I took a call yesterday from a woman in the southern tier. We get 2-3 of these calls in a typical week from all over the United States. Fortunately this woman lived only a few hours away—for the sake of this article we’ll call her “Bonnie”. I’m writing about her because her’s is a classic case of “late-onset-endometrial ablation failure (LOEAF)”.
Her endometrial ablation was performed 10 year ago with one of the commonly used ablation devices. She did well for nearly 10 years—which is great. Now, at age 39, she reports that beginning in the fall of 2016 she began experiencing a slight bout of abdominal pain.
Endometrial Ablation (EA) is a widely used minimally invasive technique to manage heavy or abnormal periods. Nearly 500,000 of them are performed in the United States each year. Although EA may not be a perfect answer for everyone suffering from abnormal periods its advantages include the following:
It can be performed in a physician’s office,
It requires very little time off from work—compared to hysterectomy,
Intrauterine devices (IUDs) are wonderful forms of contraception. Some IUDs –such as the Mirena and Skyla—have the advantage of helping women with heavy or irregular vaginal bleeding. Another IUD that’s still commonly used is a copper-containing IUD known as the ParaGard.
At the time they’re inserted there are typically 1 or 2 strings that are cut and visible within the vagina. These strings are important – they’re what allows your provider to remove them when it’s time to discontinue them or “change them out”. But every once in a while the IUD strings work themselves back up into the uterus and are nowhere to be found.
When this happens many physicians insist on using “blind” techniques. These methods generally involve placing an instrument into the uterus through the cervix and “searching” around for the IUD or its strings “blindly”. If done in a physician’s office this can be painful. Even when done in an operating room setting this can be a risky procedure if done “blindly”.
The Center of Menstrual Disorders announces its official recommendations for women who have undergone endometrial ablation* and EMR
(* includes NovaSure®, Hydrothermal®, ThermaChoice®, “roller-ball”)
It is now well understood that every kind of endometrial ablation (ThermaChoice, Hydrothermal Ablation and NovaSure and “rollerball procedure” as well as Endomyometrial Resection (EMR) is associated with a set of conditions known as LOEAF – late-onset endometrial ablation failure.
Late-onset endometrial ablation failure (LOEAF) is a common condition and affects between 5-40% of women depending on a variety of factors including age (the younger you are the more prone you are to develop this) and other conditions such as fibroids.
LOEAF may take on one of three forms:
Women who have previously enjoyed light or absent periods may slowly develop heavier periods. This generally happens as lining tissue has a tendency to regrow—especially in younger women. In some cases it was not possible to destroy all of the uterine lining.
Women may develop increasingly painful periods or episodes of pain without accompanying periods known as “cyclic pelvic pain” or CPP. CPP develops as a result of 2 factors—the regrowth of uterine lining and the growth of scar tissue that prevents menstrual blood from passing easily. This combination can lead to a slight increase in cramps at the time of your expected period or it can result in incapacitating “labor-like” pains that occur above the pubic bone (suprapubic), in the right or left lower quadrants or even in the lower back. This pain is typically caused by a hematometra. Learn more about hematometra.
The inability of access the uterine cavity should a biopsy be required at some point in your life. This is very important to remember. If you develop post-menopausal bleeding or require assessment of the uterine cavity (for cancer screening) conventional methods of assessment such as ultrasound, sonohysterogram, diagnostic hysteroscopy and endometrial biopsy are no longer reliable. You can see why from the picture above—the uterine cavity is typically blocked by scar tissue. Future assessment required specialized skills known as sonographically-guided hysteroscopic biopsy. This is often referred to reoperative hysteroscopic surgery (RHS). You can click here to learn more.
The purpose of this article is not to explain how these biopsies or treatments can be provided. However here are the “take-aways”.
Recommendations for Women Who have undergone any form of Endometrial Ablation or Endomyometrial Resection
If you have undergone any form of endometrial ablation or resection procedure you should be seen annually.
At the time of your annual you should report any change in bleeding patterns or inform your provider if you’re developing cyclic pelvic pain that is worsening or new.
A transvaginal ultrasound examination should be a part of your annual visit. This allows the physician to establish a “baseline” of what your uterus looks like and makes it easier to diagnose subtle changes.
If you are ever seen in an emergency room for abdominal or pelvic pain please remind your emergency room physician—who is often not a gynecologist– that you had an endometrial ablation or resection and to contact our office for further guidance.
The Center for Menstrual Disorders has a world-wide reputation in the recognition of and management of endometrial ablation failures. These recommendations do not reflect practice guidelines by any major professional organization such as the American College of Obstetrician and Gynecologists (ACOG) or the American Association of Gynecologic Laparoscopists (AAGL). However, we have been managing these issues since 1989 and have published numerous articles on this subject in multiple peer-review journals.
I wrote this for Father’s Day 2010—but I think you’ll still find it relevant!
Happy Father’s Day
More than any person in my life—what I stand for, what I believe in and what I hope to pass on–has been shaped by my father.
Last month I wrote about my mom, one of the most compassionate, kind and hard-working and devoted women I’ve ever known. Today, with Father’s Day fast approaching, I hope you’ll indulge me as I write about my dad—a man for whom my love and admiration still grows–and the importance of fatherhood.
I do not write as an authority on fatherhood. Instead I write as someone who’s had a privileged childhood—not one of material wealth but a childhood filled with challenges guided by the most trustworthy parents a boy could have.
I can speak with authority about two things—the legacy of my dad and what I’ve observed about the current state of fathers in our culture.
My Father and his Legacy
My dad, Israel, was born over a century ago in Opatów, Poland on September 6, 1908. Opatów or “Apt” was settled in the 15h century as a small commercial town in southern Poland. Like many Polish towns of the early 20th century it had a rich rabbinic history and more than its share of poverty. Continue reading “Father’s Day – My Dad and his Legacy”→