Hysteroscopic endometrial ablation
Endometrial ablation is a medical procedure that is used to remove (ablate) or destroy the endometrial lining of a uterus. This technique is most often employed for people who suffer from excessive or prolonged bleeding during their menstrual cycle but cannot or do not wish to undergo a hysterectomy. The procedure is most commonly done on an outpatient basis. Placenta accreta may occur if the patient becomes pregnant after endometrial ablation, so birth control is recommended. However, heavy menstrual bleeding is most commonly due to dysfunctional uterine bleeding or adenomyosis. If patient does not want hysterectomy or endometrial ablation, another option with norethisterone can be given.
A number of competing procedures are available.
Transcervical resection of the endometrium (TCRE) uses a hysteroscope equiped with a cauterization loop that avails for resection of the endometrium. It is a proven procedure, being a day-care procedure with rapid recovery.
The HTA System uses a small telescope-like device called a hysteroscope which is inserted into the uterus through the cervix, to help doctors safely confirm proper probe placement and to see the area they are treating. This device circulates heated saline which burns the lining of the uterus. This procedure will stop, or significantly decrease, menstrual bleeding. 94% of patients who have undergone this procedure reported a satisfactory decrease in menstrual flow.
With the Novasure system a mesh is introduced into the cavity and the lining is destroyed by applying electrical energy to the mesh that will thermally damage the adjacent endometrium. 87% of patients have a successful reduction in bleeding down to normal levels.
An alternative is the Thermachoice III balloon that is filled with heated fluid to destroy the uterine lining. The fluid is safely contained in a flexible and non-allergenic material that conforms to most uterine shapes and sizes with no reduction of efficacy. Novasure® was compared with ThermaChoice® balloon ablation in a randomized trial of 126 women. There were no operative complications in either group. At five-year follow-up, the Novasure® versus ThermaChoice® groups had significant differences in the frequency of amenorrhea (48 versus 32 percent), repeat ablation (one woman in each group), or hysterectomy (10 versus 13 percent).
Older methods utilize hysteroscopy to insert instruments into the uterus to destroy the lining under vision using laser or electrical current in a small loop. Another system introduces a radio-frequency rod that emits energy to destroy the uterine lining.
After the procedure, the endometrium heals by scarring, reducing or removing the possibility of future uterine bleeding. The patient may develop amenorrhea, however hormonal functioning will remain unaffected.
Approximately 80% of those who undergo this procedure will have reduced menstrual bleeding. Of those, approximately 45% will stop having periods altogether. However, a second procedure or a hysterectomy will be required in approximately 22% of cases.
Although uncommon, the procedure can have serious complications including:
- Perforation of the uterus
- Burns to the uterus (beyond the endometrial lining)
- Pulmonary edema or embolism
- Bowel burn leading to death. See Maude database, Novasure.
- Post-ablation tubal sterilization syndrome
- Hysteroscopic Surgery, by King’s College Hospital. August 2013
- Cooper, K. G.; Bain, C.; Parkin, D. E. (1999). "Comparison of microwave endometrial ablation and transcervical resection of the endometrium for treatment of heavy menstrual loss: A randomised trial". The Lancet 354 (9193): 1859–1863. doi:10.1016/S0140-6736(99)04101-X. PMID 10584722.
- Page 122 in Desai (January 2002). Gynecology Endoscopic Surgery: Current Concepts. Jaypee Brothers Publishers. ISBN 978-81-7179-937-4.
- Hydro ThermAblator System (HTA). Instructions for use. 2005 Boston Scientific Corporation.
- NovaSure. Instructions for use. 2004 Cytec Corporation.
- Gynecare Thermachoice III. Instructions for use. 2008 ETHICON, Inc. a Johnson & Johnson Company.