Endometrial ablation is an out-patient surgical procedure which was designed to destroy the lining of the uterus (endometrium). This procedure has proven an excellent alternative to hysterectomy when the woman suffers from excessive uterine bleeding. It is not effective for large fibroids (leiomyomata) or cancer. More than 85% of women who experience excellent results with endometrial ablation are able to avoid hysterectomy-- usually permanently!
The procedure of endometrial ablation is performed through an operating scope that looks like a narrow telescope. This is called a hysteroscope because the physician is able to 'scope' inside the uterus. The original procedure was performed by Milton Goldrath, M.D. at Sinai Hospital in Detroit in 1979. He taught me his techniques in 1984. However, the original procedure was time consuming using the tip of a Yag laser. Improved techniques were devised in the mid 1980's using an electrical ball. This is called a 'roller-ball' procedure.
ROLLERBALL ENDOMETRIAL ABLATION
The instrument used is called an 'operating' hysteroscope. Hysteroscopy is the surgical procedure of looking into the endometrium to determine if an abnormal structure can be seen. The operating hysteroscope allows the gynecologist to remove tissue. He or she may use an electrical ball or bar to 'burn away' the surface of the uterus. This is similar to the electric pens used in wood burning. Destroying the endometrium is termed an endometrial ablation as seen in the photograph at right.
Hysteroscopy is usually an office procedure. Operative hysteroscopy in usually an out-patient surgical procedure. In office hysteroscopy is relatively easy. Out-patient operative hysteroscopy is much more difficult to perform. Very few individuals reach the level of experience of those of the members of the American Association of Gynecologic Laparoscopists. That is why certain manufacturers have designed in-office and out-patient procedures to assist these surgeons. The most frequently used method is the Thermachoice(TM) by Ethicon and the Hot Water Method by MEI.
The Thermachoice device uses a special baloon that is placed into the uterus through the cervix by the surgeon. Hot water is circulated in the balloon. After 9 minutes, the procedure is terminated. The limitations of this method is that fibroids or a different shape to the uterus renders this procedure less than ideal.
The Hot Water Method devices by Milton Goldrath and marketed by MEI uses no balloon. Based on Goldrath's studies, the device allows water to fill all the cavities. The procedure is performed with the surgeon observing through the operative hysteroscope. The procedure takes 3 minutes. Both these procedures can be performed in an office with appropriate safe guards.
The resectoscope is the most difficult tool to master. For this surgical procedure, the surgeon used a wire loop to cut-out strips of endometrium and the deeper myometrium (muscle). Because there is much more tissue destruction, there is less ability for the uterus to regenerate the endometrial lining. The resectoscope also is able to cut-out polyps and scarring from abnormal development. AT LEFT is the FIBROID! AT RIGHT, the resectoscope has removed the FIBROID entirely! Data from our office confirms that a successful RESECTOSCOPE left women with no menstrual flow more than 85% of the time. In the last two years, in more than 50 cases, only one woman needed a hysterectomy while 6 had very light menstrual flow. Resectoscope is twice as effective as Thermal Ablation for those who perform this procedure routinely.
When an endometrial ablation fails, it is often due to Adenomyosis. This is a condition associated with multiple childbirths. After each pregnancy, the endometrial glands grow deeper into the myometrium (muscle wall of the uterus). In some women, these glands grow down more than 1/3 to ever half way through the wall. In these cases, even the deepest resectoscope will not be able to stop the uterine bleeding from these deep glands. In these cases, hysterectomy is best to control the problem of uterine bleeding.
Fibroids or leiomyomata are muscle tumors that grow in the uterus. If these growths are within the uterine cavity, it may be possible to cut them out using the resectoscope. If they grow through the walls of the uterus, they cannot be removed. If they are left behind, it is possible that they will grow and cause problems that would necessitate a hysterectomy. Fibroids are surgically removed in women of childbearing age when they become large and obstructive. Small fibroids are usually left alone. It is a myth that menopause will shrink fibroids. Everyone is different. We educate our patients that oral contraceptives and estrogen replacement may enlarge fibroids. Gn-RH agonists, Lupron and Synarel, are used to shrink fibroids. But their use is limited to approximately 9 months.
The most important step is to talk to your doctor and understand the medications, office and out-patient surgical options available to you!