If you are considering any type of endometrial ablation (EA) you should strongly consider endomyometrial resection (EMR) and why I believe it has many advantages over any of the ablation techniques that are available today. Here’s a bit of background on each. Keep in mind that in 1988 I became the first physician in Western NY to successfully perform endometrial ablation and had extensive experience with it before I set out to on a different direction and invented the technique of EMR.
First of all—What is endometrial ablation?
Endometrial ablation is the systematic burning of the uterine lining. The goal of endometrial ablation is to destroy –through burning—the uterine lining and replace it with scar tissue so that it no longer grows and sheds each month. If endometrial ablation is 100% successful the woman no longer experiences a monthly period. This does not cause menopause—which occurs when the ovaries stop producing eggs along with several classes of hormones. Because the uterine lining is important for pregnancy, endometrial ablation is only offered to women who have completed their families.
In order to destroy the uterine lining—and keep it from growing back–it is important to destroy the very base of the lining tissue called the endometrial basalis. A good analogy would be if you were trying to destroy a patch of grass in your front lawn using a blow torch. The only way it will work is if you apply enough heat to destroy the deep grass roots. If you simply apply heat to the blades of grass above the ground the grass regenerates and grows back. The challenge with endometrial ablation is to deliver enough heat to the lining so that the basal layer–the equivalent of roots—is destroyed without causing injury to other pelvic organs. If the basal layer isn’t destroyed the endometrium easily regenerates and grows back.
Early days of endometrial ablation (1988-1991)
When I first began performing endometrial ablation (EA) at Highland Hospital in 1988 we used a $110 thousand laser (neodymnium: YAG). The laser represented a major breakthrough in gynecology and allowed us to treat women with abnormal uterine bleeding in a simple outpatient procedure that often avoided hysterectomy. The laser was introduced through a hysteroscope so that we could actually look and work inside the uterine cavity. In the picture just below the laser fiber is introduced through a special telescope—called a hysteroscope—which then heats up or “cooks” the uterine lining.
Within a year (1989) the FDA had approved an electrified hysteroscope known as a “rollerball”resectoscope. The resectoscope was both less costly and more efficient—an example of sometimes “cheaper is better.” Although we were able to treat dozens of women with the laser it was soon replaced by “rollerball” resectoscope which was more effective in destroying the tissue inside the uterus (endometrium).
Within 2-3 years however it became apparent that even the “rollerball” resectoscope did not produce entirely predictable and acceptable results. At least 40% of women continued to have vaginal bleeding after endometrial ablation—which meant there was plenty of room for improvement.
One of the reasons, I felt, for the lack of predictability with endometrial ablation is that “burning” or “cooking” the uterine lining is not a very reliable way of destroying it!
In the meantime….
Even though endometrial ablation was performed in different parts of the world it never really caught on in the United States. But this changed in 1995 when a series of devices began making their appearance on the American and European markets. These devices were designed to improve the safety of endometrial ablation and encouraged many physicians—for the first time—to strongly consider their use.
Thanks to these devices, endometrial ablation became an important tool for gynecologists in this country and in Europe. However, while these devices improved the safety of endometrial ablation they did not improve their results! These systems—which include the ThermaChoice Balloon, Hydrothermal Ablation and NovaSure devices—account for nearly 400,000 ablation procedures performed in the U.S. each year.
The problem with endometrial ablation
It is now recognized that 25% of women undergoing endometrial ablation with these devices will subsequently undergo a hysterectomy within 3-4 years. The number of women who are dissatisfied with the results is likely to be higher but many of them simply elect to accept their results and not undergo further surgery.
Endomyometrial Resection (EMR): Definition and Goals
Endomyometrial Resection (EMR) grew out of the need to improve the results of endometrial ablation while not compromising on safety.
Definition: Endomyometrial resection is the systematic removal of the entire uterine lining (including the basal endometrium) together with the underlying muscle in order to insure that a known depth of lining tissue and muscle is removed—not burned. This is done to insure that the very base of the endometrium (lining tissue) has been removed and does not survive.
Goals: There are 3 goals of endomyometrial resection:
- To achieve a highly reliable outcome of diminished or absent menstrual bleeding compared to endometrial ablation techniques.
- To have a specimen that can be sent to a lab for analysis and determine whether or not there is a precancerous or cancer lesion of the uterus as well as other conditions that increase the risk for abnormal uterine bleeding.
- To minimize the risk for endometrial ablation failure which frequently requires some form of subsequent surgery—especially hysterectomy.
How does Endomyometrial Resection provide more reliable outcomes than endometrial ablation? What are the specifics?
There are several ways of comparing endomyometrial resection and endometrial ablation. The first is determine how many women stop having periods altogether (amenorrhea) following both procedures. The second—and more important—is to determine what percentage of women will require a second procedure. The “second” procedure may be either a repeat procedure or a hysterectomy.
Comparison of Medical versus Surgical Abortion
|Endomyometrial Resection||Endometrial Ablation|
|Amenorrhea (no further periods)||85.5% (10)||40-50%|
|Requiring second procedure||5% (8, 10)||25% (1 – 3, 8)|
If endomyometrial resection (EMR) is so successful why aren’t more physicians performing it?
To successfully perform EMR requires 3 separate skills:
First. The physician must develop expertise in operative hysteroscopy. EMR requires the skill to operative inside the uterine cavity. Most expert hysteroscopists around the world are self-taught as these skills are generally not learned during a typical residency or fellowship program. Most “minimally invasive” gynecologic surgeons are laparoscopists who are trained to operative inside the abdominal or pelvic cavity. They utilize small, narrow instruments passed through small skin incisions. Operative hysteroscopy, however, is an entirely different skill that requires the ability to perform surgery inside the uterine cavity and without skin incisions. Most major communities have barely a handful of skilled hysteroscopists.
Second. The physician needs to be skilled in dynamic ultrasound or “ultrasound guidance”. In addition to a surgical skill the physician needs to be perform and direct imaging during surgery and learn to rely on ultrasound images to guide their surgery.
Third. The physician must be able to assemble and maintain a “team” devoted to hysteroscopic surgery. Our “team” consists of a surgeon, 2 nurse practitioners and 2 medical technicians –with over 80 years of combined experience in operative hysteroscopy.
Simply stated, this is not the kind of expertise that is easily acquired!
If you are seriously considering an endometrial ablation you should take the time to learn about endomyometrial resection. EMR is an office-based procedure (11) that is extremely safe in our hands and produces results that we believe are superior to any of the endometrial ablation techniques. EMR has been well studied – in many cases we have over 20 year follow-up. In addition to these advantages EMR also provides an abundant amount of tissue for laboratory analysis. In a significant number of patients EMR has been able to diagnose both cancerous and pre-cancerous lesions that were missed on endometrial biopsy as well as D and C.
But the bottom line for most women is simply this— the results of EMR are better. You are more likely to achieve your desired outcome with EMR compared to any ablation procedure. To learn more about endomyometrial resection contact our office and schedule an appointment for a consultation.
- Munro MG. ACOG Practice Bulletin: endometrial ablation. Obstet Gynecol 2007; 109:1233-47.
- Longinotti MK, Jacobson G, Hung Y, et al. Probability of hysterectomy after endometrial ablation. Obstet Gynecol 2008; 112:1214-20.
- McCausland AM, McCausland VM. Long-term complications of minimally invasive endometrial ablation devices. J Gynecol Surg. 2010; 26:133-49.
- Gimpelson RH, Kaigh J. Endometrial ablation repeat procedures case study. J Repro Med. 1992;37:629-34.
- Wortman M. Daggett A. Reoperative hysteroscopic surgery in the management of patients who fail endometrial ablation and resection. J Am Assoc Gynecol Laparosc. 2001; 8:272-7.
- Wortman M, Daggett A, Deckman A. Ultrasound-Guided Reoperative Hysteroscopy for Managing Global Endometrial Ablation Failures. J Minim Invasive Gynecol. 2013. IN PRINT.
- Wortman M, Daggett A. Hysteroscopic endomyometrial resection: a new technique for the treatment of menorrhagia. Obstet Gynecol. 1994; 83:295-8.
- Wortman M. Minimally Invasive Surgery for Menorrhagia and Intractable Uterine Bleeding: Time to Set Standards. Journal of the AAGL. 1999; 6: 369-373.
- Wortman M. Sonographically Guided Hysteroscopic Endomyometrial Resection. Surg Technol Int. 2001. Dec 1; XXI: 163-169.
- Wortman M, Daggett A. Hysteroscopic Endomyometrial Resection. JSLS 2000; 4(3): 197-207.
- Wortman M, Daggett A, Ball C. Operative hysteroscopy in an office-based surgical setting: review of patient safety and satisfaction in 414 cases. J Minim Invasive Gynecol. 2013: 10;26-6