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Hysteroscopic endometrial ablation: The operation
Hysteroscopic endometrial ablation: The operation
If you are considering having an endometrial ablation or have an endometrial ablation planned, it is important to know all you can about it. This includes:
- why you need this operation
- what it will be like
- how it will affect you
- what risks are involved
- any alternatives.
The information here is a guide to common medical practice. Each hospital and doctor will have slightly different ways of doing things, so you should follow their guidance where it is different from the information given here. Because all patients, conditions and treatments vary it cannot cover everything. Use this information when making your treatment choices with your doctors. You should mention any worries you have. Remember that you can ask for more information at any time.
What is the problem?
You may be having problems with your periods. Your periods may be heavy. You may be bleeding between your periods. You may be bleeding after you have passed the menopause when you should have no more periods. A scan may have shown thickening of the lining of your uterus, which is called the endometrium. We use a special narrow telescope, called a hysteroscope, to examine your uterus.
What is the endometrium?
The endometrium is the lining of your uterus. Your uterus lies in the centre of your pelvis. It is about the size of your clenched fist and is hollow with a special lining. The lowest part of your uterus jutting down into your vagina, is ‘the neck of the womb’, also called your cervix. Cervical smears are taken from the surface of your cervix. The rest of your uterus is called the body. It thins out at the top to form two hollow tubes called the Fallopian tubes. You have a Fallopian tube on each side. These run sideways to end near your left or right ovary.
Your endometrium changes with your monthly menstrual cycle. Chemicals from your ovaries, called hormones, control your menstrual cycle. Every month your endometrium is shed as a period provided you are not pregnant or past the menopause.
Near the middle of your cycle you release an egg from one of your ovaries. Hormones from your ovaries will have already thickened your endometrium, ready to receive the egg. If your egg is fertilised by a sperm, it will stick firmly to your endometrium and develop into a baby in your uterus. If it is not fertilised, your hormones change. This change makes your endometrium come away with some bleeding; this is a period. After a few days a new thin layer of endometrium forms. This starts to thicken, ready to receive a fertilised egg during your next cycle. After the menopause, your ovaries stop producing the hormones that control your menstrual cycle. Your endometrium remains thin and your periods stop.
What has gone wrong?
We have been unable to find a definite cause for your period problem. We will have ruled out serious conditions, such as fibroids or cancer, using tests like a hysteroscopy and endometrial biopsy. In some way, the shedding mechanism of your endometrium is not working properly. This condition is called dysfunctional uterine bleeding. Tablet medication will not have helped with the problem.
What is a hysteroscopic endometrial ablation?
An endometrial ablation is an operation to permanently destroy the endometrium lining your uterus. We pass a special telescope, called a hysteroscope, through your vagina and cervix and into your uterus. We pass instruments down the hysteroscope to destroy your endometrium. There are several ways of destroying the endometrium. These are:
- Roller ball diathermy - This instrument has an electrically heated metal ball on one end. We roll this back and forth across the lining to destroy it. The electric current can also seal any bleeding areas. You will usually need a general anaesthetic for this.
- Laser ablation - This is an established way of doing this operation and is very similar to diathermy. It is less used due to the high cost and availability of the laser equipment. There is no evidence that it is much better that the other ablation treatments. You will usually need a general anaesthetic.
- Balloon ablation - This is a simple but effective method of destroying your endometrium. We insert a special thin-walled, plastic balloon into your uterus and fill it with warm water. We then heat the water inside the balloon. The temperature of the water and time that the balloon is left inside your uterus is carefully controlled electronically. Only the endometrium is destroyed. We can do this operation under local anaesthetic.
- Microwave treatment - A newer technique called microwave endometrial ablation (MEA) does not use a hysteroscope. It uses microwaves to heat the inside of your uterus to destroy your endometrium. Again, this can be done under local anaesthetic.
Your gynaecologist will be able to discuss the pros and cons of each type of treatment with you.
Weeks before your operation you will need drug treatment to make your endometrium thinner and reduce its blood supply. These drugs are usually danazol tablets or hormone injections, called GnRH analogues. During the ablation no tissue samples are taken for examination under the microscope. For this reason a few weeks before the operation we may give you a hysteroscopy and endometrial biopsy. This is an examination of your uterus and taking a sample of your endometrium for examination under the microscope.
We aim to stop your bleeding problems by completely destroying the endometrium lining your uterus. We call this process ablation.
If your endometrium is completely destroyed you will have no further periods. If a small amount of your uterus lining remains, your periods should be light.
The endometrium has great powers of regeneration. It can grow back if only a very small amount is not destroyed. We cannot guarantee that this operation will permanently stop your periods. Most women, about 85%, are pleased with the result after four years. Some of the remaining women will need a repeat ablation or even an operation to remove the uterus, called a hysterectomy.
After an ablation you will have much less chance of becoming pregnant, but it can still occur. You must still use contraception. Only some forms of contraception are suitable. Sterilisation is ideal. The contraceptive pill and the coil (IUCD) are not.
Are there any alternatives?
If your bleeding is not severe, treatment with hormones and other drugs may help. A special device like a coil, called a Mirena IUS, can be put into your uterus. It contains hormones that stop your endometrium working.
Instead of destroying the endometrium the lining can be removed; this is called an endometrial resection. There is a separate leaflet in this series covering this operation. An endometrial resection provides good tissue samples for examination under the microscope. You would not need the hysteroscopy examination and tissue sample that we usually do weeks before an ablation. Another advantage is that we can also remove any fibroids that are lying just below the surface of your endometrium during the resection.
A hysterectomy, where you uterus is removed, is the only operation guaranteed to permanently stop your periods and bleeding problems. If you have other problems with your uterus, such as a prolapse or a disease of the cervix, a hysterectomy is often the most effective treatment. Discuss the various options with your gynaecologist.
What if you do nothing?
If you do nothing, and you have not reached the menopause, your period problems are likely to continue until you do. If you have heavy bleeding, you may become anaemic over time. Anaemia is when your blood does not contain enough oxygen-carrying, red blood cells.
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