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ENDOMETRIAL ABLATION

Introduction

Hysterectomy, a major surgical operation, is performed to provide relief for many women suffering from heavy and prolonged uterine bleeding. The removal of the uterus can frequently result in significant physical strain and psychological stress, not only for the woman, but also for her mate and family. Much of the anxiety associated with this operation is being cast aside, thanks to a technique known as ablation of the endometrium. This procedure has proven to be an effective method to stop uterine bleeding without removing the uterus. This new procedure gives hope to many women who cannot tolerate the stress of a traditional hysterectomy for physical or psychological reasons.

A traditional hysterectomy would involve an abdominal incision, almost a week in the hospital and a long recovery period at home. Some women feel they have lost a measure of their femininity while others feel the traditional operation has made sexual contact less fulfilling. Endometrial ablation avoids surgical incisions and requires only a few hours stay in the out-patient surgery center. Patients undergoing this procedure are usually back on their feet and enjoying normal activities within 24 hours. Laparoscopic hysterectomy may be an alternative, which significantly decreases hospitalization time and recovery time, but again, is a more invasive procedure - ask your physician for more information.

The Doctor must rule out cancer of the uterus prior to Endometrial Ablation. This is accomplished by obtaining an endometrial biopsy in the office. A biopsy is the removal of a tiny piece of tissue (bread crumb size) lining the uterus (endometrium). This may cause some momentary sharp cramps. A pathologist will examine the biopsy sample under a microscope to determine if any cancer is present. If cancer is found,  ablation of the endometrium is not indicated. Instead, a  hysterectomy may need to be performed.

Pre-Operative Care

Your Doctor may require that you take a hormone, called Lupron, prior to your procedure. This medication will cause the lining of the uterus to shrink or atrophy, resulting in less bleeding before and after surgery. Since this medicine suppresses (decreases) your ovarian function, you may notice hot flashes, headaches, vaginal dryness, and possibly irregular or no period.

In most cases, you must come to the hospital or ambulatory surgical facility with an empty stomach, so no food or liquids should be consumed after midnight preceding the scheduled surgery day.

Anesthesia

General Anesthesia is rarely necessary. We administer a local in the vaginal area and the anesthesiologist gives sedating medication.

Surgery

Using a hysteroscope, the Doctor is able to thread the end of a cautery instrument through the natural path of the cervix and into the uterus. A hysteroscope is a thin tubular instrument containing two parallel channels, one for an aspiration cannula and one for the cautery element. With an operating room video monitor as a guide, your physician systematically directs the electrical energy into the tissue of the endometrium, or inner walls of the uterus. The electrical energy is transferred to heat energy under the surface of the endometrium, coagulating the walls of the uterus. This cuts off the blood supply to the uterine lining resulting in cohesion of the walls. The procedure "ablates" or destroys the endometrial tissue to a depth of approximately four millimeters. Since the uterine muscle is approximately 20 (twenty) millimeters thick, the major part of the uterine muscle is left untouched. When the hysteroscope is withdrawn, the inner walls of the uterus bind together. This procedure is usually completed in less than 30 minutes. "Roller ball" electrocautery is one of several methods of ablating the endometrium. 

Others include Novasure, Thermachoice, and Hydrothermablation (HTA).  They all have similar success rates. Novasure uses cautery and HTA uses hot water which circulates around the cavity slowly and gently ablates (shrinks) the lining. It can be done while you are awake and you can even watch if you desire.  The cautery methods are faster, but crampier and most patients prefer to not be awake. Thermachoice is a balloon with hot water in it.  It is placed in the cavity, like the Novasure, without hysteroscopic viewing of the ablation.  Some practitioners prefer methods like HTA and roller ball because they can see the entire procedure.

Illustration shows position of the hysteroscope for endometrial ablation procedure.

Success Rate

Absent or reduced menses will occur in approximately 80%-90% of cases. Those who continue to bleed may need further treatment.

Patients wishing to be pregnant should not undergo this procedure, as it may cause sterility. On the other hand, do not rely on it as a means of birth control. Tubal sterilization may be performed at the same time, which requires a laparoscopy.  The Essure sterilization procedure can be done through the hysteroscope and avoids major surgery and in certain cases can be done at the same setting as ablation.

Risks

Possible (but rare) complications include:

  • fluid overload (especially in the lungs)
  • uterine perforation (hole in the uterus with possible bleeding and need for hysterectomy) or injury to surrounding structures such as bowel
  • infection
  • anesthesia risks

Talk to your doctor about these risks.

Post-Operative Recovery

General: You may experience some cramping which can be controlled with medication. General anesthesia may cause a feeling of prolonged drowsiness and nausea. A sore throat may occur if an airway (tube to aid breathing) was inserted during anesthesia.

Activity: You have no restrictions after 24 hours.

Work: You may return to work as soon as you feel ready.

Diet: If nausea occurs, take only liquids by mouth until it passes. You may resume your regular diet as soon as you feel ready.

Sex: Abstain from sexual relations until your post-operative check-up unless otherwise instructed.

Wound Care: Do not douche, use tampons or place any medications in the vagina unless otherwise instructed. You may have some bleeding or spotting after the procedure. If you have bleeding that is heavier or longer than a normal period, a foul-smelling discharge, severe pain or fever of 101° Fahrenheit lasting 24 hours or more, call your health center.

Medications:
Most post-operative pain is not severe and may be relieved by such over-the-counter preparations as Tylenol, Nuprin, and Advil. Resume taking any prescribed medications.





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