Definition and Overview

Endometrial ablation is the surgical removal of the endometrial lining of the uterus and is often prescribed for patients who are suffering from abnormal or dysfunctional uterine bleeding . It can be performed as a minimally invasive procedure using laser beam, thermal ablation (heat), freezing, heated free fluid, or electricity.

The endometrial lining, also known as the endometrium, is the inner mucous membrane of the uterus. It is made up of layers of connective tissue, which thickness depends on the individual’s hormonal influences. When the female individual reaches reproductive age, the single layer of connective tissue she begins with in life becomes two, covering the inside of the uterine cavity.

The first layer of tissue lining the uterus is called the functional layer, which develops as menstruation ends, and is completely shed once the cycle starts again. Underneath the functional layer is the basal layer, which is not shed during the menstrual cycle, and is the base from where the functional layer develops.

Normally, the arteries providing the blood supply to the functional layer constrict, cutting off valuable glucose and oxygen. This tissue layer eventually dies and is shed off during menstruation. For patients suffering from abnormal or dysfunctional uterine bleeding, this procedure does not take place resulting in heavy bleeding during menstruation.

Who Should Undergo and Expected Results

Endometrial ablation is typically recommended by gynaecologist for:

  • Patients who experience unusually heavy bleeding during menstruation or those who experience menstrual cycles longer than seven days.

  • Non-pregnant women who do not plan on having more children. Endometrial ablation can be considered as a last recourse because like hysterectomy, the procedure is permanent and irreversible.

  • Patients whose excessive menstrual bleeding is not responding to other forms of treatment.

  • Patients with existing medical issues or conditions that make them ineligible to undergo hysterectomy.

Endometrial ablation is not recommended for:

  • Patients who experience uterine bleeding that is caused by cancerous growths - Cancerous cells that cause uterine cancer typically burrow deep into the organ and are not completely removed by simply destroying the endometrial lining.

  • Women who are suffering from an active genital tract infection.

Following endometrial ablation, patients can expect to have a noticeably decreased blood flow during menstruation with some reporting that their menstrual cycle has completely stopped after the procedure. Younger patients can expect better results than their older counterparts, but may experience heavy bleeding after several months. They can then return for a repeat procedure.

How Does the Procedure Work?

Before the procedure, a biopsy of the endometrial lining will be performed to determine whether the excessive vaginal bleeding is caused by cancer. The gynecologist can also perform or order imaging procedures to see the inside of the uterus without resorting to invasive surgical methods. Imaging procedures help the doctor determine if there are fibroids (benign tumours) or polyps under the endometrial lining. When present in the uterine lining, these growths can be the cause of heavy vaginal bleeding. The fibroids and tumours can simply be removed without irreversibly destroying the whole uterine lining. If the patient is wearing an IUD, it should be removed before the procedure begins.

The patient can also be prescribed medication for hormonal therapy a couple of weeks before the procedure to reduce the size of the endometrial lining. A smaller or thinner tissue lining increases the chances of having a successful procedure.

The surgeon will then dilate the patient’s cervical opening to pass the instruments into the cavity of the uterus. These instruments can dispense laser, heat, freezing cold, or electricity, which can destroy the uterine lining. Choosing what kind of method will be used for the endometrial ablation procedure will depend on the size, shape, and condition of the patient’s uterus and the presence of benign growths. The surgeon will also need to consider whether the patient has undergone hormone therapy before the procedure, and what kind of anaesthetics or sedation the patient desires.

Modern technology has allowed this procedure to be performed in a relatively short period. It can be completed in a single clinic or outpatient centre visit, but if symptoms do persist, the patient may be asked to return for a repeat of the procedure.

Possible Complications and Risks

There are several risks and possible complications involved in undergoing endometrial ablation. The uterus can be accidentally perforated if the surgeon is not careful enough to just scrape the endometrial lining. The cervical opening can also be damaged during the insertion of the instruments required to remove or destroy the layer of connective tissues covering the affected organ.

Other possible complications include infection to the uterus, as well as injuries and burns to the uterine cavity and even the intestines.

In some ablation procedures, fluid will be used to expand the uterine cavity to perform the procedure properly. This fluid can be absorbed into the bloodstream, leading to a condition known as pulmonary oedema.

Some patients report that they experience nausea, abdominal cramping, and abnormally frequent urination as well as bloody discharge after the procedure.

Reference:

  • Lentz G. Endoscopy: Hysteroscopy and laparoscopy: Indications, contraindications and complications. In: Lentz GM, Lobo RA, Gershenson DM, Katz VL, eds. Comprehensive Gynecology. 6th ed. Philadelphia, PA: Elsevier Mosby; 2012:chap 10.
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