis can be screened through ultrasound or magnetic resonance imaging (MRI).

Is endometrial ablation possible with bicornuate uterus?

In general, endometrial ablation techniques are contraindicated in women with an abnormal-shaped uterus. However, a study published in 2009 by the NCBI (National Center for Biotechnology Information) presented two cases of bicornuate uteri suffering from heavy menstrual period that were successfully treated with EA.

The report explains that, even though EA is possible, each uterine cavity has to be treated separately. It is possible nowadays thanks to the use of hysteroscope, which allows proper adjustment of the procedure.

Does endometrial ablation hurt?

EA procedures are done using either local or general anesthesia, so the patient feels no pain throughout the procedure. During the recovery process, women can feel some discomfort or pain, but it should disappear within 1 or 2 days. If further complications such as foul-smelling discharge or blood clots appear, contact your doctor immediately.

Does endometrial ablation affect the implantation of a fertilized egg?

Indeed. To understand why, let me explain you what is the function of the endometrium. This regenerative lining called uterine or endometrial lining is an environment that contains and supports a growing pregnancy after embryo implantation.

In other words, when a fertilized egg lands on the endometrium, the lining of the womb supports and nurtures the pregnancy. If no endometrial lining exists, the fertilized egg has no fertile endometrium to implant and receives neither support nor nurture.

Does endometrial ablation mean no more periods?

Theoretically, yes. If the ablation is done properly and the endometrial lining is removed completely, it does not exist anymore and will not shed monthly. However, if a part of the endometrium remains still in the uterine cavity, it is possible for the woman to still have periods, but much lighter or in the form of a mild spotting.

Suggested for you

After endometrial ablation, getting pregnant is not possible in most cases or, in case it occurs, a high number of risks would be involved. If you want to have a child after endometrial ablation and are interested in IVF with a gestational carrier and an egg donor, see also: What is gestational surrogacy?

Are you interested in learning more about the endometrium? This regenerative lining of the uterus is fundamental for getting pregnant, but can lead to problems that can indeed be solved through endometrial ablation. Be it as it may, you can read more here: Definition of 'endometrium'.

Finally, and as seen earlier, monthly menses are expected to disappear after endometrial ablation. Do you know how does the menstrual period work? Although it varies from woman to woman, there following is a general guide to it: Understanding the menstruation.